Midwife Licensure Exam The Midwife's Public Health Service Delivery — BEmONC and MNCHN from the Midwife's RoleSummary

The DOH's evidence-based strategy to reduce maternal and neonatal deaths through a continuum of care packages (pre-pregnancy, pregnancy, childbirth, postpartum/newborn, and child care) delivered across a linked network of health facilities. It is based on the principle that most maternal and newborn deaths are caused by predictable, treatable complications if a skilled provider and functioning facility are within reach at the critical moment. Administrative Order 2008-0029 formally adopted this approach.

The seven concrete, life-saving interventions that every Basic EmONC facility must be able to perform: (1) administer parenteral antibiotics (IM/IV) for maternal sepsis and chorioamnionitis, (2) administer parenteral oxytocic/uterotonic drugs (oxytocin) for prevention and treatment of postpartum hemorrhage, (3) administer parenteral anticonvulsants (magnesium sulfate) for severe pre-eclampsia and eclampsia, (4) perform manual removal of the placenta, (5) perform removal of retained products of conception (manual vacuum aspiration/MVA), (6) perform assisted vaginal delivery (vacuum extraction), and (7) perform basic newborn resuscitation with bag and mask. These are measured as indicators of facility capacity and are the minimum standard for any facility claiming to offer emergency obstetric care.

All seven BEmONC signal functions plus two additional capabilities: (8) perform cesarean section (major surgery) and (9) perform blood transfusion. A CEmONC facility is typically a provincial or secondary hospital with surgical capacity and blood bank services. Together, the 9 functions represent the complete package of emergency care. The DOH standards aim for one CEmONC facility per 500,000 population.

The single most important intervention to prevent postpartum hemorrhage, the leading cause of maternal death in the Philippines and globally. AMTSL has three sequential steps: (1) administer oxytocin 10 IU intramuscularly (IM) within one minute of the baby's birth, after ruling out a second twin, (2) deliver the placenta by controlled cord traction with counter-traction on the uterus, and (3) perform uterine massage immediately after placental delivery and continue monitoring uterine tone. The entire sequence should take 5–10 minutes. AMTSL reduces the risk of postpartum hemorrhage by 60% and is a core midwifery skill performed at every birth.

A four-step, time-bound protocol for immediate newborn care that every midwife performs at every birth: (1) immediate and thorough drying of the newborn for the first 30 seconds to stimulate breathing and prevent hypothermia, (2) early skin-to-skin contact by placing the dried baby prone on the mother's abdomen or chest, (3) properly timed cord clamping—clamp and cut the umbilical cord only after cord pulsations stop, usually 1 to 3 minutes, to transfer iron stores and improve the newborn's blood volume, and (4) non-separation of mother and baby for early initiation of breastfeeding, ideally within the first 90 minutes of life. These steps work together to stabilize the newborn's temperature, breathing, heart rate, and nutrition while promoting bonding.

The SDN is the linked set of health facilities organized to provide the full MNCHN service package without gaps. The continuum of care has two dimensions: (1) across time, from pre-pregnancy through pregnancy, childbirth, postpartum, and childhood; and (2) across place, from home and community, through the Barangay Health Station (BHS) where the midwife identifies risk and gives prenatal care, to the Rural Health Unit (RHU) or BEmONC facility for skilled birth attendance, and finally to the CEmONC hospital for major surgery or transfusion if needed. A break at any point—a missed prenatal danger sign, a delayed referral, an unavailable ambulance—is where mothers and newborns die. The ideal network includes roughly one BEmONC facility per 125,000 population and one CEmONC per 500,000.

The three-delays framework identifies where maternal deaths occur: (1) delay in deciding to seek care (often due to lack of knowledge or recognition of danger), (2) delay in reaching care (due to distance, transport, or cost), and (3) delay in receiving appropriate care (due to facility unpreparedness or lack of skilled staff). The MNCHN strategy and the midwife's role are designed to overcome each delay. The midwife tackles delay 1 by teaching pregnant women danger signs during prenatal visits; delay 2 by ensuring a birth plan that names the facility and arranges transport; and delay 3 by stabilizing the mother before referral and communicating ahead so the receiving facility is prepared.

Republic Act 7392, the Philippine Midwifery Act, defines the midwife as a legally recognized skilled birth attendant authorized to provide normal maternal, newborn, family-planning, and community care and to recognize and refer complications. Within the BEmONC package and under DOH-approved protocols and training, the midwife may directly: administer the first dose of parenteral oxytocin for prevention and treatment of postpartum hemorrhage, administer the loading dose of magnesium sulfate for severe pre-eclampsia or convulsions before referral, administer the initial dose of parenteral antibiotics for sepsis or prolonged rupture of membranes, perform newborn resuscitation with bag and mask, perform active management of the third stage of labor (AMTSL) at every birth, and—when trained and when no physician is immediately available—perform manual removal of the placenta and bimanual uterine compression as stabilizing measures. In emergency and life-threatening situations, a trained midwife may administer life-saving drugs to the mother and newborn in accordance with DOH guidelines. Procedures such as complex MVA, vacuum extraction, cesarean section, and blood transfusion belong to appropriately trained team members or CEmONC.

Magnesium sulfate is the anticonvulsant of choice for preventing and treating eclampsia (seizures in pregnancy or postpartum). A trained midwife, according to DOH protocols, administers the loading dose (typically 4 g IV over 10 minutes or 10 g IM in divided doses into each buttock) to a woman with severe pre-eclampsia or eclampsia as a life-saving, stabilizing measure before and during referral to CEmONC. MgSO4 does not lower blood pressure but prevents and stops seizures, which are immediately life-threatening to mother and baby. The dose, route, timing, and monitoring (for signs of toxicity such as loss of reflexes or respiratory depression) are critical details tested on the MLE.

A competent referral is not simply 'send her to the hospital.' The midwife must: (1) **recognize** the danger sign early—hemorrhage, convulsions, high fever, obstructed labor, retained placenta, or a non-breathing newborn; (2) **stabilize** the patient by starting the appropriate first-line intervention (e.g., uterotonic for hemorrhage, MgSO4 for eclampsia, resuscitation for non-breathing newborn), keeping the mother or baby warm, maintaining an IV line if possible, and preventing further deterioration; (3) **communicate ahead** to the receiving CEmONC facility so they know a critical case is coming and can prepare; (4) **accompany or arrange transport** and carry a complete written referral note documenting the history, vital signs, findings, interventions already given with times and doses, and clinical impression; (5) **follow up** on the outcome and learn from the case. This five-step model ensures continuity and safety across the referral chain.

A central MNCHN policy is that all births should take place in a health facility with a skilled birth attendant (doctor, nurse, or trained midwife) present. Home births attended by traditional birth attendants (*hilots*) are actively discouraged because life-threatening complications such as postpartum hemorrhage can kill within hours, and a home has neither the drugs (oxytocin, antibiotics, anticonvulsants) nor the escalation route (transport to CEmONC) to manage emergencies. The midwife's prenatal teaching and birth planning are directed toward steering every pregnant woman toward a BEmONC-capable facility for delivery.

The FHSIS is the DOH's routine system for capturing the midwife's public health work. Prenatal visits, tetanus immunization, births attended, postpartum visits, complications, referrals, and outcomes all flow into the Target Client List (TCL) and monthly reports, which then roll up to municipal, provincial, and national indicators such as the maternal mortality ratio (MMR) and neonatal mortality rate (NMR). Accurate FHSIS recording is not merely administrative paperwork; it is how the program knows whether the MNCHN strategy is working and where to direct resources. The midwife is responsible for accurate, timely recording.

MNCHN is the overarching DOH strategy; BEmONC and CEmONC facilities are the concrete infrastructure through which MNCHN is delivered. Every BEmONC facility must have the seven signal functions in place; every CEmONC facility must have all nine. The network of these facilities ensures no pregnant woman or newborn is left without an escalation option.

AMTSL is performed at the moment the baby is born and immediately after to prevent postpartum hemorrhage (leading cause of maternal death). EINC/Unang Yakap is performed in the first critical minutes and hours to stabilize the newborn and prevent hypothermia, respiratory failure, and poor feeding (causes of early neonatal death). Together, they form the immediate protective package at birth.

The midwife's prenatal teaching addresses delay in deciding; birth planning and transport arrangement address delay in reaching; and stabilization before referral plus communication with the receiving facility address delay in receiving. Each intervention is targeted to overcome a specific delay.

RA 7392 authorizes the midwife to administer life-saving drugs and perform specific procedures (oxytocin, MgSO4, antibiotics, resuscitation, manual placental removal) as part of stabilization before referral. These interventions are not the full management of the complication but are first-line, stabilizing actions that buy time and improve the chance of survival during transport to CEmONC.

The midwife is typically a core member of the BEmONC team at the RHU or equivalent facility. The midwife's intrapartum work (AMTSL, EINC, assessment, initial stabilization, and referral decision) is grounded in a BEmONC setting where the seven signal functions are available or accessible within minutes.

The SDN is the physical embodiment of the continuum of care. MNCHN defines what services are needed at each stage (pre-pregnancy, pregnancy, intrapartum, postpartum, childhood); the SDN ensures these services are linked so that a woman and child move seamlessly (or via organized referral) through the system without gaps.

The midwife's daily work—prenatal visits, births, referrals, outcomes—is captured in FHSIS. This data rolls up to show whether MNCHN targets are being met, whether facility coverage is adequate, and where maternal and neonatal deaths are occurring. Accurate recording by midwives is the foundation of data-driven program improvement.