Midwife Licensure Exam The Midwife's Public Health Service Delivery — Family Planning Provision by MidwivesRevision Notes

Exam Tips

• MLE loves to ask: 'What is the legal basis for FP provision by midwives in the Philippines?' Answer: RA 10354.
• Remember the two guiding principles together: Informed Choice + Voluntarism. Both are one package.
• If an MLE question describes a midwife refusing FP to an unmarried woman or teenager, the correct answer involves RA 10354 and non-discrimination.
• The phrase 'free and informed decision' = informed choice. Memorize both phrasings.

Key Points

• RA 10354 guarantees universal access to medically safe, effective, legal, affordable, and quality reproductive health care including modern contraception.
• The core principle of the RH Law is INFORMED CHOICE and VOLUNTARISM — no client may be coerced into or out of any FP method.
• The midwife must provide medically accurate and complete information on ALL methods, even those she does not personally provide.
• Services must be non-discriminatory: age, marital status, and number of children are NOT barriers to FP counseling and provision.
• Confidentiality and privacy must be upheld at every FP encounter.
• FP counseling must be offered at EVERY relevant contact: postpartum, post-abortion, prenatal, and well-woman visits — not only when the client asks.
• DOH's Family Planning Competency-Based Training (FP CBT) program governs which methods a midwife is trained and authorized to provide.
• The midwife counsels; the METHOD CHOICE belongs to the woman (and her partner if she so wishes).
• All modern FP methods are provided FREE OF CHARGE at government health facilities under the RH Law.

Definitions

Section Title

Legal Framework: RA 10354 (RH Law, 2012) and the Midwife's Mandate

Common Mistakes

• Confusing RA 10354 (RH Law, 2012) with RA 7392 (Midwifery Act, 1992) — they are different laws with different purposes.
• Thinking a midwife needs additional certification for COCs, POPs, DMPA, or condoms — she does NOT. These are part of her standard FP service package.
• Assuming a married or older woman has priority access to FP — RA 10354 prohibits age and marital status discrimination.
• Forgetting that FP counseling is an ACTIVE duty at every health contact, not just when a client requests it.

Exam Tips

• Memorize the method categories as three groups: (1) Midwife independently provides: COCs, POPs, DMPA, condoms, LAM, SDM, counseling. (2) Needs additional certification: IUD, implant. (3) Refer for surgery: BTL, vasectomy.
• DMPA dose memorization: 150 mg IM q13 weeks. Write it out until automatic.
• For breastfeeding questions: always choose POPs or DMPA — never COCs in the first 6 months.
• LAM memory trick: Baby Under 6, Breastfeeding Exclusively, No Bleeding (amenorrhea) — ALL THREE must be YES simultaneously.
• SDM fertile window: days 8-19. CycleBeads are red on days 8-19 (danger = avoid unprotected sex).
• Dual protection = condom + effective method. Remember: condoms are the ONLY STI-protective FP method.

Key Points

• A trained midwife independently provides: COCs, POPs, DMPA injectable, male/female condoms, LAM, SDM, and FP counseling.
• IUD insertion/removal and subdermal implant insertion/removal require ADDITIONAL DOH competency-based certification — without this, the midwife COUNSELS and REFERS.
• Bilateral tubal ligation (BTL) and vasectomy are SURGICAL procedures — completely outside the midwife's scope; she COUNSELS and REFERS.
• The 'certification-required' methods for MLE purposes are: IUD and implant.
• The 'refer entirely' methods for MLE purposes are: BTL (female sterilization) and vasectomy (male sterilization).
• Condoms are the ONLY FP method that also protects against HIV and STIs — promote DUAL PROTECTION for at-risk clients.
• All hormonal methods (COCs, POPs, DMPA, implant) work primarily by preventing ovulation and/or altering cervical mucus.
• Long-Acting Reversible Contraceptives (LARCs) include IUD and implant — highly effective because they remove user error.

Definitions

Section Title

The FP Method Mix: What a Midwife Can Independently Provide

Common Mistakes

• Giving COCs to a breastfeeding mother in the first 6 months postpartum — estrogen suppresses milk production. Use POPs or DMPA instead.
• Confusing the DMPA interval: it is every 3 MONTHS (13 weeks), NOT every month. The dose is 150 mg IM.
• Thinking a midwife can insert an IUD or implant right after completing the general FP training — she needs the SPECIFIC DOH certification for each procedure.
• Forgetting that vasectomy and BTL are ALWAYS referred — no level of midwife training covers surgical sterilization.
• Applying LAM beyond 6 months or when menses have returned — LAM has strict, simultaneous conditions.

Exam Tips

• MEC Categories memory: 1=Always OK, 2=Generally OK, 3=Usually NO, 4=NEVER.
• Any scenario with 'migraine with aura + COCs' = MEC Category 4 → switch to progestin-only.
• Scenarios with breastfeeding mother less than 6 months: COCs = MEC Category 4; POPs/DMPA = MEC Category 1.
• Always check BP before hormonal methods — a BP question in the MLE about FP almost always points to COCs/DMPA.
• Pregnancy checklist = 'quick start' concept — allows same-day initiation if pregnancy is reasonably excluded.

Key Points

• The WHO Medical Eligibility Criteria (MEC) classify a client's eligibility for each method into four categories (1-4).
• MEC Category 1: No restriction — use the method in any circumstance.
• MEC Category 2: Advantages generally outweigh risks — method can be used.
• MEC Category 3: Risks usually outweigh advantages — method not recommended unless no alternatives; careful follow-up needed.
• MEC Category 4: Method MUST NOT be used — unacceptable health risk (absolute contraindication).
• The midwife uses a PREGNANCY CHECKLIST to be reasonably sure the client is not pregnant before starting hormonal methods or IUD, allowing immediate initiation rather than waiting for next menses.
• Blood pressure MUST be measured before starting COCs or DMPA — estrogen-containing methods are MEC 3-4 for significantly elevated BP.
• Key contraindications to estrogen-containing methods: migraine with aura, history of thromboembolism or stroke, severe hypertension, breastfeeding < 6 months postpartum, active liver disease.
• Progestin-only methods (POPs, DMPA, implant) are generally safer for women who cannot take estrogen.
• Before IUD insertion: screen for signs of pregnancy and reproductive tract infection (RTI) — treat or refer RTI before insertion.
• SDM is only for women with REGULAR cycles of 26-32 days — irregular cycles disqualify the method.
• Focused history elements: age, parity, breastfeeding status, LMP, smoking, headaches/migraine with aura, known hypertension, liver disease, diabetes, clotting history, breast cancer history.

Definitions

Section Title

Eligibility Screening: WHO Medical Eligibility Criteria (MEC) and Pregnancy Checklist

Common Mistakes

• Skipping blood pressure measurement before prescribing COCs or DMPA — this is a required screening step.
• Confusing MEC Category 2 (can use) with Category 3 (usually not recommended) — Category 3 is a caution, not a green light.
• Starting an IUD without first ruling out RTI — active infection is a contraindication to IUD insertion.
• Offering SDM to a woman with irregular cycles — SDM only works for regular 26-32 day cycles.
• Using the terms 'absolute contraindication' in clinical language — the correct MEC term is Category 4.

Exam Tips

• GATHER acronym: Greet-Ask-Tell-Help-Explain-Return. Write it out repeatedly until automatic.
• REDI acronym: Rapport-Exploration-Decision-Implementation. Note 'Decision-making' is the step where the method is chosen.
• MLE scenario: midwife helps client pick a method = 'Help' in GATHER, 'Decision-making' in REDI.
• Any question about preventing FP dropouts from side effects → answer involves ADVANCE counseling about expected side effects (the 'Explain' step in GATHER).

Key Points

• Counseling is itself a service the midwife provides — it is not just an introduction to giving pills.
• Two main counseling frameworks tested in the MLE: GATHER and REDI.
• GATHER stands for: Greet, Ask, Tell, Help, Explain, Return.
• REDI stands for: Rapport-building, Exploration, Decision-making, Implementation.
• Good counseling is what makes informed choice real — it is the ethical foundation of FP provision.
• The midwife presents all methods honestly, including effectiveness, side effects, and correct use.
• She must never withhold information to push a preferred method, and must always tell the client she can return to switch or stop at any time.
• Counseling includes advance warning about EXPECTED side effects so the client is not frightened into stopping prematurely.
• For SDM, the midwife counsels the COUPLE together — partner cooperation is essential for this method.
• LAM is always taught as a BRIDGE to a follow-on method, not a permanent solution.

Definitions

Section Title

FP Counseling Frameworks: GATHER and REDI

Common Mistakes

• Mixing up GATHER steps — confusing 'Tell' (about methods) with 'Explain' (correct use after choice is made).
• Omitting the 'Return' step — follow-up planning is a mandatory part of the GATHER counseling session.
• Counseling only the woman for SDM — the partner MUST be included because the method requires couple cooperation.
• Treating LAM as a long-term method — it is a BRIDGE; always counsel on a follow-on method before the baby turns 6 months.

Exam Tips

• Warning signs memory: the ABCDs of FP danger: Abdominal pain (severe), Bleeding (heavy/abnormal), Chest pain, Dizziness/severe headache with visual changes.
• HTSP intervals: LIVE BIRTH = 24 months wait; MISCARRIAGE/ABORTION = 6 months wait.
• DMPA grace: 2 weeks early, 4 weeks late — this is the re-injection flexibility window.
• Any MLE question about FP data collection → answer involves TCL and FHSIS.
• CPR = the FP program success indicator. A DOH/LGU increasing CPR = more women using modern FP.

Key Points

• Most FP dropouts happen because clients are frightened by EXPECTED side effects nobody warned them about — good counseling prevents this.
• Common and NORMAL hormonal side effects: irregular spotting, amenorrhea, headache, breast tenderness, slight weight change — most resolve within 1-3 months.
• Amenorrhea and spotting on DMPA or POPs are EXPECTED and HARMLESS — the midwife reassures the client.
• WARNING SIGNS requiring PROMPT REVIEW (not normal): severe abdominal pain, chest pain, severe headache with visual changes, heavy abnormal bleeding, leg pain/swelling.
• The midwife offers a METHOD SWITCH rather than letting a client simply stop and risk unintended pregnancy.
• Follow-up is built into every method: set a RETURN DATE for pill resupply, next DMPA injection, or condom restocking.
• The TARGET CLIENT LIST (TCL) for FP flags clients who are overdue for re-injection or resupply.
• Healthy timing and spacing: wait at least 24 months after a live birth before the next pregnancy; at least 6 months after miscarriage or abortion.
• FP services are recorded on the FP Client Record and the TCL, feeding the FHSIS (Field Health Service Information System).
• The Contraceptive Prevalence Rate (CPR) is the public health outcome indicator for FP programs.
• FP is an MNCHN cornerstone because healthy timing and spacing PREVENTS high-risk pregnancies before they begin.
• DMPA re-injection grace window: up to 2 weeks EARLY or 4 weeks LATE from the scheduled date.

Definitions

Section Title

Side Effects, Warning Signs, Follow-Up, and the Public Health Frame

Common Mistakes

• Confusing expected side effects (spotting, amenorrhea) with warning signs — they require completely different responses.
• Allowing a client to stop DMPA without offering an alternative method — always counsel on switching, not just stopping.
• Forgetting the DMPA grace window: 2 weeks early or 4 weeks late is acceptable, but the midwife should track the due date on the TCL.
• Recording FP data on the wrong form — FP client records and TCL are specific tools; they are not the same as general health records.
• Stating that the spacing interval after miscarriage is 24 months — it is 6 months after miscarriage/abortion; 24 months is after a live birth.