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

The foundational Philippine law that guarantees universal access to medically safe, effective, legal, affordable, and quality reproductive health care, including a full range of modern family planning methods. It is grounded in the principles of informed choice and voluntarism—no client may be coerced into or out of any method. The law mandates non-judgmental, confidential, and non-discriminatory service delivery regardless of the client's age, marital status, or number of children.

The ethical principle that every client must receive complete, medically accurate, and unbiased information about all available family planning methods—including effectiveness, benefits, side effects, how each is used, and what happens if the method fails. The client then freely chooses a method based on her own values and circumstances. The midwife counsels; she does not decide for the client. No method may be forced on anyone, and no client may be coerced into refusing a method.

A DOH-trained midwife can independently provide: Combined Oral Contraceptives (COCs), Progestin-Only Pills (POPs or 'mini-pills'), DMPA injectable (Depo-Medroxyprogesterone Acetate, 150 mg IM every 3 months), condoms, Lactational Amenorrhea Method (LAM) counseling, Standard Days Method (SDM or CycleBeads counseling), and comprehensive family planning counseling using frameworks like GATHER or REDI. These methods require no special certification beyond the basic midwife training in family planning competency.

The Intrauterine Device (IUD) and subdermal contraceptive implant are highly effective long-acting reversible contraceptive methods. A midwife may counsel clients about them and refer appropriately, but she may only insert and remove them after completing the DOH competency-based training and certification specific to that procedure. Without certification, attempting to provide these methods is outside her scope and is unsafe.

Bilateral tubal ligation (female sterilization) and vasectomy (male sterilization) are surgical procedures. The midwife counsels clients who are interested in permanent contraception about all options, including sterilization, but she does not perform these procedures. She refers the client to a facility with surgical capability (BEmONC or higher).

COCs contain both estrogen and progestin. They are among the most commonly dispensed methods in BHS and RHU settings. The midwife screens for contraindications, dispenses pills, and counsels on correct daily use: one pill at the same time each day, starting within the first five days of the menstrual cycle for immediate protection. She teaches missed-pill rules and reminds the client that COCs do not protect against sexually transmitted infections. COCs are NOT given to breastfeeding mothers in the first 6 months postpartum because estrogen reduces milk supply.

POPs contain only progestin and are the pill of choice for breastfeeding mothers (safe at any postpartum interval) and women who cannot tolerate estrogen. Unlike COCs, POPs must be taken at nearly the same time every day (a tight window—missing by more than three hours is treated as a missed pill). POPs are safe for breastfeeding and do not suppress milk supply.

DMPA is a progestin-only injectable contraceptive administered by the midwife intramuscularly (IM) at a dose of 150 mg every 3 months (every 13 weeks), typically into the deltoid or gluteal muscle. It is safe for breastfeeding mothers, requires no daily action by the client, and is highly effective and discreet. The midwife counsels that a return to fertility can be delayed after stopping (average 10 months), and that irregular spotting or amenorrhea is common and not harmful. The midwife tracks re-injection appointments and may give the injection within a grace window of up to 2 weeks early or 4 weeks late.

LAM is a natural, temporary family planning method the midwife teaches to new mothers. It is effective only when ALL THREE of these conditions are met simultaneously: (1) the baby is under 6 months old, (2) the mother is fully or nearly fully breastfeeding (exclusive breastfeeding, on demand, day and night), and (3) the mother remains amenorrheic (menses have not returned). Once any one condition fails, LAM is no longer reliable and the mother must switch to another method. LAM is always taught as a temporary bridge to a follow-on method, never as the only long-term contraceptive plan.

SDM is a fertility-awareness method suited to women with regular menstrual cycles between 26 and 32 days in length. The couple avoids unprotected intercourse on cycle days 8 through 19, the fertile window. The method uses CycleBeads (color-coded beads on a string) to track the cycle and identify fertile days. The midwife counsels the couple together because the method depends on the partner's cooperation and understanding. It requires a committed, communicative couple and high user motivation.

Male condoms are latex, polyurethane, or other barrier devices that prevent sperm from entering the reproductive tract. Female condoms (if available) work similarly but are inserted by the woman. Condoms are the ONLY contraceptive method that protects against sexually transmitted infections (STIs) including HIV. The midwife dispenses condoms freely and promotes dual protection—use of a condom plus a more effective method (like COC or DMPA) for clients at risk of both pregnancy and STIs.

The WHO MEC is a classification system that guides safe contraceptive provision by categorizing a client's medical suitability for each method into four categories: Category 1 (use in any circumstance, no restriction), Category 2 (generally use, advantages outweigh risks), Category 3 (method not usually recommended unless alternatives unavailable, risks usually outweigh advantages), and Category 4 (must not be used, unacceptable health risk). The midwife uses the MEC to screen clients and ensure that only medically appropriate methods are offered.

Safe family planning depends on correct screening. The midwife takes a focused history including: age, number of children, breastfeeding status, last menstrual period, smoking status, history of migraine with aura, known hypertension, liver disease, diabetes, history of blood clots or stroke, or personal/family history of breast cancer. She measures blood pressure before starting hormonal methods (COCs and DMPA) because estrogen-containing methods are restricted (MEC 3-4) in women with significantly elevated BP. She screens for signs of pregnancy using a pregnancy checklist before starting hormonal methods or IUD. She screens for reproductive tract infection and treats or refers before IUD insertion.

Before starting a hormonal contraceptive (COC, POP, DMPA), the midwife uses a standardized checklist to be reasonably sure the client is not pregnant. The checklist includes: Is she within the first five days of her menstrual cycle? Has she been using a reliable contraceptive method consistently and correctly? Has she not missed any pills or had a device dislodge? Does she have no signs or symptoms of pregnancy (no recent amenorrhea, no breast tenderness, no nausea)? If yes to any of these, or if she is unsure, the midwife may still start the method (no harm if she is not pregnant) or may advise her to return in 7 days for blood test if desired. The key is that the pregnancy checklist allows safe, immediate start rather than making the woman wait for her next menses.

GATHER is a mnemonic for a structured counseling approach: Greet (establish rapport and respect), Ask (listen and explore the client's needs, concerns, and contraceptive history), Tell (provide accurate, complete information about methods in a way the client understands), Help (help the client decide which method is best for her), Explain (explain how to use the method correctly), Return (arrange follow-up and make clear she can return anytime to ask questions or switch methods). GATHER is client-centered and ensures informed choice.

REDI is an alternative structured counseling approach: Rapport-building (establish trust and a safe, non-judgmental environment), Exploration (ask open-ended questions to understand the client's needs, concerns, preferences, and any barriers), Decision-making (present methods suited to the client's situation, discuss pros and cons, help the client weigh options), Implementation (ensure the client understands how to use the method, what to expect, when to return, and when to seek help). Both GATHER and REDI achieve informed choice through different organizational steps.

Healthy timing and spacing of pregnancy (HTSP) is the clinical goal of family planning within the MNCHN continuum. The evidence-based recommendations are: wait at least 24 months between a live birth and the next pregnancy to reduce risks of maternal and perinatal complications; wait at least 6 months after a miscarriage or induced abortion before the next pregnancy. These intervals allow the mother's body to recover, reduce the risk of prematurity and low birth weight, and improve child survival. HTSP is why family planning is described as the upstream prevention of high-risk pregnancies.

Hormonal contraceptive methods commonly cause side effects such as irregular spotting or amenorrhea, headache, breast tenderness, or weight changes. Most of these settle within the first few months. A key role of the midwife is to give clients honest, advance information about what is normal so they are not frightened and do not drop out of the method. The midwife distinguishes between expected side effects (reassure, follow up) and warning signs that require prompt evaluation or referral (severe abdominal pain, chest pain, severe headache with visual changes, heavy or prolonged bleeding). If a client is troubled by a side effect, the midwife may switch her to another method rather than lose her to unintended pregnancy.

The Contraceptive Prevalence Rate (CPR) measures the proportion of women of reproductive age (usually 15–49 years) who are using a modern contraceptive method. Family planning services are recorded on the FP client record and the Target Client List (TCL) for family planning, which feed into the Family Health Service Information System (FHSIS). These records track new acceptors, current users, method mix, dropouts, and lost-to-follow-up clients. The FHSIS provides data on performance against national MNCHN targets and informs regional and national family planning strategy.

RA 10354 mandates that family planning services be confidential and non-discriminatory. The midwife does not disclose a client's use of contraception to anyone (not even the client's partner or family) without the client's explicit consent. She serves all clients without judgment or discrimination based on age (including adolescents and young unmarried women), marital status, number of children, religion, or any other factor. Every client, regardless of circumstance, has the right to access family planning information and services.

Condoms are the only method protecting against STIs/HIV. For clients at risk of both pregnancy and STIs, the midwife promotes dual protection—a condom plus a more effective method (COC, DMPA, IUD, implant). This integrates family planning with STI/HIV prevention.