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Chapter 1

INTRODUCTION

Maternal and neonatal health is one of the most important elements of human

development. From the conceiver to the conceived, ample professional care is

imperative in order to fulfill and to sustain fertility. Maternal health refers to the health

of women during pregnancy, childbirth and the post-delivery period. Meanwhile,

neonatal health is the health of the new-born baby.

According to Gruskin, Cottingham, Hilber, Kismodi, Lincetto, and Roseman

(2008), maternal and neonatal health are central for the MDGs, the global roadmap

for eradicating poverty and improving human well-being by the year 2015.

Based on the Philippine Health Statistics by the Department of Health (2009),

the Philippines had a total of 1, 745, 585 live births. Per 1000 live births emerge a

rate of 0.9 when it comes to maternal deaths, while infant deaths show the rate of

12.4. In locality, the Davao Region proves to have maternal mortality as one of its

challenges in human resource development. Two of Davao Regions main goals in

terms of health and nutrition are infant mortality rate shall be reduced from 8.1

deaths per 1,000 live births in 2009 to 5.0 deaths per 1,000 live births in 2016.

Maternal mortality rate shall be reduced from 121 deaths per 100,000 live births in

2009 to 45 deaths per 100,000 live births in 2016 (National Economic and

Development Authority [NEDA], 2011). Provided that the MDGs goal achievement

seeks its deadline at 2015, extended efforts must be made in order to accomplish

such. In Davao City in particular, infant mortality rate reveals itself at 12.1 as the


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highest among other places in the region such as Davao del Norte with the rate of

4.2 and Davao Oriental at 5.2 and maternal mortality rate in Davao City is observed

at 38.9. Whereas the goal of MDG by 2015 is that the rate of infant mortality be

reduced to 2.1 and maternal mortality to 11.7 (DOH, 2012). These rates are

calculated on the basis of 1,000 per live births.

In line with the Millennium Development Goals which targets the reduction of

maternal and child mortality, this Administrative Order 2008-0029 establishes the

guidelines on how to carefully administer maternal and child health from conception

until birth. The Maternal, Newborn, and Child Health and Nutrition Manual of

Operations (MNCHN MOP) seeks to guide Local Government Units (LGUs) in

carrying out MNCHN services to people who are most at risk of maternal and

neonatal deaths. Through this, the Philippines will be on the road with the world in

reducing maternal and neonatal mortality, fulfilling the MDGs and actualizing human

rights

As stated in the MNCHN Manual of Operations (2011), community level

providers include barangay health stations. Primary health care, equipped with

skilled health practitioners, serves as the initial point wherein individuals and families

in the community seek their health care needs especially to maternal and neonatal

needs.

According to Administrative Order 2008-0029, ideally, every pregnancy must

be wanted, planned and supported. It also must be properly managed all throughout

by skilled birth attendants/skilled health professionals.


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In spite of the ideals being emphasized, people resort to availing maternal

and neonatal health care from Traditional Birth Attendants (TBAs) or hilots thats one

of many factors that led maternal and neonatal death rate on high levels. As stated

in the MNCHN MOP,

This [TBAs or hilots] contributes to three delays that lead to maternal and neonataldeaths such as delay in identification of complications, delay in referral, and delayin the management of complications. This could explain why TBSs, even if trained,has had little impact on reducing maternal and neonatal mortality.

Furthermore, after the implementation of Administrative Order 2008-0029,

available data show that from 2009 and 2011 revealed an increase of maternal

mortality from 162 to 221 deaths. (Umil, 2013, April 9).

Poor health service in geographically isolated and depressed areas, late

referrals during birth and even during pregnancy period also renders the current

situation, particularly in Davao. Health providers could not keep up the pace in

tracking all maternal and neonatal cases since most barangay health centers in such

areas lack equipment and machineries that can be utilized in deliveries and check-

ups. In addition, some health stations also lack personnel who can facilitate in such

matters that include doctors, nurses, and midwives. (Capon, 2014, February 15).

Thus, given the data showed, it is imperative and significant to study this

matter, as this would contribute to development with respect to handling of maternal

and neonatal issues by health practitioners of barangay health stations in line with

the Administrative Order 2008-0029 in Davao City, that there should be heightened

stringency , particularly on the availability of ample services, facilities, and human

resource in order to attain the necessary means of fulfilling the goals of both MDG 4

and 5 that is proposed in the Administrative Order 2008-0029.


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Statement of the Problem

The study seeks to answer the following objectives:

1. What is the socio-demographic and economic profile of barangay

health station practitioners?

2. What is the level of knowledge of barangay health station practitioners

with regards to Administrative Order 2008-0029?

3. What is the extent of compliance of barangay health station

practitioners on Administrative Order 2008-0029 in terms of human

resource, logistics and services?

4. What are the attitudes of barangay health station practitioners toward

the Administrative Order 2008-0029?

Theoretical Framework

This system is anchored at the General Systems Theory of Ludwig von

Bertalanffy, which explains that a system may be defined as a set of social,

biological, technological or material partners co-operating on a common purpose

(Hjrland & Nicolaisen, n.d.). The MNCHN strategy, especially the Manual of

Operations, follow a distinct system at which maternal and neonatal services must

be catered. This include network of facilities. Specifically defined in Ludwig von

Bertalanffys General Systems Theory, Systems are "sets of elements standing in

interaction. These sets of elements form part the whole of the system. Thus, if the

parts do not interact the way they should, then the whole will not become justified as

a system.


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Since the health practitioners form part of the elements of the whole system

of the deliverance of MNCHN services, this study will examine the level of

knowledge, extent of compliance, and their attitudes towards the Administrative

Order 2008-0029. Consequently, these instruments of analysis will determine if the

health practitioners have partaken in the efforts of the country in rapidly reducing

maternal and neonatal mortality.

In the form of the framework, we describe a system wherein where we

perceive that this study may actualize its objectives. With every part of the system,

these serve as the elements at which the whole of the goal of the reduction of

maternal and neonatal will be achieved. Human rights immediately follow the

universal provision of the right to health. With the efforts o f worlds governments

under the United Nations comes the Millennium Development Goals. In the

Philippine context, the country also has initiated its own efforts of minimizing

maternal and neonatal mortality by the promulgation of the Administrative Order

2008-0029. The barangay health station practitioners, the front liners of the delivery

of maternal and neonatal services, are inquired of their level of knowledge regarding

the Administrative Order on the following: pre-pregnancy, antenatal services, care

during pregnancy, and post-partum and postnatal care. Following their knowledge of

the said specifics, their attitudes towards the Administrative Order will be gathered,

as well as their extent of compliance regarding the AO and its specifics. Their extent

of compliance, in turn, also results from their level of knowledge regarding the

Administrative Order 2008-0029. The General Systems theory of Bertalanffy may


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justify the adequacy of this whole system. With the cooperation of each, the whole of

the system will be rendered significant.

Figure 1.1 Analytical Framework of the Study

HUMAN RIGHTS

RIGHT TO HEALTH

MDG 4 & 5

ADMINISTRATIVE ORDER

NO. 2008-0029

RESPONDENTS LEVEL OF KNOWLEDGE

PRE-PREGNANCY

SERVICES

ANTENATAL

CARE

CARE DURING

PREGNANCY

POST PARTUM &

POSTNATAL CARE

RESPONDENTS

ATTITUDES

RESPONDENTS EXTENT OF

COMPLIANCE


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Scope and Limitations of the Study

The study will focus on health practitioners, particularly attending physicians,

nurses and midwives level of knowledge, extent of compliance and attitudes toward

the implementation of Administrative Order 2008-0029. The study will also focus on

the socio-demographic profile of the respondents, which includes their age, sex,

religion and highest educational attainment and their qualifications as a health

practitioner that includes their job description, years of practice and the district that

they are assigned or are currently working.

The study will encompass particularly health practitioners in urban barangay

health stations in all the three political districts in Davao city.

Significance of the Study

The results of the study will be significant to the following stakeholders:

Department of Health

Given that the study is under the umbrella of the implementations of the

Department of Health, this study would further enhance and materialize the statistics

observed and also, this study can contribute to aid lacking means of development in

the concentrated area.

Davao City Local Government

The data that will be gathered and analyzed by the researchers can be

utilized by the local authorities of the city in the further evaluation of the

effectiveness of the MNCHN MOP. This will also explore and analyze the situations


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in the local conditions of the health care facility. Hence, will allow health officers to

reevaluate the status quo of their implementation mechanisms.

Davao City Health Office

The results of the study will help the management of the institution in its drive

towards improving its reforms, specifically in areas where maternal and neonatal

healthcare is mostly needed. Accordingly, we hope that the study can also provide

additional information as to how can they effectively follow the provisions and

guidelines set by Administrative order 2008-0029 in the rapid reduction of maternal

and neonatal mortality and the risks that are attached to it.

Political Science educators

This study will be helpful for the said individuals as this provide a local

scenario that is useful for the appreciation and application of theories, principles and

concepts learned from class. Furthermore, will result to a formulation of effective

actions that they can incorporate in such subject matters they will teach that relates

to the interplay of politics and in the health milieu.

Future Researchers

The data revealed in the study can later on become a source of reference for

students aiming to conduct further research on maternal and neonatal related

studies.


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Operational Definition of Terms

Attitude refers to how the respondents perceive or see the Administrative Order

2008-0029.

Barangay Health Stations refer to public clinics specializing in maternal and

neonatal-related cases in urban areas.

Compliancerefers to the obedience of the respondent on the Administrative Order

2008-0029.

Economic Profile refers to the job description, years of practice and the assigned

sub district of the respondent.

Health Practitionersrefer to the attending skilled midwives, nurses and physicians.

Level of knowledgepertains to the depth of input idea of the respondents regarding

AO 2008-0029.

Socio-demographic profilerefers to the characteristics of the respondent in terms

of their age, sex, and highest educational attainment.


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Chapter 2

REVIEW OF RELATED LITERATURE

This chapter contains the following studies and literature that are relevant to

the understanding of the initiatives and programs of the Department of Health on the

rapid reduction of maternal and newborn mortality. Specifically, this chapter includes

the definition of the Millennium Development Goals 4 and 5, womens rights to

health, quality of health care, Maternal and neonatal condition in the Philippines,

foreign programs and Philippine government agencies.

Millennium Development Goals 4 and 5

The Millennium Development Goals and Beyond 2015 are eight international

developmental goals created by the United Nations during the Millennium Summit in

the year 2000. These developmental goals are opt to be achieved within the first 15

years of the new millennium. The MDGs ought to make the lives of every citizen of

the world better by fulfilling these goals. Two of the eight MDGs are the fourth, which

is to reduce child mortality and the fifth which is to improve maternal health.

According to the United Nations (n.d.), the worlds countries and

developmental organizations have stretched their efforts as far as they can reach in

order to meet the needs of the worlds poorest.

The 4th

MDG targets the reduction of the under-five mortality rate by two-

thirds from 1990 to 2015 (UN, n.d.). With the same time span and rate of reduction

as that of the 4th, the 5thMDG targets the reduction of maternal mortality ratio. The


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indicators for monitoring progress for the 4 th target are under-five mortality rate,

infant mortality rate, proportion of 1 year-old children immunised against measles;

the indicators of monitoring progress for the improvement of maternal health are

maternal mortality ratio and proportion of births attended by skilled health personnel

(UN, n.d.).

Womens Rights on Health

According to Chapter 3 Section 13 entitled Access to Information and

Services Relating to Womens Healthin Republic Act 9710: Magna Carta for Women

(2009), ...the State shall at all times provide for comprehensive, culture -sensitive,

and gender-responsive health programs and services covering all stages of a

womans life cycle. Initially, among essential health concerns that must be gained

access to by women is the maternal care in both pre and postnatal aspect (RA 9710,

2009). This means that aside from the Administrative Order 2008-0029, another

enactment regarding womens health had been crafted to address womens medical

or health needs.

As incorporated in the introduction, the achievement of the Millennium

Development Goal 5 is the purpose of examining the compliance of Administrative

Order 2008-0029. The study of Adam, Lim, Mehta, Bhutta, Fogstad, Mathai, Zupan

and Darmstadt (2005) entitled Achieving the Millennium Development Goals for

Health:Cost Effectiveness Analysis of Strategies for Maternal and Neonatal Health

in Developing Countries have set a conclusion that;

preventive interventions and primary health care at thecommunity level for mothers and newborns are extremely cost


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effective, but the millennium development goals for maternal andchild health wont be achieved without universal access to clinicalservices as well.

Policy makers are guided in the examination of how resources should be

maximized in order to achieve health related Millennium Development Goals. It also

measures whether health in the scope of maternal and neonatal aspect is being

delivered effectively and promptly.

Attaining maternal and neonatal care will be best received not only in the

primary and the community care level. Universal access means access by all people

to all levels of health care. The study also mentions the presence of a skilled

attendant at birth in a health facility. For example, normal delivery care by a skilled

attendant (Adam, et. al, 2005). WHO (1997) affirms that skilled health personnel or

skilled health attendants are such doctors, either specialist or non-specialist, and

persons who acquire midwifery skills. These personnel must be able to detect

obstetrical complications and to facilitate delivery skillfully.

A specific order for neonatal health care has also been made. Administrative

Order no. 2009-0025 of the Department of Health (2009) entitled Adopting New

Policies and Protocol on Essential Newborn Care proposes that correct and

appropriately-timed interventions given to the newborn during this period will benefit

both the newborn and the mother as these will avert approximately 70% of avoidable

newborn deaths. This administrative order that focuses on neonatal deaths is similar

that of the aforementioned and the prioritized administrative order of this study which

is the Administrative Order 2009-0029. Health care providers, as mentioned in AO


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no. 2009-0025, are given systematic guidelines and policies in the implementation of

thorough interventions that will prevent further neonatal deaths.

As stated by Basilio (n.d.), in her presentation Addressing MDG 4 & 5

Through the MNCHN Strategy, reducing the maternal mortality ratio by 75% remains

a difficult challenge. The compliance of the discussed Administrative Order 2008-

0029 must be thoroughly examined in order to ensure the facilitation of medical

services that can reduce further mortality rates among maternal and neonatal

populace.

Maternal and Neonatal Health Care

Maternal Health Care, as stated by the Department of Health Philippines

[DOH] (2000), consists of the care of the woman, her safe delivery, postnatal care

and examination, and the care for her lactation. This renders that in every stage of

pregnancy, the right health care must be catered to ensure the safety and

nourishment of the mother and of the infant.

Maternal health care aids in ameliorating behaviors and knowledge about

pregnancy and pregnancy-related among women, families, and communities that

are essential to the health and the well-being of women (WHO, 1997).

In order for the pregnant woman to be able to carry the infant inside her

womb and to carry herself as well, she needs to be accommodated by a medically

adept health worker to ensure that she will be updated and taken cared of with her

physical, emotional, and social being during pregnancy. Furthermore, it also

provides assistance in the womans well being after the delivery of the infant. This is


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for the fact, that women undergo severe pain during delivery. As the woman cope

with the physical pain and the emotional pressures stricken upon her, she may be

guided accordingly with all the care she must need until delivery.

The first stage of Maternal Health care is the Prenatal Care. According to

Littleton and Engebretson (2002), ...prenatal care allows psychological,

physiological, cultural, and social concerns to be addressed while maternal and fetal

well-being and the overall pregnancy status are monitored simultaneously. Prenatal

care predicts the probable risks posed towards the pregnant woman; ...guides in the

identification of risk factors, danger signs, and to be able to do appropriate

measures (DOH, 2000). At this time, a detailed medical history and physical

examination are completed for baseline data (Littleton and Engebreston, 2002).

Using this historical data, medical health officials will refer to this throughout the

course of the patients pregnancy. The data about the patients history must be

accurate in order for the health attendants to prescribe apt and adequate measures

of medical assistance.

The second stage of Maternal Health is Antenatal Care. WHO (1997)

declares that Antenatal care prescribes the right medical behavior during pregnancy,

helps detect complications, and assigns the step-by-step procedure as to how the

pregnant woman attends to her needs.

The final stage is the postpartum period. Willacy (2013) states that, the

puerperium (postpartum period) covers the 6-week period proceeding birth, during

which time the changes that occurred during pregnancy revert to the non-pregnant

state. Physiological and psychological changes occur in the body of the then


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pregnant woman. Adequate health care is catered during this 6-week period of

postpartum stage.

Quality of Health Care

Health care refers to medical care of myriad goods and services that maintain

improve or restore a persons health, which renders to an individuals physical or

mental well-being. (Santerre & Neun, 2010)

According to the Magna Carta of Patients Rights (2008), the Right to Access

to Quality Public Health Care where:

the patient has the right to functioning public health and healthcare facilities, goods and services and programs needed and sufficientquantity. They shall likewise be provided with health facilities and serviceswith adequate provision of essential drugs, regular screening programs,appropriate treatment of prevalent diseases, illnesses, injuries anddisabilities, including provision of public health insurance. Towards thisend, the government shall, as far as practicable, approximate theinternational standard allocation for the health sector as set by WorldHealth Organization. (Title III, Sec.5, para.1).

With this representation, it allows the patient to be given with complete,

adequate, and quality accommodation by the public health care providing institution

through its available services by its medical or health care practitioners within the

World Health Organizations bounds or standards.

According to Donabedian (1980), the quality of medical services may also be

inconsistent. Quality differences are rendered or reflected in the medical care

institution or providers structure, the process of how things operate, and/or outcome

that is rendered from the overall performance of the medical care provider.


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Structural Quality is reflected in the physical and human resources of the

medical care provider, such as the facilities or to the availability of amenities,

including the medical equipment, personnel training and their experiences, and

administration. Process quality reflects the specific action of health care providers

take on behalf of patients in delivering and following through with care. Process

quality might include access (waiting time), data collection that encompasses from

gathering the background history of the situation of the individual up to its treatment.

Outcome quality refers to the impact of care on the patients health and welfare as

measured by patient satisfaction, work lost to disability or post care mortality rate.

(Santerre & Neun, 2010).

Even with particular guidelines or standards set, there is always a great

chance that those given standards are not met because of lack of power in terms of

human, or facility resources causing faulty or series of loopholes appearing in the

institution that would render certain events of not properly accommodating the

patients needs.

As cited by Baroma et al. (2010), Hospital officials admit that they are forced

to lower admission standards when hiring replacements. Its a tough choice that

hospitals could insist on maintaining standards when hiring new nurses, or kill their

remaining staff with overwork (p.36).

The Philippine General Hospital, the countrys premier training hospital, used

to take applicants with a minimum grade of 90, but now a 75 will do, with the hospital

(p.36).


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In the study of Amoguis et al. (2004), Some hospitals reported that they had

to hire unlicensed nurses or those nurses that have not yet taken the nursing

licensure exams or those fresh graduates to replace those nurses that has years of

experience who have resigned. Other hospitals as have said, reported occurrences

of misbehaving nurses who should have been suspended from their duties, but were

tolerated (p.16).

In some cases, hospital officials spend a huge amount of time in interviewing

and screening health worker applicants as replacements for those who left.

However, shortly after those applicants are oriented, trained and hired, they would

then resign from such position making another tedious cycle in finding other new

applicants to fill in the positions.

Based on the study of Amoguis et al., (2004), 55% of the nurses disliked of

the idea of the abundance in medical facilities and resources. More than 74% stated

and disagreed the idea of the abundance of human resources in Davao Medical

Center (DMC), now Southern Philippines Medical Center (SPMC), due to the lack of

nurses and doctors and other health workers or personnel. According to the studys

respondents, the normal nurse to patient ratio in a day is 1N:30 patients which is

three times greater from that of the ideal which is 1N:10 patients. Some of which are

taking care of 20-25 patients in critical conditions or needs. Because of such, nurses

claim that majority of them cannot serve and give quality care to all the patients

individually due to the lack of financial assistance and hard time experience of failing

to provide enough workers which leads them to take enough creative medical or

under health care assistance.


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The hospitals are large enough to be able to accommodate the huge number

of patients. However, the number of patients could not be fully accommodated due

to limited facilities resulting to loss.

Maternal and Neonatal Condition in the Philippines

According to Romualdez, dela Rosa, Flavier, Quimbo, Hartigan-Go, Lagrada

& David (2011), of grave national and international concern is the relatively high

maternal mortality ratio of 162 per 100 000 live births. Drastically during 2011,

mortality rate for Filipino mothers has increased to 221 per 100,000 live births

(Alave, 2012).

The drastic rise of maternal mortality is alarming, because the 2015 deadline

is almost near. The numbers of deaths implicate poor quality of health care. If

maternal deaths continue to rise continually until 2015, then it is evident that the 4 th

and 5thMDGs are not achieved.

According to the MNCHN Manual of Operations (2011), 55 percent of births

are delivered at home, of which 36 percent are attended to by TBAs or hilots.

Traditional birth attendants are informal care providers of maternal and neonatal

patients who have not received professional medical training. In Davao City, out of

33, 202 live births, 4, 291 live births were delivered by Traditional Birth Attendants

(DOH, 2009). Because of lack of medical training and background of TBAs or hilots,

the quality of health care being delivered is insufficient and unreliable.


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Foreign Programs

A woman dies from complications in childbirth every minuteabout 529 000

each year the vast majority of them in developing countries (United Nations

Childrens Fund [UNICEF], 2014). The uprising number of maternal and neonatal

mortality since the end of the 20thcentury have pushed heads of states of the world

to collectively endorse the Millennium Development Goals 4 and 5. This is to reduce

the continuous increase in maternal and neonatal deaths between 1990 and 2015.

This is due to complications that are difficult to predict, which requires emergency

obstetric response. Hence, access to professional care in gestation period, delivery,

and a month after the delivery is the key to saving these women and children from

unwanted deaths. As a response, UNICEF in partnership with the United Nations

Populations Fund (UNPFA), World Health Organization (WHO) and other partners in

countries with high maternal mortality, have helped in improving the emergency

obstetrics care. These organizations work with policy makers in establishing

emergency obstetrics care as a priority in national health plans of countries having

high maternal and neonatal death rates.

UNICEF also operates through advocacy, technical help and funding, which

enables it to help local communities in providing information to women and their

families with regard to pregnancy complications, on birth spacing, timing and limiting

for nutrition and health, and on improving the nutritional status of pregnant women to

prevent low birth weight or other problems (UNICEF, 2014).

In accordance to the projects initiated by several organizations, a United

States Agency for International Development under HealthGOV program extends its


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arms to the Philippines in the form of an Integrated Maternal, Neonatal, Child Health

and Nutrition and Family Planning project (I-MNCHN/FP) in the island of Luzon. This

technical assistance will help increase demand for and supply for maternal,

neonatal, child health, and nutrition (MNCHN) and family planning (FP) services.

HealthGOV aims to strengthen the capacity of local government units (LGUs) in

planning, providing, managing maternal, newborn, child health, and nutrition

(MNCHN) services. Relative to the improvement of emergency obstetrics care, the

project also focuses on health systemsincluding health management budgeting,

and planning. This improves delivery of health services, ensures health financing

and widens health insurance coverage nationwide, renders contraceptive security

and management of logistics, promotes civil society engagement, and refines data

quality and health information system. The project worked in more than 600 LGUs in

25 provinces across Luzon, Visayas, and Mindanao regions (Research Triangle

Institute [RTI], 2014).

Philippine Government Agencies

The Department of Health (DOH) led the national implementation of

improving health care and services especially to improve the general health status of

the population by reducing maternal and infant mortality rate through increasing

venture or investment for primary health care, the AO 2008-0029, administering the

Maternal Neonatal and Child Health and Nutrition Strategy. As the DOHs initiative in

the fulfillment of the Millennium Development Goals 4 and 5; these continuous


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efforts of the Philippines Government will be adapted by Philippine hospitals in the

form of Maternal, Neonatal and Child Health and Nutrition (MNCHN) strategies.

The Department of Healths Maternal, Newborn, and Child Health and

Nutrition (MNCHN) strategy identifies the population that is at risk and is in need of

examination within a particular area, renders the services needed by the patients in

the area, and examines the efficiency of Department Of Health central office units,

the Centers for Health Development, Local Government Units and other partners in

implementing the strategy.

The Millennium Development Goals 4 and 5 are the main goals in which the

United Nations and the rest of the world want to optimally achieve. Literature related

to the reduction of child mortality and the improvement of maternal health was

provided by the UN as bearers of the goals. Directly having cause and effect to one

another, womens rights to health is sustained by Goals 4 and 5. Connecting the

rights of women to health is the maternal and neonatal health care. Under the

specifics of maternal and neonatal care, the quality of health care follows. Below it is

the maternal and neonatal conditions of the Philippines. The former suggests the

ideal quality of health care, while the latter states the real situations of the countrys

maternal and neonatal aspects. The maternal and neonatal conditions of the

Philippines directly connect with MDGs 4 and 5. The MDGs 4 and 5 immediately

precedes foreign programs, because the United Nations work internationally. These

foreign programs are efforts of other countries in reducing maternal and neonatal

mortality. Philippine government agencies come after foreign programs, which in

turn greatly affects the quality of health care in the country.


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RRL MAP

Millennium

Development Goals 4& 5

United Nations, (n.d.)

Foreign ProgramsUNICEF (2014)

Research Triangle

Institute (2014)

PhilippineGovernment

AgenciesDOH

Womens Right to HealthMagna Carta for Women (2009)

Adam, T., et al (2005)Basilio, J. (n.d.)

WHO (1997)AO 2009-0026 (2009)

Maternal and Neonatal HealthCare

Department of Health (2000)WHO (1997)Littleton, L.Y., & Engrebretson,

J.C. (2002)Willacy, H. (2013)

Quality of Health CareSanterre, R. & Neun S. (2010)

Magna Carta of PatientsRights (2008)

Donabedian, A. (1980)Baroma, E., et al (2010)

Amoguis, A., et al (2004)

Maternal and NeonatalConditions in the

PhilippinesRomualdez, et al (2011)

Alave, K. (2012)


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Chapter 3

METHODOLOGY

This chapter presents the methodology in conducting the study, which

includes the research design, locale of the study, unit of analysis, data collection,

variables and measures, data analysis and ethical considerations.

Research Design

This study is descriptive in design, quantitative in approach. The study

wanted to know the level of knowledge, extent of compliance, and attitudes of health

workers particularly nurses, midwives and physicians on their respective barangay

health stations to Administrative Order 2008-0029.

Locale of the Study

This study will be conducted within the Davao Region, specifically Davao City.

Located in the province of Davao del Sur, It is one of the major business hubs in

Mindanao because of its favorable environment for trade and commerce, making its

local conditions conducive for rapid development of the Citys quality of liv ing,

specifically health care.

With 16 district health offices, Davao City has a total number of 114 Barangay

Health Stations/Centers, but ironically, maternal mortality ratio in Davao City is

comparably higher than that of Davao del Sur, Davao Oriental and Compostela

Valley. This was according to the National Statistical Coordination Board XI (2013),


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when they said that Davao with a baseline of 46.6 during 1990; it aims to reduce the

rate by three-quarters, making its target 11.7 by the year 2015. But as of 2012, the

rate only declined by at least 7.7, making it only 38.9.

Unit of Analysis

The selection of respondents is being guided by the following criteria:

1.) Health practitioners who are attending on maternal and neonatal patients,

regardless of their age.

2.) Health practitioners who are willing to answer the provided survey questions.

3.) Health practitioners who practice their profession for at least one year.

4.) Health practitioners must be residing within Davao City.

Sampling Procedure

The study will make use of a multi-stage probability sampling. Wherein the

first stage will include the three districts of Davao City; the second stage will identify

1 urban baranggay per sub-district, and third stage will take BNHS practitioners as

respondents through simple random sampling.


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Variables and Measures

Variables Measures

Profile of Respondents

Socio-demographic Profile:

1. Age2. Sex3. Religion4. Highest educational attainment

Economic Profile:

5. Job Description6. Years of Practice7. District Assignment

Levels of knowledge of health

practitioners of District 1 main healthcenters regarding AO 2008-0029 Yes or No

What is the extent of compliance ofhealth practitioners on AdministrativeOrder 2008-0029 in terms of humanresource, logistics and services?

Never, Sometimes, Most Often, Always

Attitudes towards AO 2008-0029 Strongly Disagree, Disagree, Agree,Strongly Agree

Research Instrument

The researchers will utilize survey questionnaires with the use of a structured

interview schedule as their research instrument in the conduct of the study.


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Data Collection

To test the validity and usability of the instrument, the researchers will

conduct a pre-test of the instrument prior writing a request letter addressed to the

medical institutions, asking for an authorization to conduct the study. Granted that

the request letter will be approved, the researchers will immediately procure a list of

maternal and neonatal health practitioners from the district. After which, they will be

scheduled for a face-to-face, structured interview schedule relative to the availability

of their time.

The researchers will utilize the E-W-E method as their framework in

conducting the interview. The said method has 3 basic ways that the researchers will

use in initiating their interview.

With the E-W-E already equipped, the researchers Explains to the

respondents the purpose of the study, Why are they chosen for the study, and the

Expected duration of the interview.

Data Analysis

Given that this research is quantitative, The researchers will utilize the

Analysis of Variance (ANOVA) as their statistical tool in determining whether there is

a significant difference among the three districts health station practitioners in their

socio-economic profiles, levels of knowledge, extent of compliance and attitudes

towards the AO 2008-0029.


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Ethical Considerations

With the respondents list identified, the researchers will ask the enlisted

health workers consent for an interview. They will be informed about the rationale

behind the study and the reason why they are chosen as respondents. Upon the

approval of the said practitioners, names will be kept confidential if they wish not to

reveal their names. It is also on the discretion of the respondent on which mode of

dialect he or she will be interviewed. In an event that the respondent does not wish

to answer some questions, the researchers will leave it as is unanswered. Like the

health practitioners, the researchers must also secure the confidentiality of the

health practitioners identity with regard to their economic profile and highest

educational attainment. If the patients manifest consent, only then names are

included in the data. The researchers must be flexible with their respondents. This

means that the researchers will attend to the respondents, in which the former will

get information in the best and most comfortable time, place, and manner from and

for the latter.


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REFERENCES:

Adam, T., Lim, S.S., Mehta, S., Bhutta, Z.A., Fogstad, H., Mathai, M., Zupan, J., andDarmstadt, G.L. (2005). Achieving the Millennium Development Goals forHealth: Cost Effectiveness Analysis of Strategies for Maternal and Neonatal

Health in Developing Countries. Retrieved on January 30, 2014 fromhttp://www.bmj.com/content/331/7527. Alave,K. (2012). Maternal Mortality rate rose in 2011, says DOH. Philippine Daily

Inquirer. Retrieved on January 29, 2014 fromnewsinfo.inquirer.net/214829/maternal-mortality-rate-rose-in-2011-says-doh.

Amoguis, A., Castillo, M.C., Etulle, G., Villaviray, M.N., Yap, M. (2004). A Study onSelected Health Care Characteristics of a Private and a Public Hospital inDavao City.

Baroma, E., Delos Reyes, M.V., Jambangan, A.D.C., Quibo, G., Victoriano, J.(2010), LINGAP: A Study on the Watchers Perceptions and Experiences ofthe Elderly Patients on their Right to Health in the Southern Philippine

Medical Center (SPMC).Basilio, J. (n.d.). Addressing MDG 4 & 5 Through the MNCHN Strategy. Manila,Philippines: Department of Health. Retrieved January 29, 2014 fromadpcn.org/downloads/AddressingMDG45.pdf

Burnard, P.(1991). Counseling Skills for Health Professionals. Cheltenham: NelsonThornes.

Capon, C. R. (2014, February 15). Failure to Meet MDG: Maternal Mortality RemainsHigh. EdgeDavao. Retrieved on March 19, 2014 fromhttp://www.edgedavao.net/index.php?option=com_content&view=article&id=14397:failure-to-meet-mdg-maternal-mortality-remains-high&catid=68:the-big-news&Itemid=96.

Davao City Health Office (2011) Health District Profile. Davao City: Philippines.Retrieved on March 12, 2014 fromhttp://davaohealth.brinkster.net/HealthDistrictProfile.asp

Department of Health (2009). The 2009 Philippine Health Statistics Department.Manila: Philippines. Retrieved on March 11, 2014 fromwww.doh.gov.ph/.../PHILIPPINE%20HEALTH%20STATISTICS%2020

Donabedian, A. (1980). Explorations in Quality Assessment and Monitoring: TheDefinition of Quality and Approches to its Assessment, 1. Health

Administration Press.Gruskin, S., Cottingham, J., Hilber, A.M., Kismodi, E., Lincetto, O., & Rosemand,

M.J. (2008). Using human rights to improve maternal and neonatal health:history, connections and a proposed practical approach.Retrieved February6, 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649451/

Littleton, L.Y., Engebretson, J.C. (2002). Maternal, Neonatal, and WomensNursing. Albany, New York: Delmar Thompson Learning.

National Statistical Coordination Board XI (2013), Region XI MDG Watch. Retrievedon March 12, 2014 from http://www.davao.gov.ph

National Statistics Office (2007). Demography of Davao City. Retrieved on February12, 2014 from http://www.davaocitygov.ph/davao/demography.aspx
http://www.bmj.com/content/331/7527http://davaohealth.brinkster.net/HealthDistrictProfile.asphttp://www.doh.gov.ph/.../PHILIPPINE%20HEALTH%20STATISTICS%2020http://www.davaocitygov.ph/davao/demography.aspxhttp://www.davaocitygov.ph/davao/demography.aspxhttp://www.doh.gov.ph/.../PHILIPPINE%20HEALTH%20STATISTICS%2020http://davaohealth.brinkster.net/HealthDistrictProfile.asphttp://www.bmj.com/content/331/7527


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National Economic and Development Authority (2011). Davao RegionalDevelopment Plan 2011-2016. Davao City: Philippines. Retrieved on March12, 2014 from www.neda.gov.ph/wp-content/uploads/.../RegXI_RDP_2011-2016.pdf

Research Triangle Institute. (2014). RTI International: Global Health Projects:

Philippines. Retrieved January 27, 2014 fromhttp://www.rti.org/page.cfm?obj=47224CB2-7F5D-4F8E-86E6D72A30C78FF4Reyala, J. P., & National League of Philippine Government Nurses. (2000).

Community health nursing services in the Philippines. Manila . Philippines:Community Health Nursing Section, National League of PhilippineGovernment Nurses, Inc.

Romualdez, A., dela Rosa, J., Flavier, J., Quimbo, S., Hartigan-Go, K., Lagrada, L. &David, L. (2011). The Philippines Health System Review (Health Systems inTransition, Vol. 1 No. 2). Geneva, Switzerland: The World HealthOrganization.

Santerre, R., & Neun, S. (2010). Health Economics: Theory, Insights, and Industry

Studies (5

th

ed.). US: South-Western, Cengage Learning.Umil. A. M. (2013, April 09). Banning home births to worsen, not improve maternaldeath rate health groups. Bulatlat. Retrieved on March 19, 2014 fromhttp://bulatlat.com/main/2013/04/09/banning-home-births-to-worsen-not-improve-maternal-death-rate-health-groups/.

Umusig, E., Cayogyog, A., Miraflores, Z.(2012). Regional Health Research andDevelopment Consortium XI: Activity Report for the Agenda Setting onMaternal and Child Health. Davao City, Philippines.

United Nations Childrens Fund (n.d.). UNICEF Goal: Improve Maternal Health.Retrieved January 27, 2014 from http://www.unicef.org/mdg/maternal.html

United Nations Childrens Fund (2008). THE STATE OF THE WORLDS CHILDREN2009 unite for children Maternal and Newborn Health. New York, USA: UnitedNations Childrens Fund. Retrieved January 6, 2014, fromwww.unicef.org/sowc2013/report.html

United Nations Human Rights Council(2009). Resolution 11/8. Preventablematernal mortality and morbidity and human rights.New York, USA: UNHuman Rights Council.Retrieved February 6, 2014 fromhttp://ap.ohchr.org/documents/E/HRC/resolutions/A_HRC_RES_11_8.pdf

United Nations (n.d.). Millennium Development Goals (MDGs). Retrieved January26, 2014, from http://www.un.org/documents/ga/res/55/a55r002.pdf

United Nations. (n.d.). Millennium Development Goals. Retrieved from January 29,2014 from http://www.un.org/millenniumgoals/bkgd.shtml.

United Nations Population Fund (2006). Maternal and Neonatal Healthin East and South-East Asia.Bangkok, Thailand: UNFPA Country TechnicalServices Team. Retrieved January 28, 2014, fromwww.unfpa.org/upload/lib_pub_file/613_filename_bkmaternal .pdf

Willacy, H. (2013). Postnatal Care (Puerperium). Retrieved on January 29, 2014from www.patient.co.uk/doctor/postnatal-care-puerperium.
http://www.unicef.org/mdg/maternal.htmlhttp://ap.ohchr.org/documents/E/HRC/resolutions/A_HRC_RES_11_8.pdfhttp://www.un.org/documents/ga/res/55/a55r002.pdfhttp://www.un.org/millenniumgoals/bkgd.shtmlhttp://www.un.org/millenniumgoals/bkgd.shtmlhttp://www.un.org/documents/ga/res/55/a55r002.pdfhttp://ap.ohchr.org/documents/E/HRC/resolutions/A_HRC_RES_11_8.pdfhttp://www.unicef.org/mdg/maternal.html


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World Health Organization [WHO].(1997). Coverage on maternal care. A listing ofavailable information (4th ed.). Geneva, Switzerland: World HealthOrganization


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Levels of Knowledge, Extent of Comp l iance and A tt i tudes of Baranggay Health

Station Practi t ion ers on Admin istrative Order 2008-0029

Date of Survey:

I. Profile of the respondent.

A. Socio-Demographic Profile

1. Sex: _____ Male _____ Female

2. Age:_____ 20 and below _____ 41-50_____ 21-30 _____ 51-60_____ 31-40 _____ 61 and beyond

3. Religion:_____ Roman Catholic_____ Protestant_____ Others, specify: ________

4. Highest Educational Attainment (School and Place):a. Tertiary: _____________________________________b. Graduate School: __________________________________

i. Year completed: _______

B. Economic Profile as a Health Practitioner

1. Job Description:_____ Doctor_____ Midwife_____ Nurse

2. Years of Practice: ___

3. Sub-district Assignment:_____ District 1_____ District 2_____ District 3


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II. Levels of knowledge of healthcare practitioners about AO 2008-0029

Statement Yes No

1. MDG 4&5 aims to reduce maternal and neonatal mortality by 2015

2. The AO 2008-0029 aims to address maternal and neonatal mortalityrate reduction in the Philippines

3. Activities regarding the AO 2008-0029 include the activeinvolvement of the healthcare workers.

4. The traditional birth attendants (TBAs) are included based on thedefinition of a skilled birth attendant

5. The rural-urban gap in skilled care during childbirth can be narrowedthrough achievement of MDG 4&5 addressed in AO 2008-0029

6. One of the challenges faced by the health community is the lack ofhealthcare workers in hard-to-reach areas in Davao City

7. Progress in expanding the use of contraceptives by women hasslowed down.

8. Poverty and lack of education result to high adolescent birth rates

9. Use of contraception is lowest among the poorest women and thosewith lack of education

10. Large disparities in giving budget allocation from the government aresome of the challenges that are being faced by the healthcarecenters.

III. Extent of compliance of maternal and neonatal practitioners on AO 2008-0029

HUMAN RESOURCE

StatementsNever(01)

Some-times(02)

MostOften(03)

Always(04)

1. There is an enough number of healthprofessionals in the institution to cater allmaternal and neonatal issues

2. There are catchments that cater at least 2barangay health stations3. The health needs of women, mothers, andchildren are adequately assessed.

5. The mothers receive holistic care (e.g.Pain relief, repair of laceration, andcounseling) from sufficient number ofattendants after she has given birth.

6. The essential newborn care services arehelpful in detecting further complicationsduring post-delivery.


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LOGISTICS

Statements NeverSome-times

MostOften

Always

1. There is proper administration in theinstitution2. There are not enough facilities to cater thedemands of maternal and neonatal issues3. There is no proper execution of services inthe institution

4. There is proper coordination between thecatchments of barangay health stations.

5. The support services are being deliveredon time, such as birth plan, home visit, andsafe blood supply.

SERVICES

Pre-Pregnancy


MostOften

Always

1. Provides maternal nutrition (vitamins)

2. Provides Family Planning services3. Provides counseling on healthy lifestyle/s

4. Provides information on health caring andseeking behavior

5. Facilitates prevention and management ofother diseases (e.g. STI, HIV, etc)

Pregnancy


MostOften

Always

1. Provision of essential antenatal care

2. Giving of maternal nutrition

3. Information on health caring and seekingbehavior (e.g. Support Services,Diagnostic/Screening Tests)

4. Counseling on healthy lifestyle

5. Facilitates in prevention and managementof other diseases (e.g. STI/ HIV, Anemia,etc)


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Delivery


MostOften

Always

1. Facilitates clean and safe delivery

2. Delivering of Basic emergency obstetricand newborn care

3. Delivering of comprehensive emergencyobstetric care

4. Care of the preterm babies and/or lowbirth weight babies

5. Counseling and provision of bilateral tuballigation (BTL) services

Post-Delivery

Statements NeverSome-

times

Most

Often

Always

1. Identifying of early signs and symptoms ofpostpartum complications (e.g. Hemorrhage,infection, and hypertension)2. Prescribing of maternal nutrition

3. Counseling on family planning (e.g. Birthspacing, modern family, planning methods)

4. Counseling on healthy lifestyle (e.g. Safersex and HIV/STI prevention, smokingcessation, healthy diet and nutrition, andphysical activity)5. Prevention and management of other

diseases (eg. STI/HIV/AIDS, Anemia)6. Prevention and management of abortioncomplications

7. Removal of retained products ofconception

8. Treatment of Infection

IV. Attitudes of maternal and neonatal practitioners in compliance toward AO2008-0029

StatementsStronglyDisagree

Disagree AgreeStrongly

Agree

1. The AO 2008-0029 has contributed to theefficiency of the institutions delivery of itsservices2. The AO 2008-0029 has not led thereduction of maternal and neonatal mortalityin the area


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3. I make it a point to follow all theguidelines provided by the AO 2008-0029

4. I can not see the significance of the AO2008-0029 on the reduction of maternal andneonatal mortality

5. I believe Traditional Birth Attendants or

hilots can help reduce maternal andneonatal mortality

6. I can maximize materials in the facilitybecause of the Administrative Order 2008-0029

7. I find the facility a clean and conduciveenvironment for its patients

8. I find the protocols of AO 2008-0029 tobe hindering my optimal work ethics9. I like working in this facility

10. I feel that my patients are satisfied withthe services the facility gives.

V. Suggestions

1. What are effective suggestions or recommendations as to how the AO 2008-0029 can be improved?

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