by AVIGAIL M. OLARTE

VALLEHERMOSO, CARMEN, BOHOL — Had she been in the same situation eight years ago, Jesusa Panes would have probably just given birth at home, even without her husband in sight, and even if her neighbor the hilot (traditional birthing attendant) happened to be drunk. But things have not been the same for expectant mothers in this town since 2002, and so when the child in her belly starting demanding to be let out, Panes began trudging toward the birthing center that was several minutes away by foot from her home.

	THESE days, mothers like Lilia Angcog can give birth for only P500. [photo by Avie Olarte]

The drunken hilot did his duty by swaggering behind her, seeing to it that she got to the center safely. Carmen is in fact the only town in Bohol that has legislated that all mothers must give birth at designated birthing facilities in five barangays or at the town’s birthing center (rural health unit or RHU), a P2.5-million, sprawling facility that offers first-class service for very low fees. Carmen’s laws also say a hilot should bring laboring mothers to the nearest birthing clinic to ensure a comfortable and safe delivery. And even if a hilot is trained, he or she cannot aid in a delivery, unless a midwife sits nearby to oversee the process.

The result of such legislation has been practically no maternal death in Carmen’s 29 barangays in the last five years, save for one in 2006. According to Dr. Josephine Jabonillo, Carmen’s municipal health officer (MHO), that unfortunate mother-to-be tried to deliver at home, with her father-in-law as the hilot. The father-in-law turned out to be untrained; the woman hemorrhaged to death.

“Most maternal deaths can be prevented,” says Jabonillo, an obstetrician/gynecologist. “Mothers all over the world die due to the same major complications of pregnancy: hemorrhage, hypertension, sepsis, and unsafe abortion.”

	Location map of Carmen, Bohol courtesy of Wikipedia

Globally, women continue to die due to complications of pregnancy and childbirth at a rate of one per minute. The limited progress in making motherhood safer is more alarming in developing countries, where 99 percent of maternal deaths occur every year. Here in the Philippines, about 10 to 12 women die every day due to pregnancy-related causes. The government has even admitted that it may not meet its commitment to achieve Millennium Development Goal (MDG) Number 5 — to drastically reduce the number of maternal deaths — by 2015.

And yet here is this town of 41,519 people that has been demonstrating just how far better local governments can be at keeping mothers healthy. Aside from its innovative laws regarding maternal health, Carmen also has what it calls the Enhanced Safe Motherhood Program (E-SM), which not only pushes for a RHU-based delivery, but also includes a pre-natal assessment, monthly check-ups, access to medicines, and other maternal health services — all for a nominal fee.

TO FULLY appreciate what Carmen has accomplished so far, consider this: as late as 2005, the proportion of births attended by skilled health workers nationwide stood at 63.7 percent. In 2006, meanwhile, the national maternal mortality rate — the number of deaths per 100,000 live births — was 162. To be considered as having met MDG No. 5, the Philippines has to have all births attended by skilled health workers by 2015, as well as have reduced the maternal mortality rate to 52.3.

This predominantly agricultural town with more than half of its people living under the poverty line has managed to best those numbers — and how.

Yet even up close, there seems to be nothing that can make Carmen stand out among other rural towns across the Philippines. There are the small town center that passes for its urban area and a collection of dusty barangays. There are some cars and jeepneys and a lot of motorcycles. And just like any other Philippine town, there are children — lots of them — scampering about in the streets.

Then again, there is that birthing center, a 10-bedroom facility that is complete with delivery tables and laboratory equipment and can top the services of any hospital in this province some 800 kms south of Manila. Completed in 2006, it won a Sentrong Sigla Award (Center for Vitality) the very next year. According to the Department of Health (DOH), it is one the best rural health units in the country.

	For the past five years, Carmen has had no maternal deaths except for one in 2006. Credit that to its award-winning rural health unit, which is complete with bedrooms, delivery tables, and laboratory facilities. [photo by Avie Olarte]

Building a good facility was on top of Jabonillo’s list when she became the town’s health officer in 2002. But she says it was no easy task, recalling that she had to first lobby hard with the local government officials.

“Carmen at the time had a very high record of maternal death,” Jabonillo recounts, “So I told the mayor we had to address it.”

Although the E-SM was Jabonillo’s idea, the local health board (headed by the mayor, and with Jabonillo, a councilor, and a nongovernmental organization representative as members) helped craft the program.

Jabonillo says that the town records revealed that the maternal deaths in Carmen were often caused by unhygienic and improper birth delivery practices. She also noted that there were also few skilled birth attendants, while women barely had access to pre-assessed normal delivery from the provincial hospitals.

These days, aside from the main one in the town center, five of Carmen’s barangays have birthing facilities. There are no doctors in these centers, but a midwife is usually on call, along with an army of barangay health workers; should any complications arise, an ambulance (Carmen has six) can be dispatched to bring the pregnant woman to the RHU.

But convincing the women to try the services of these clinics proved difficult. For one, the women thought they would be charged high rates. For another, they were simply more used to the hilot, some of whom even discouraged the pregnant women from going to the RHU. (This is, after all, a country where half of births still occur at home, and a third assisted by hilots. In Bohol, 17 percent of all the births in 2006 were aided by trained and untrained hilots, most or 53 percent are assisted by midwives.)

On E-SM’s first year, the RHU had a total of only eight deliveries. But by 2006, which was also the year the council passed the ordinance banning trained hilot from delivering babies, about 400 women ended up giving birth in the town facility.

“Maternal and birth complications were reduced to 50 percent,” Jabonillo says, leading to Carmen’s near-zero maternal death record.