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


2

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.


3

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 neonatal
deaths such as delay in identification of complications, delay in referral, and delay
in 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.


4

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.


5

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 of 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


6

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



7

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


8

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.






9

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.
Compliance refers 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 Practitioners refer to the attending skilled midwives, nurses and physicians.
Level of knowledge pertains to the depth of input idea of the respondents regarding
AO 2008-0029.
Socio-demographic profile refers 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 4
th
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 4
th
, the 5
th
MDG targets the reduction of maternal mortality ratio. The


11

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 Health in 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 the
community level for mothers and newborns are extremely cost


12

effective, but the millennium development goals for maternal and
child health wont be achieved without universal access to clinical
services 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


13

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


14

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


15

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 health
care facilities, goods and services and programs needed and sufficient
quantity. They shall likewise be provided with health facilities and services
with adequate provision of essential drugs, regular screening programs,
appropriate treatment of prevalent diseases, illnesses, injuries and
disabilities, including provision of public health insurance. Towards this
end, the government shall, as far as practicable, approximate the
international standard allocation for the health sector as set by World
Health 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.


16

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).


17

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.


18

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 5
th
MDGs 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.




19

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 20
th
century 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


20

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


21

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.


22

RRL MAP


























Millennium
Development Goals 4
& 5
United Nations, (n.d.)
Foreign Programs
UNICEF (2014)
Research Triangle
Institute (2014)
Philippine
Government
Agencies
DOH
Womens Right to Health
Magna Carta for Women (2009)
Adam, T., et al (2005)
Basilio, J. (n.d.)
WHO (1997)
AO 2009-0026 (2009)

Maternal and Neonatal Health
Care
Department of Health (2000)
WHO (1997)
Littleton, L.Y., & Engrebretson,
J.C. (2002)
Willacy, H. (2013)
Quality of Health Care
Santerre, R. & Neun S. (2010)
Magna Carta of Patients
Rights (2008)
Donabedian, A. (1980)
Baroma, E., et al (2010)
Amoguis, A., et al (2004)
Maternal and Neonatal
Conditions in the
Philippines
Romualdez, et al (2011)
Alave, K. (2012)


23

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 living,
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),


24

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.








25

Variables and Measures
Variables Measures
Profile of Respondents
Socio-demographic Profile:

1. Age
2. Sex
3. Religion
4. Highest educational attainment

Economic Profile:

5. Job Description
6. Years of Practice
7. District Assignment
Levels of knowledge of health
practitioners of District 1 main health
centers regarding AO 2008-0029
Yes or No
What is the extent of compliance of
health practitioners on Administrative
Order 2008-0029 in terms of human
resource, 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.







26

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.




27

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.










28

REFERENCES:
Adam, T., Lim, S.S., Mehta, S., Bhutta, Z.A., Fogstad, H., Mathai, M., Zupan, J., and
Darmstadt, G.L. (2005). Achieving the Millennium Development Goals for
Health: Cost Effectiveness Analysis of Strategies for Maternal and Neonatal
Health in Developing Countries. Retrieved on January 30, 2014 from
http://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 from
newsinfo.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 on
Selected Health Care Characteristics of a Private and a Public Hospital in
Davao 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 of
the 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 from
adpcn.org/downloads/AddressingMDG45.pdf
Burnard, P.(1991). Counseling Skills for Health Professionals. Cheltenham: Nelson
Thornes.
Capon, C. R. (2014, February 15). Failure to Meet MDG: Maternal Mortality Remains
High. EdgeDavao. Retrieved on March 19, 2014 from
http://www.edgedavao.net/index.php?option=com_content&view=article&id=1
4397: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 from
http://davaohealth.brinkster.net/HealthDistrictProfile.asp
Department of Health (2009). The 2009 Philippine Health Statistics Department.
Manila: Philippines. Retrieved on March 11, 2014 from
www.doh.gov.ph/.../PHILIPPINE%20HEALTH%20STATISTICS%2020
Donabedian, A. (1980). Explorations in Quality Assessment and Monitoring: The
Definition 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 February
6, 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649451/
Littleton, L.Y., Engebretson, J.C. (2002). Maternal, Neonatal, and Womens
Nursing. Albany, New York: Delmar Thompson Learning.
National Statistical Coordination Board XI (2013), Region XI MDG Watch. Retrieved
on March 12, 2014 from http://www.davao.gov.ph
National Statistics Office (2007). Demography of Davao City. Retrieved on February
12, 2014 from http://www.davaocitygov.ph/davao/demography.aspx


29

National Economic and Development Authority (2011). Davao Regional
Development Plan 2011-2016. Davao City: Philippines. Retrieved on March
12, 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 from
http://www.rti.org/page.cfm?obj=47224CB2-7F5D-4F8E-86E6D72A30C78FF4
Reyala, 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 Philippine
Government 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 in
Transition, Vol. 1 No. 2). Geneva, Switzerland: The World Health
Organization.
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 maternal
death rate health groups. Bulatlat. Retrieved on March 19, 2014 from
http://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 and
Development Consortium XI: Activity Report for the Agenda Setting on
Maternal 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 CHILDREN
2009 unite for children Maternal and Newborn Health. New York, USA: United
Nations Childrens Fund. Retrieved January 6, 2014, from
www.unicef.org/sowc2013/report.html
United Nations Human Rights Council (2009). Resolution 11/8. Preventable
maternal mortality and morbidity and human rights. New York, USA: UN
Human Rights Council. Retrieved February 6, 2014 from
http://ap.ohchr.org/documents/E/HRC/resolutions/A_HRC_RES_11_8.pdf
United Nations (n.d.). Millennium Development Goals (MDGs). Retrieved January
26, 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 Health
in East and South-East Asia. Bangkok, Thailand: UNFPA Country Technical
Services Team. Retrieved January 28, 2014, from
www.unfpa.org/upload/lib_pub_file/613_filename_bkmaternal.pdf
Willacy, H. (2013). Postnatal Care (Puerperium). Retrieved on January 29, 2014
from www.patient.co.uk/doctor/postnatal-care-puerperium.


30

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












































31

Levels of Knowledge, Extent of Compliance and Attitudes of Baranggay Health
Station Practitioners on Administrative 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






32


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 mortality
rate reduction in the Philippines


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


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


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


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


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


8. Poverty and lack of education result to high adolescent birth rates
9. Use of contraception is lowest among the poorest women and those
with lack of education


10. Large disparities in giving budget allocation from the government are
some of the challenges that are being faced by the healthcare
centers.




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


HUMAN RESOURCE
Statements
Never
(01)
Some-
times
(02)
Most
Often
(03)
Always
(04)
1. There is an enough number of health
professionals in the institution to cater all
maternal and neonatal issues

2. There are catchments that cater at least 2
barangay health stations

3. The health needs of women, mothers, and
children are adequately assessed.

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

6. The essential newborn care services are
helpful in detecting further complications
during post-delivery.



33



LOGISTICS
Statements Never
Some-
times
Most
Often
Always
1. There is proper administration in the
institution

2. There are not enough facilities to cater the
demands of maternal and neonatal issues

3. There is no proper execution of services in
the institution

4. There is proper coordination between the
catchments of barangay health stations.

5. The support services are being delivered
on time, such as birth plan, home visit, and
safe blood supply.



SERVICES

Pre-Pregnancy
Statements Never
Some-
times
Most
Often
Always
1. Provides maternal nutrition (vitamins)
2. Provides Family Planning services
3. Provides counseling on healthy lifestyle/s
4. Provides information on health caring and
seeking behavior

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






Pregnancy
Statements Never
Some-
times
Most
Often
Always
1. Provision of essential antenatal care
2. Giving of maternal nutrition
3. Information on health caring and seeking
behavior (e.g. Support Services,
Diagnostic/Screening Tests)

4. Counseling on healthy lifestyle
5. Facilitates in prevention and management
of other diseases (e.g. STI/ HIV, Anemia,
etc)




34


Delivery
Statements Never
Some-
times
Most
Often
Always
1. Facilitates clean and safe delivery
2. Delivering of Basic emergency obstetric
and newborn care

3. Delivering of comprehensive emergency
obstetric care

4. Care of the preterm babies and/or low
birth weight babies

5. Counseling and provision of bilateral tubal
ligation (BTL) services



Post-Delivery
Statements Never
Some-
times
Most
Often
Always
1. Identifying of early signs and symptoms of
postpartum complications (e.g. Hemorrhage,
infection, and hypertension)

2. Prescribing of maternal nutrition
3. Counseling on family planning (e.g. Birth
spacing, modern family, planning methods)

4. Counseling on healthy lifestyle (e.g. Safer
sex and HIV/STI prevention, smoking
cessation, healthy diet and nutrition, and
physical activity)

5. Prevention and management of other
diseases (eg. STI/HIV/AIDS, Anemia)

6. Prevention and management of abortion
complications

7. Removal of retained products of
conception

8. Treatment of Infection


IV. Attitudes of maternal and neonatal practitioners in compliance toward AO
2008-0029

Statements
Strongly
Disagree
Disagree Agree
Strongly
Agree
1. The AO 2008-0029 has contributed to the
efficiency of the institutions delivery of its
services

2. The AO 2008-0029 has not led the
reduction of maternal and neonatal mortality
in the area



35

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

4. I can not see the significance of the AO
2008-0029 on the reduction of maternal and
neonatal mortality

5. I believe Traditional Birth Attendants or
hilots can help reduce maternal and
neonatal mortality

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

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

8. I find the protocols of AO 2008-0029 to
be hindering my optimal work ethics

9. I like working in this facility
10. I feel that my patients are satisfied with
the 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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