By Kerrianne Gifford
REAL MUNICIPAL (population 27,000) is in the Province of Quezon about four hours drive away from Manila. The spoken languages are Tagalog and English. Last year ICM delegates, Jane Evans, Betty-Ann Daviss, Anne Frye and I were lucky to visit for one day. I returned for three weeks in March 2000.
Edna Beguia is one of the province's Community or Rural Health Midwives and had become my friend through correspondence. She encouraged me to come and stay. Annie Lester, another ARM member had already stayed there for six weeks after the ICM conference and I'd had a postcard from her saying that being in Real had been a most amazing time for her. Annie and I have since caught up since my return and we are both fully enchanted by the place and will be returning again next year, hopefully. Maybe others will come with us as the people there love visitors. There is much to share with one another.
How do you paint a picture of a lush tropical paradise on the edge of the Pacific ocean where people are faced with the overwhelming challenges of little money, little employment, some scary problems like rabies and TB, no welfare system and only minimal access to very basic free health care, yet an intact community where much fun and joy and banter is happening continually? There is a road system beside the ocean front but none into the mountains (only walking paths). Most children attend primary and high
school. Postal and civil services are functioning well and do not appear to be corrupted. Perhaps it is because the food is fantastic in the form of plentiful rice, fish, chicken and tropical fruit and veg, and there is a very safe water supply and add the dancing and fiestas that mostly everybody seems very well in Real.
There are about six villages and each has a Rural Health midwife. The government midwives are paid 6,000 pesos or œ100 a month. This is a very low wage. The private midwives are paid about 1,000 pesos per birth by the women. Private midwives exist as there is no government posts for them. These midwives are called upon when the government midwife is not available or because the women prefer one over the other.
The Beguia family is full of midwives. Edna's mother, Lola Hosta (Lola is word for granny) is a traditional private midwife who has attended thousands of birth and has never had a maternal death. She has an extensive knowledge of herbs. Edna has a degree in Midwifery and did part of her education in a hospital in Manila where she could attend anything up to 16 births in a shift. In more than 20 years as a midwife she too has never had a maternal death in her village. She has nearly died herself at the hands of machine gun fire many years ago but she said that praying saved her. Edna does many things including all gynaecological screening. Edna's daughters, Ta Ta and Rachel, are also midwives. Ta Ta has delivered many babies already. As a young girl, she used to go with her Lola before she even undertook her diploma. Rachel is newly qualified and has a community health degree as well.
Ta Ta and I went to four home births in my short stay. All the women of the villages give birth in their homes unless the midwives detect any problems pre-natally and make a referral to Manila for further investigation. Often the women cannot afford to go to Manila and the midwives try and find some money for them or attend the woman at home anyway. It seems that the midwives are prepared for and experienced with any eventuality. From an epidemiological perspective I can't give you any confirmed figures. The Beguias' homebirth rate is about 98% and they report (I believe very honestly) no maternal deaths and a small number of IUFD and neonatal deaths. I felt that the women were getting the best possible care in the most challenging of circumstances. It was obvious that the Beguias didn't hesitate to refer when they thought it necessary either by observation or well-honed intuition. PIH and suspected placenta praevia seemed to be the main reasons women were sent to Manila.
Pre-natal clinic is a 'walk-in when you please' affair on Tuesday or Friday mornings in Edna's home (or any other time if you're a worried pregnant woman). The women often come in twos or threes and it's a very social atmosphere. If they come very early, Ta Ta may even do a pre-natal check in her pyjamas (see front cover). Everything is very, very, relaxed except I watched Ta Ta being very precise about her checks - taking blood pressure, abdominal palpation and listening to the foetal heart with her stethoscope. The women let me practise my skills and I got better at using the stethoscope as the women thought my Pinard was a bit odd! No urine analysis was done as the dipsticks are too expensive and not supplied by the government. Neither are sterile gloves or cord clamps - the midwives buy these as well.
The women whose labours were imminent were often visited at home. We travelled on a noisy motorbike with no lights (this was a rather exhilarating experience for me at night time once I had got through the fear barrier). This way I got to meet some of the women before the births and got their permission to attend. They all seemed to be happy about it and it also felt okay to me. I was able to witness two primigravida women give birth, truly normally. Both labours lasted about 12 hours; the midwives attended only once in early labour and then for the last four hours. The women were amazing - labouring in an intense, quiet way. They had no expectation of pain relief. Massage and gentle emotional support were Ta Ta's main midwifery tools to help them. Very few VEs were done and the fetal heart was listened to about hourly. One woman (4' 11") gave birth to a 4 kg baby with ease in three pushes and the 5' woman gave birth to 3.6 kg baby after about an hour of pushing.
I attended two other labours; one woman had six previous live births and a small second twin dying during one labour; her seventh labour was a two hour affair - and all went well. The other woman was having her second baby and here I witnessed the only complication, apparently very rare indeed, a retained placenta. The woman would not travel to Manila and asked Ta Ta to remove it; this was done with prayers and an impressive adeptness under the most basic of circumstances with the woman showing very little sign of discomfort and little bleeding. Ta Ta prescribed antibiotics and it transpired that the woman (even though she could afford them) did not take them as she preferred a herbal mixture her mother made for her. This woman did very well post-natally as did all the others. The birth was during the day.
There was a lot of attention paid to cord care owing to concerns about neonatal tetanus. The women were immunised against this in pregnancy and it is something I feel I need to know a lot more about. All the babies thrived on their mothers' milk and I can't wait to see them next year.
Part of the picture doesn't always lend itself to celebration but rather stoicism. One young woman, newly arrived from a far away mountain village, with five children already was visited by us when we found out about her a few days after the birth of her sixth. None of the midwives had been called for. She birthed by herself in a bare fishing hut. Someone had cut the cord and put ash on to seal it. Ta Ta was worried about neonatal tetanus in this case. When Ta Ta asked "why did you not call the midwife?", the woman answered that she was too embarrassed. It was not certain if this tiny 2 kg baby would survive. Her husband had been ill and they had no money at all. Ta Ta told her that the midwives did not need paying but it is part of the tradition here for the women to give some small amount. Amongst other things, there is mixture of animist, catholic and protestant beliefs informing the culture here but I'm not sure where tipping the government midwife fits! The baby did survive, nursing from her mother, and we managed to pass on a donation to help the family a little.
I brought back lots of photographs and slides including pictures of the babies Annie had seen born in the previous June. More importantly I reconfirmed my belief in womankind's power to give birth without interference and the role of the midwife in supporting this. There are other stories from the Beguias especially where labour did not progress straightforwardly and yet outcomes were still good, and sometimes to me who was listening closely, seemingly miraculous.
The above account is just a small report but I hope you enjoyed it. Later in the year Annie and I will be presenting slides and sharing some more of the stories. We (and any interested others) are going to do some fund-raising as the women and midwives would like a small birth centre. This would be for women without basic housing for giving birth or for those who don't feel so comfortable at home for the usual reasons and also as a safe haven. It would help raise the profile of the midwives there also. Edna would like to include a birthing pool and this would overlook the Pacific Ocean. I think I would fancy that as a place to give birth also! Anyway this project including raising emergency transport monies (see page 44) will have a target of £5000.
... And one day in the not too distant future the RM Birth Centre might end up being be a place where Edna would welcome other UK midwives and students to learn about Real Midwifery.
Kerrianne Gifford
This article was originally published in Midwifery Matters ISSUE 85 Summer 2000, p10-11
LW updated February 4, 2005