Introduction

This report on the Community Diagnosis (CD) activity in Eastern Samar is based on household data collected from 880 mothers living in 27 barangays (villages) covered by nine Barangay Health Stations (BHSs) of four municipalities: Balangiga, Salcedo, Maydolong, and Oras. Cluster sampling was used, with 220 households taken from each study municipality. The sample includes only those households where there was a child aged 3 years or below. The CD activity was assisted by UNICEF with funding from the Australian International Development Assistance Bureau (AIDAB) of the Australian government.

The analysis mainly describes the patterns drawn out from the combined data for the four study municipalities. Municipal breakdowns were included in the tables to facilitate the next activities: the community feedback and focus group discussions, and municipal health planning (MHP) for MCH by the municipal core groups in the different study municipalities.

Readers from different academic disciplines tend to vary in presenting and appreciating the data from this survey. For their benefit, the frequencies and the denominators used to extract the percentages were reflected in most tables to facilitate recalculations.

Table 1-A presents the household socio-economic data, Table 1-B presents the indicators of household socio-economic status, and Table 1-C presents the socio-economic status scores of the 880 survey households in Eastern Samar.

Household Socio-Economic Data. There were 880 households enrolled in the Eastern Samar survey. These were home to 5,376 household members, for an average of 6.1 members per household. This figure for the sample households is higher than the 1990 census average of 5.3 members per household for the four study municipalities.

Seven out of ten households (69.5 percent) live in houses made out of light materials (i.e., nipa or cogon roof, bamboo/thatch walls, earth or bamboo floor). One out of four households (25 percent) lives in a house made out of mixed materials (i.e., nipa roof, but wooden walls and floor). And only a few households (5.4 percent) live in houses made out of strong materials (i.e., GI sheets roofing, wood or cement walls, wood or cement flooring).

The housing classification adapted for this survey stands further improvement or rationalization. As in many other surveys, and for want of an appropriate model, we viewed type of housing from a "socio-economic" angle (i.e., cost of construction as inferred from the type of materials used), rather than from a "comfort" angle (i.e., houses made out of light materials provide better comfort in tropical climates).

Four out of five households (80.8 percent) were nuclear: husband, wife, and an average of four children. The other fifth had extended kin, a breakdown of which can be found in Table 3-B.

In almost three out of four cases, the lots on which the houses were built were owned by the household heads or spouses (20.2 percent) or by their respective parents (53.1 percent). Only few houses (5.8 percent) were built on tenanted land. These figures partly reflect a land-owning pattern that contrasts rural Eastern Samar with rural Leyte, where feudal agrarian relations are a reality, i.e., tenant-farming is fairly common, poblacion-based landlords own wide tracts of land in rural villages, and squatting on public and private land is widespread (Borrinaga and Koh; 1990).

Only few (6.5 percent) of the sample households have access to rural electrification.

For cooking, nine out of ten households (90.1 percent) used wood for fuel. Most of the other households used oring (charcoal, 6.2 percent) or liquified petroleum gas or LPG (2.9 percent) for fuel.

Half of the sample households (50.1 percent) did not own any of the following appliances included in the survey: radio, cassette tape player (or karaoke), gas range, electric fan, refrigerator, television, and betamax (video-cassette player). Among the appliance owners, the transistor radio was the most widely owned gadget (44.1 percent of the sample households). In lieu of, or in addition to a radio set, a cassette tape player (or karaoke) was owned by one out of eight households (12.3 percent of the sample households). A few other well-off households also owned one or several of the other mentioned appliances.

Almost nine out of ten households (89.2 percent) did not own a vehicle of any type. Among the vehicle owners, there were more households which owned watercrafts (39 bancas and 14 pumpboats) than land vehicles (27 bicycles, 15 motorcycles, and 4 jeeps/ jeepneys). These data on vehicle-ownership partly quantify the observations that Eastern Samar households have greater access to watercrafts than land vehicles for their intra-municipal transportation needs (i.e., between coastal barangays, or to and from upstream barangays).

In terms of sanitary facilities, over one-third of the households (37.5 percent) have water-sealed toilets, while a few have antipolo-type toilets (pit privies). Six out ten households (59.5 percent) did not have toilets.

The sample households fetched water for various purposes from several sources. For drinking, the hand pump was the common "safe" source availed of by more than four out of ten households (43.3 percent). The communal faucet, a welcome alternative amenity for Eastern Samar residents, was availed of by almost three out of ten other households (29.3 percent). A few households (1.9 percent) have piped-in faucets. However, more than two out of ten households got their drinking water from "less safe" sources including springs (12.9 percent), streams/rivers (actually waterholes or diggings by their banks, 9.6 percent), and open dug wells (2.3 percent).

For kitchen use, three out of five households got their water from "safe" sources such as hand pumps (34.1 percent), communal faucets (24.4 percent), and piped-in faucets (1.7 percent). The other households drew water for kitchen use from "less safe" sources such as streams/rivers (14.3 percent), open dug wells (13.9 percent), and springs (11 percent).

For bathing and washing laundry, which are partly social activities in the rural areas, the households availed of water from diverse sources. Two out of five households (41.8 percent) bathed and washed their laundry in streams/rivers. The rest were almost evenly distributed among other sources such as communal or piped-in faucets (14.1 percent), hand pumps (16 percent), open dug wells (16.8 percent), and springs (10.3 percent).

Indicators of Household Socio-Economic Status. We adapted from a similar presentation on indicators of household socio-economic status formulated by Dr. Michael L. Tan for the Mountain Province Project (Tan; 1993). In Table 1-B, we slightly differed from the Tan model by including among the list of household amenities the ownership of homelot by the household head/spouse and access to communal faucet as water source for kitchen use. Considering that only a few survey households have access to rural electrification in Eastern Samar, the ownership of electric-powered television, betamax, or refrigerator (which were separate items in the Tan model) were instead merged with the ownership of cassette tape player (or karaoke), gas range, or electric fan under a common, "another appliance" category.

Like the Mountain Province findings, the figures in Table 1-B challenge several mainstream assumptions including the idea that most Filipino households, no matter how poor, now have transistor radio sets. They also dispute official statistics that claim most Filipino households have water-sealed toilets.

Socio-Economic Status Scores. We adopted the scoring system for socio-economic status proposed in the Tan model (Table 1-C). We gave 1 point for access to each of the amenities listed in Table 1-B for a potential maximum of 10 points. Still, despite the substitution of several indicators in the Tan model to include amenities available in Eastern Samar, the mean score for all four study municipalities was only 1.69 (e.g., lower than the 1.84 mean in Mountain Province). Indeed, a fifth of the households (21.4 percent) had none of the identified amenities. And none of the households had a score higher than 8.

We hope that our data and presentation in Tables 1-B and 1-C contribute to the efforts at measuring socio-economic status in areas which are considered homogeneously "poor".

The index we adapted did show differences in poverty in Eastern Samar, which is perceived to be one of the "poorest" provinces in the country. However, a comparison of the socio-economic status between provinces currently implementing the Community Diagnosis process, using the Tan model or our adaptation, could help determine whether or not the perception about the magnitude of the poverty in Eastern Samar is borne out by comparative data at the household level.

Table 2-A presents demographic data about the 880 respondent mothers, Table 2-B presents demographic data about the husbands as reported by the respondents, and Table 2-C presents data about the school participation rates of school-age sons and daughters in the survey households.

Respondent Mothers. The respondent mothers’ ages ranged from 16 to 57, with a mean age of 29.8 + 7. Nearly half (44.2 percent) of them were not natives of the barangays of their current residence. However, since only about 11 percent of the respondents came from provinces outside Eastern Samar, the social displacement may not be too severe. Marriage was the reason cited for moving into their new barangays by almost all (nine out of ten) non-native respondents.

The average educational attainment of the respondent mothers was First Year High School. Almost one out of eight (11.4 percent) had reached college, while another four out of ten (41 percent) had reached high school.

The data above and in Tables 2-B and 2-C help to dispute official statistics that the illiteracy rate in Samar Island was 74.3 percent in 1990 (Medical Action Group; 1993). Indeed, a comparison with data generated by a UNFPA-funded survey in Leyte in 1988 (Abilar and Borrinaga; 1988) showed greater percentages of mothers in Eastern Samar with either high school or college educational attainments than their Leyte counterparts. In the Leyte survey, over one out of eight mothers (12.6 percent) had some college education, but barely another one out of four (26.3 percent) had reached high school.

Less than half (43.6 percent) of the mothers were engaged in other work aside from their household chores. Seven out of ten working mothers (30.4 percent of total respondents) were into farming, presumably as co-workers of their farmer-husbands. Six out of ten (26.4 percent of total respondents) earned cash from their other work, which included wage-earning and entrepreneural activities. More than half (56.4 percent) of the respondent mothers claimed they performed only domestic work.

In the domestic front, the mothers claimed that watching over the children (48 percent), washing the laundry (33.5 percent), and cleaning the house (11.4 percent) were their most time-consuming work.

Very few of the mothers (only 9) had worked abroad. But at least three out of five (61.4 percent) claimed they had worked in Metro-Manila, while about one out of five (19.3 percent) had worked in other places outside Metro-Manila.

Incidentally, for a cultural phenomenon in Samar Island, this survey was perhaps the first attempt to quantify women’s migration to and from Metro-Manila and other places. Official statistics in 1990 showed that the out-migration rate of 277 per 1,000 population for the whole Samar Island was the highest in the country (Medical Action Group; 1993). What the statistics failed to account was the net migration rate (i.e., discounting the out-migrants who came back). The survey findings showed that almost three out of five natives of the barangay (58 percent) who had worked in Metro-Manila eventually returned and settled down in marriage.

Most women of Eastern Samar were not involved in formal organizations. Five out of six respondent mothers (83.4 percent) claimed they were not members of any formal organization. Those with organizational memberships (not necessarily active participation) were divided among diverse groups including barangay organizations (i.e., the elective barangay councils), cooperatives, church groupings, women’s groups, Parents-Teachers Association, etc.

The mothers were also asked a question about their membership in the tiklos, the cultural farm-labor cooperative believed to be still practiced in many areas of Samar Island. The survey showed that only one out of eight mothers (12.3 percent) was a member of the tiklos. This finding partly indicates that the study communities have now been absorbed into a cash economy (i.e., farm labor was now mostly paid in cash).

Husbands. Based on the reports of the respondent mothers, the average age of the husbands was 33.5 + 8. Their average educational attainment was Grade Six, a year lower than the average attainment of the wives. One out of ten (10.4 percent) have reached college, but the proportion of another group who have reached high school, over one out of four (26.3 percent), was comparably lower than the figure for the wives (41 percent).

Compared with findings from the 1988 Leyte survey (Abilar and Borrinaga; 1988), the Eastern Samar husbands have slightly higher percentages for both high school and college attainments (i.e., only 8.4 percent for college attainment and 23.4 percent for high school attainment in the Leyte sample).

In terms of employment, three out of four husbands (75.2 percent) were either farmers (of own farm, 56.7 percent; of tenanted land, 2.3 percent) or fishermen (15.7 percent). These data quantified the physical observations that the study areas were farming and/or fishing communities, and the finding noted earlier that tenant-farming seem to be uncommon in Eastern Samar. The other husbands were involved in various trades and entrepreneural activities such as carpentry and driving, and in other types of employment. A few were jobless.

Their barangays of residence were the work venue of almost five out of six husbands (82.6 percent). Among those whose places of employment were outside their barangays, nearly half (7.5 percent) work in the poblacion, neighboring barangay, or another town of Eastern Samar. They were followed by those who work in Metro-Manila (6.8 percent). Very few work in another province or abroad.

School Participation Rates of School-Age Children. We included the presentation in Table 2-C both as demographic information and as indicator of the socio-economic capacity of the sample households to keep their children in school. The data showed that nearly seven out of eight (86.3 percent) of the children aged 7-12 years were in grade school, but less than half (43.8 percent) of the children aged 13-16 years were attending high school.

Alarmingly, the rate of college attendance among children aged 17-21 years (7.3 percent), has dipped lower than the percentages for college attainment of both their mothers and fathers. Perhaps the college attainment gap between parents and children can be closed, or a higher rate may even be shown for the children, when the educational attainment of those teenagers who have gone to and worked in Metro-Manila will be taken into consideration. Otherwise, this finding indicates an unfortunate impact of the economic poverty in Eastern Samar.

Comparative data from the 1988 Leyte survey (Borrinaga; 1990) showed higher percentages of school attendance by school-age children in this province than in Eastern Samar. In Leyte, nine out of ten (90.4 percent) of the sample children aged 7-12 years were in grade school, almost seven out of ten (69.3 percent) among those aged 13-16 years were in high school, while one out of six (17 percent) of the children aged 17-21 years was enrolled in college.

Table 3-A presents data on assistance from non-household members for child care, Table 3-B presents data on household members assisting in child-minding, and Table 3-C presents a comparison of sons and daughters as child-minders.

Table 3-A shows that the mothers of the respondents were the leading non-household members who helped them in various aspects of child care such as child-minding, assistance during birthing, care of the sick child, and wet-nursing. The mothers-in-law, neighbors, and siblings of the respondents were also involved in most of these activities. The hilots and the rural health midwives, whether or not they were the delivery attendants themselves, were likewise mentioned to have assisted the respondents during birthing.

Table 3-B shows that all categories of household members had assisted the respondent mothers in child-minding, although the percentages clearly showed that this role is female in orientation. The sons and daughters were important sources of support.

Table 3-C shows disaggregated age groupings for sons and daughters as child-minders. Child-minding starts at a very early age, and the rising percentages for the sons and daughters as child-minders were not much differentiated in the 0-4 and 10-14 age groups. However, among the children in the 15-19 and 20-24 age groups, the percentages for the son-minders dropped significantly compared to that of the daughter-minders.

Table 4-A presents data on the pregnancy history of the respondent mothers with focus on their last pregnancy, Table 4-B presents official statistics on birth attendance in Eastern Samar, and Table 4-C presents a comparison on the initiation of breastfeeding immediately after delivery and place of delivery.

Desire for, and Signs and Symptoms of the Last Pregnancy. Almost nine out of ten respondent mothers (88.9 percent) claimed that their last pregnancy was a "wanted" event, while the rest (11.1 percent) claimed that their last pregnancy was "unwanted" by them.

The most common signs and symptoms cited for the last pregnancy were amenorrhea or no menstruation (69.2 percent), nausea and vomiting (37.2 percent), and dizziness (22.6 percent). There were others mentioned by the respondents, but most of these appeared to be effects of, or related to, the three most frequently cited signs and symptoms.

Taboos during Pregnancy. The respondent mothers were inquired about taboos during their last pregnancy, specifically smoking, drinking alcohol, problem husbands, and specific food items. The survey showed that one out of ten mothers (10.6 percent) smoked tobacco, one out of three (33.3 percent) drank alcohol (tuba, beer, or liquor), nearly one out of four (24.5 percent) had a problem husband, and also about one out of four (24.2 percent) was prohibited from partaking of specific food items.

For those mothers with problem husbands, drunkenness or alcohol drinking by the husbands was the vice cited in almost two out of three cases.

Among the food taboos, fresh fish was the leading item that some mothers were prohibited from eating. However, the advise to exclude fish, other protein sources such as meat and squid, and a few vegetable items from the diet of the pregnant woman, by virtue of their association with certain local beliefs, has potentially adverse effects on the health and nutrition of both the mother and the fetus. This practice must be discouraged and reoriented.

Of course, there is also both cultural and health reasons for disallowing pregnant mothers from craving for such items as salty or sweet foods, and uncooked rice.

Pre-Natal Care. Five out of six respondent mothers (83.2 percent) submitted themselves for pre-natal care during their last pregnancy. The other sixth (16.8 percent) did not avail of this service.

The mothers who availed of pre-natal services first submitted themselves for consultation between the fourth and fifth months of their last pregnancy (average of 4.5 months). Between three to four pre-natal consultations (average of 3.3) were performed during this pregnancy.

Almost eight out of ten mothers who sought pre-natal care (64.8 percent of the total respondents) contacted the rural health midwife (RHM) at the Barangay Health Station (BHS) covering their barangays of residence for this service. Another one out of ten mothers (9.3 percent of the total respondents) sought pre-natal care at the poblacion-based Rural Health Unit (i.e., the Main Health Center). A few others availed of pre-natal care offered at the government hospital. Of note, the hilots or traditional birth attendants were not popularly sought for pre-natal care.

The survey showed that, among the mothers, pre-natal care is the best utilized and most accessed health service provided by the government’s public health system in the rural areas. The contact of the mothers with the health system through this service, and the social culture around this activity, could be used as focal points for other maternal and child health (MCH) interventions in the field.

For those mothers who did not seek pre-natal consultation, the leading reason cited was the distance of their houses from the health centers (i.e., place too far). There were other reasons, but most of them were personal or attitudinal in nature.

Birth Delivery. Almost all (97.4 percent) of the respondent mothers claimed that their babies were born "full-term" (i.e., full nine-months gestation). Only a few babies were delivered prematurely.

One out of six mothers (17 percent) reported complications during their last delivery. Prolonged labor was the common complication cited by four out of five reporting mothers. However, this matter about prolonged labor appeared to be largely perceptual. The average length of labor was 5.8 hours for more than nine out of ten mothers who delivered within 24 hours. Yet there were mothers who complained of prolonged labor despite the fact that their length of labor was much lesser than the average.

Other complications reported by a few mothers included excess bleeding, edema, breech presentation of the fetus, and retained placenta.

Almost all the respondent mothers (92.2 percent) delivered their babies at home. The rest were delivered elsewhere, mostly (6.9 percent) in the government hospital.

This survey underscored a dilemma for the Department of Health (DOH) pertaining to delivery attendance. As noted earlier, the hilots were virtually not sought for pre-natal care; yet they were called to attend at seven out of ten (71.9 percent) last delivery of the respondent mothers. While the rural health midwives, who were sought to provide pre-natal care to a great majority of these same mothers, were only called to attend at one out of seven (14.1 percent) deliveries. This health worker shift among the mothers remains a cultural reality that the rural health midwives are faced with and have long accepted.

However, in the past, the DOH attempted to both defy the culture and belie the above reality in its effort to "professionalize" the health service coverage (i.e., the hilots were presumed to be not "professional" enough). This thrust was manifested in monitoring and evaluation procedures that pressured the field health workers to report an altered and inaccurate health care picture at the community level. An example is the presentation on birth attendance in Eastern Samar in Table 4-B, which showed that the rural health midwives had attended at six out of ten deliveries, while the hilots had only attended at one out of three deliveries. Unfortunately, reports of this type have been contradicted by the findings of this and many other surveys.

Majority (52.4 percent) of the respondent mothers had other persons assisting the delivery attendants when they last gave birth. The mothers and husbands of the respondents topped the list of assistants, which mostly consisted of family relations, during their last delivery.

Some six out of ten delivery assistants performed massage, pressing and similar gestures on the stomach of the laboring mothers. At best, these acts were intended to give moral support to the mothers during the difficult circumstance of giving birth. The other assistants served as caretakers or cooks, ran errands, boiled water, or fed the mothers after their delivery.

The hilots cut the umbilical cord of seven out of ten babies (71.5 percent of the total deliveries), while the rural health midwives cut the cord of nearly one out of six babies (15.1 percent). The cord of a few babies were cut by barangay health workers (BHWs), who perhaps tried to build on this experience to become future hilots themselves.

The surgical scissors was used to cut the umbilical cord of seven out of ten babies (69.7 percent). The improvised bamboo knife, an instrument associated with hilots, was used to cut the cord of one out of five babies (20.4 percent). The survey showed that more hilots are now using the surgical scissors for cutting the cord of babies. This is a positive indicator of their openness to adopt new ideas and technologies to upgrade their services.

The cord tie (i.e., special cotton thread) was used to tie the umbilical cord stump of more than eight out of ten babies (84.2 percent). This was usually boiled by the hilots or midwives before being used. The cord clamp was also availed of in a few cases (7.5 percent), notably in Oras town (used in one out of five babies).

Rubbing alcohol was the popular substance placed on the umbilical cord stump of three out of four babies (74.7 percent). Merthiolate, iodine, and betadine were also used as substitutes for rubbing alcohol in a few instances.

The urgency of resolving the DOH ambivalence towards the hilots, and the need to reorient some of these health workers away from their potentially harmful practices, were underscored again by the survey findings on other substances put on the cord stumps of babies. In addition to the use of the bamboo knife for cord-cutting by some hilots, their use of talcum powder, lana (coconut oil-based solution), scrapings from coconut shell, baby oil, ash, or powdered jackfruit leaf as substances placed on the cord stumps potentially expose the affected babies to cord infections. These practices must be discouraged and refocused, perhaps through appropriate educational and supervisory measures for the concerned hilots.

Initiation to Breastfeeding. More than three out of four babies (77.7 percent) had the breastmilk of their mothers for their first food. Breastfeeding was initiated within six hours after delivery by seven out of eight mothers who breastfed their babies (68.3 percent of total respondents). Half of the other breastfeeding mothers cited "no milk" as the reason for their failure to breastfeed within six hours after giving birth.

The presentation in Table 4-C showed a higher percentage of breastfeeding within six hours after birth for babies delivered at the government hospital (82 percent) than for babies delivered at home (77.4 percent). However, chi-square test showed that the difference between the two figures is not significant. Still, the higher breastfeeding percentage for hospital-delivered babies suggests that the Baby-Friendly Hospital Initiative (BFHI) of the DOH has already filtered down to the district hospital level in remote areas of Region VIII.

Post-Natal Care. Seven out of eight respondent mothers (87.4 percent) submitted themselves for post-natal care during the month following their last delivery. The rate of availment of post-natal care by the mothers was higher than their rate of availment of pre-natal care (83.2 percent). This pattern contrasts with comparative data from the 1988 Leyte survey (Borrinaga; 1990), which showed a decline in the availment of post-natal care by the mothers after they highly availed of pre-natal care (down to 68.8 percent from 87.4 percent).

Less than two-thirds (62.5 percent) of the respondent mothers availed of post-natal care provided by hilots, while nearly one out of five (19.4 percent) availed of post-natal care provided by rural health midwives. Compared with the figures for delivery attendants, the number of mothers who sought the hilots for post-natal care reduced by almost 10 percentage points (down from 71.9 percent), while the number of mothers who sought the rural health midwives for post-natal care increased by more than 5 percentage points (up from 14.1 percent).

During the month following the mothers’ last delivery, the hilots conducted an average of 5.6 visits to those mothers who sought them for post-natal care. On their part, the rural health midwives averaged 3.1 contacts with the mothers who sought their post-natal care services.

Table 5 presents data on child rearing and caring, particularly on the aspects of breastfeeding, supplementary foods, and of a traditional feeding practice in Eastern Samar. The various items in the table utilized different denominators, which were appropriately reflected, to fit their data requirements. Greater focus was placed on the data provided by the mothers of 407 youngest children who were 12 months old or below. These mothers had less recall problems about the topic of this section during the survey.

Breastfeeding. As reflected in the previous section, more than two-thirds of the respondent mothers (68.3 percent) were able to breastfeed their infants within six hours after delivery. Still, this figure is far less than the ideal and should perhaps influence efforts to strengthen the education of mothers on breastfeeding.

Four out of five mothers (81.3 percent) were still breastfeeding their youngest children aged 12 months or below at the time of the survey. The other mothers were either bottle-feeding their infants or had already weaned them. It seems that about 20 percent of the mothers never got to breastfeed their youngest children at all.

Among the mothers who were breastfeeding, this practice was maintained until the infants turned six months old. The rate of breastfeeding rapidly declined for infants aged seven to 12 months.

The reported average length of breastfeeding for all the youngest children in the survey was 11.8 months.

There were varied reasons for the termination of breastfeeding. The fairly high percentage (34.2 percent) reporting "no milk" further underscores the need for strengthened breastfeeding education for mothers.

Supplementary Foods. The survey data showed that few mothers gave supplementary foods to infants below four months old. The leading food items given to infants in this age group were lugaw (rice porridge) and infant formula.

The most popular supplementary foods given by the respondent mothers to their youngest children were the familiar lugaw (rice porridge) and boiled rice, both of which are solely energy foods. These were followed by commercial preparations such as infant formula or Cerelac, which seem to be the source of most of the other nutrients required for child growth and development in many survey households.

However, the preference for commercial preparations appears alarming, not only because these are relatively expensive and may be a strain on the budget of many households, but also because the traditional, cheap and nutritious local alternatives such as kalabasa (squash) and camote were hardly availed of by the mothers. Indeed, when focused on the non-checklist supplementary foods for infants up to 12 months old, the survey data showed an array of pre-mixed or ready-to-eat items sold in stores (Cerelac, biscuit, ripe banana, Ceresoy, bread).

The median ages (in months) for initiating particular supplementary foods to the youngest children until their first year of age also showed that the commercial preparations were introduced much earlier than the locally grown and produced food items.

It can be inferred from the above data that, apart from illness and other physiological causes, the incidence of child malnutrition in Eastern Samar may be attitudinally rooted on the mothers’ attraction to commercial preparations as supplementary food for their children, which many of them cannot sustain for economic reasons, and on their basic disregard (which borders on innocent aversion) of the cheap, nutritious (equally, or even better) and abundant native food items (i.e., the so-called food of the "poor").

Traditional Feeding. A question was included in the survey pertaining to the unsanitary practice of giving food pre-chewed by an adult (sinupa) to children, which was a tradition in Eastern Samar. The data showed that this practice has been almost totally discarded. Only a few of the youngest children (6.5 percent) had been given sinupa.

Table 6 presents data on child growth and welfare, with emphasis on the type of interventions or services provided by the Department of Health (DOH) at the Barangay Health Station (BHS) level. The presentation was limited to the data about 500 youngest children in the sample households who were at least 12 months old, the likely age for each of these children to have had full access to the interventions or services covered by the survey.

Almost three out of four children aged 12 months to 3 years (74.4 percent) had a Yellow Card or Child Growth Chart, a home-based health record which the DOH had recommended for mothers to keep for each child. Almost five out of six of these growth charts were being utilized for monitoring the growth status of children.

One out of three mothers (33.8 percent) of youngest children aged 12 months to 3 years did not know the growth status of her child. Among the "unaware" mothers, a third possessed growth charts of their children.

Based on the mothers’ reports, which were partly validated by actual verification of the filled up items in the growth charts, majority of the youngest children aged 12 months to 3 years old were on the "road to health" (52.6 percent) or above the "road to health" (2.2 percent). This finding could perhaps help dispute the veracity of certain official statistics which cited that more than two-thirds of the pre-school children in Samar Island were "malnourished" (Medical Action Group; 1993).

Two major programs implemented by the DOH in 1993 were the National Immunization Days in April and May, and the National Micronutrient Day in October. Among the youngest children aged 12 months to 3 years, almost all (94 percent) were brought to different Patak Centers for anti-polio immunization in April and May 1993. And seven out of eight (87.2 percent) of these same children were brought to the Sangkap Centers for micronutrient (Vitamin A) supplementation in October 1993.

Immunization against six major killer diseases of childhood is a major activity of the DOH at the barangay level. In this regard, the survey showed that among children aged 12 months to 3 years, at least four out of five (81 percent) have been "completely immunized" (with BCG vaccine, three doses of DPT vaccine, three doses of oral polio vaccine, and measles vaccine). This complete immunization coverage is already high, but is still short of the "universal coverage" of 90 percent. Among the four study municipalities, only the Oras sample has achieved "universal coverage" for immunization.

Table 7-A presents demographic and perceptual data relevant to family planning, Table 7-B presents data about mothers currently using family planning methods, Table 7-C presents reasons for not using family planning methods by the majority of respondent mothers, and Table 7-D presents frequency data pertaining to gaps in family planning knowledge and usage.

Demographic Data Relevant to Family Planning. The mean age at first pregnancy of the respondent mothers was 20.6 + 4. Each mother had an average of 4.3 children from an average of 4.6 pregnancies at the time of the survey.

The data showed that, age-wise, nearly half of the mothers (47.1 percent) were "risk" cases during their first pregnancy (i.e., below 20 years or 35 years and above of age). More than two out of five mothers (42 percent) were also considered "risk" cases, for having had more than four pregnancies.

A total of 291 miscarriages were reported by the mothers, giving a ratio of one miscarriage for every three mothers.

Children Wanted by the Wives and Husbands. The respondent mothers (wives) and their husbands differed significantly on the number of children they wanted to have. Quantitatively, the wives wanted an average of 3.9 children, lesser than the average of 4.3 children wanted by the husbands. Qualitatively, the husbands wanted one child more than what their wives wanted. The husbands’ want seemed to have been fulfilled. The average number of children they wanted tallied with the average number of children in the survey households (4.3 children).

The wives gave many reasons for the lesser number of children they wanted. The foremost reason, cited by nearly one out of four wives (23.6 percent), was "husto na" (that is enough). This reason borders on exasperation and was usually supplied with qualifiers such as the difficulty of bearing and rearing a child, or the difficult economic situation of the households. The second and third reasons, "makuri an panginabuhi" (difficult to eke a living) and "makuri an panahon o kamutangan" (difficult times or situation), cited by more than one out of five wives (21.5 percent), perhaps underscore the fact that (more than anything else) it is the economic crunch on the households that pressured many wives to aspire for a limited number of children.

On a lesser scale, some wives mentioned "makuri panganak" (difficult to bear a child) and "makuri pag-ataman hin bata" (difficult to rear a child) as reasons for the number of children they wanted. Of note, one out of twelve wives (8.8 percent) did not offer any reason for the number of children she wanted.

For many wives, their want to limit their number of children was not compensated with methods or procedures to make this a reality. For instance, a significant number of respondents qualified their answers on number of children with "husto na" (that is enough), but their answers were "none" for the items on previously tried or presently using family planning methods.

Regarding the perceived reason/s for the number of children wanted by the husband, at least one out of four wives (26.7 percent) disavowed any knowledge of her husband’s answer (e.g., "diri maaram" or "I don’t know"). This finding suggests that family planning is taboo as a topic for discussion among many couples. Some wives who gave "I don’t know" answers qualified these with their own or their husbands’ vague estimates for number of children such as "until a boy (or a girl) is born," "until (the child-bearing capacity) is exhausted," "whatever (God or fate) gives," etc.

However, as reported by the wives, one out of eight husbands (11.9 percent) seemed to have realized that the number of their children was already enough. A few other husbands were also reported to have cited the difficulty to eke a living (9.4 percent) and the difficult times (6.7 percent) as reasons to justify the number of children they wanted.

More wives (38.3 percent) preferred daughters for their first child, one out of three (33.6 percent) did not have any particular preference on this aspect, while over one out of four (27.8 percent) preferred sons for their first born child.

Motivation, Effect of Religion, and Wanted Information on Family Planning. For one out of five respondent mothers (19.5 percent), the adoption of family planning appeared to be a personal decision (self, 5.7 percent; none, 4.5 percent) or one agreed with the husband (conjugal agreement, 7.9 percent; husband, 1.4 percent). Among the external motivators, the rural health midwives seemed to have influenced one out of twelve mothers (8.4 percent) to practice family planning.

The survey was planned at a time when the Roman Catholic Church was actively opposing the government’s contraceptive-based population program. In this regard, several questions were included in the survey to "feel the pulse" of the mothers on the issue. Some of the findings might seem surprising to the protagonists on both sides of the population debate.

Almost all the respondent mothers (96.5 percent) claimed to be Roman Catholics. Only four were Protestants, while 26 (3 percent) claimed membership in various fundamentalist groups now penetrating the countryside. When asked if their religious affiliation affected their decision whether or not to use family planning (i.e., contraceptives), four out of five mothers (80.7 percent) answered a categorical "No". Only one out of six mothers (16.7 percent) admitted that her religion affected in some way her decision-making related to family planning.

The mothers were asked about additional information they may want to know about family planning. Majority shrugged off the question and answered "I don’t know." Among those mothers who answered this question, a greater number wanted to know more about the rhythm method (12.4 percent of total respondents) and the pill (9.4 percent of total respondents). Few wanted to know more about IUD, withdrawal, and ligation. Of note, vasectomy, condom, and injectables, which are being actively promoted by the DOH, did not seem to find significant adherents among the surveyed mothers.

Mothers Currently Using Family Planning Methods. One out of three respondent mothers (34.8 percent) was using a family planning method at the time of the survey. Majority of these family planning users (19.8 percent of total respondents) were using non-program methods, of which the withdrawal method was the most popular (used by 15.2 percent of the total respondents).

Among the users of modern program methods (used by 9.6 percent of the total respondents), the pill was commonly availed of (by 7.5 percent of the total respondents). Few submitted for IUD insertion or ligation, only one availed of the injectable contraceptive, and none had a husband who submitted for vasectomy.

A few others (6 percent of total respondents) utilized other program methods, of which the rhythm method had the most number of users (5.1 percent of total respondents). Only eight husbands used condom.

Reasons for Not Using Family Planning Methods. Almost two out of three respondent mothers (65.2 percent) were not using any family planning method at the time of the survey. "Fear of side effects" of contraceptives was the leading reason given by nearly one out of four non-users (15.7 percent of total respondents). A similar ratio of non-users (15.2 percent of total respondents) cited "want more children" to justify their decision not to use a family planning method. The fact that the second reason was also cited by mothers who already had more than four children perhaps bolsters the observation that the household economic situation significantly influences a couple’s decision on the number of children they want to have (i.e., they would raise more children if they can afford it, less number of children if they cannot).

About one out of six non-users (10.5 percent of total respondents) cited no specific reason for her non-use of any family planning method. "No reason" is verbally expressed in Eastern Samar as "kay luga" (i.e., that’s it).

The other reasons provided by the non-users may seem lame or evasive (e.g., not too well informed, 8.6 percent; husband does not like family planning, 4.6 percent; don’t know where to get family planning service, 3.1 percent; etc.), but they have to be taken into serious consideration by program planners and implementors. Some of them appear to be based on deep-seated and honest personal sentiments.

Gaps in Family Planning Knowledge and Usage. Compared to the Mountain Province findings (Tan; 1993), which showed a great gap between knowledge and usage of family planning methods, the Eastern Samar findings reflected in Table 7-D showed only a narrow gap between family planning knowledge and usage.

A fairly wide gap between knowledge and usage is apparent for three methods (pill, withdrawal, and rhythm), but hardly for the others. One out of eight respondent mothers had previously tried the pill, but only a few (66 mothers) were currently using this contraceptive at the time of the survey.

The number of current users of the abstinence method was higher than that of the previous users. And the numbers for the previous and current users of the withdrawal method were almost equal. The increasing use of these two non-program methods, less effective they may be, and the lessening current users of the pill and the rhythm method (promoted by the DOH), suggests a growing accommodation by some mothers of the church-approved methods.

Table 8-A presents data on common illnesses among the youngest children during the past six months as reported by the mothers, Table 8-B presents data from mothers’ reports about past episodes of measles, cord infection, polio, and night blindness among their children, Table 8-C presents interventions for the reported diseases in Table 8-B, Table 8-D presents health problems among the respondent mothers at the time of the survey, and Table 8-E presents data from mothers’ reports about household deaths during the five years preceding the survey.

Child Morbidity. The respondent mothers were asked about the illnesses of their youngest children during the six months prior to the survey. The shorter time period was intended to minimize the problem of recall.

As would be expected, cough, colds, fever, and diarrhea were the leading illnesses reported by the mothers. Cough and colds, which were most commonly cited, suggest the prevalence of acute respiratory infection (ARI) in the study communities. Fever, the third common illness, is too general a symptom, but some episodes may be associated with ARI. Diarrhea may be associated with the "unsafe" drinking water source of some households, lack of hygiene, or with improper child-feeding habits.

Among the other ailments reported by the mothers were katol (skin lesions) and katol nga uga (scabies), which are often excluded from official morbidity listings. Only a few children (57 of them) were reported to have had no illness during the six months preceding the survey.

Past Episodes of Measles, Cord Infection, Night Blindness, and Polio Among Children. The respondent mothers were also inquired about past episodes of measles, cord infection, polio, and night blindness among any of their children. Nearly three out of five mothers (59 percent) reported past episodes of measles among their children. Almost one out of eight mothers (11.6 percent) reported past episode/s of cord infection among her children. Few mothers (4.6 percent) reported past episodes of night blindness among their children. And very few (1.2 percent) reported past episodes of polio among children in their households. The report on polio perhaps provides an optimistic indicator that this disease is on the brink of eradication.

Interventions for Past Episodes of Measles, Cord Infection, Night Blindness, and Polio. For every "yes" response to the question on past episodes of measles, cord infection, polio, and night blindness among the children in the household, a mother was asked about her intervention/s. Except for the case of measles, the trend points out to a growing acceptance of modern medicine by the rural people.

The interventions for measles are largely mired in tradition and local belief. The leading intervention resorted to by many mothers to deal with measles was herbal medicine (unspecified). The second intervention, the use of panhataw (rash inducer), perhaps specifies the leading intervention, links the other local interventions listed in Table 8-C, and points to the local belief about measles. The belief system may be roughly described as follows:

Measles is considered a serious disease in the rural areas. A child who gets ill with measles must be given food or herbal decoction that are perceived to induce all the rashes to "surface" on the skin. The child must not be given anything that will deter the rashes from surfacing or cause them to "sink." It is believed that the "sunk" rashes will inflict the intestines or the bones and could cause certain death.

With this description in mind, it becomes understandable why, in most instances, a child sick with measles is prohibited from taking in lemon juice (Vitamin C), other food items, or drugs that would alleviate the respiratory infection which usually develops with the disease (but could cause some of the rashes to "sink"). Unfortunately, because of the determined effort to avert a culturally perceived cause of death from measles, some children succumb to bronchopneumonia.

Perhaps the best approach to measles education is to dispel the mothers’ attachment to their local myth pertaining to the disease, without necessarily substituting this with the myth associated with modern curative medicine. Immunization against measles and appropriate "damage control" interventions during its episode (even if these would cause the rashes to "sink") are still the key to avoid deaths due to this disease.

However, some mothers have already availed of the benefits of modern medicine for the measles of their children. Consultation with the physician or hospital admission were availed of for a greater number of children. A few were given medicine, perhaps without prescription, or were brought to the attention of the rural health midwife at the health center.

The interventions for cord infection suggest that the mothers have generally accepted that this problem is outside the scope of native medicine. Thus, more cases of cord infections were referred to the physician or to the hospital for interventions. A few other mothers, perhaps acting without professional advise, administered antibiotics or alcohol on the infected cord, or gave medicine to their children with cord infection.

Still, traces of tradition remain. For children from five households, lana (coconut oil-based solution) was placed on the infected cord. If contaminated, this native intervention may have aggravated the infection.

The interventions for night blindness suggest that the mothers are better informed about the nature of this problem. Children from an equal number of households were given Vitamin A or were brought to the physician, who presumably prescribed a similar intervention (Vitamin A). Children from four households were dewormed, while those from three others were given medicine provided by the midwife (probably Vitamin A kept at the health center). For children from five households who did not benefit from any intervention, the problem perhaps disappeared after they had eaten corrective food items.

The interventions for polio suggest a shift towards modern medicine. Polio-stricken children from seven households were brought to the physician or to the hospital. But polio-stricken children from two other households were still administered binisaya (native medicine), which suggests a remaining link to tradition. Whatever, the interventions for polio after the disease has struck, whether modern or traditional, are palliative at best. The best approach to polio is prevention by immunization, which the DOH has successfully pursued over the past two years.

Present Health Problems. One out of six mothers reported a health problem bothering her at the time of the survey. Except for cough, most of the other reported complaints pertain to various aches and pains in different parts of the body. These aches and pains were probably precipitated by farm work and domestic activities of the mothers, or by other physical and emotional stresses and exertions.

Household Deaths over the Past Five Years (1989-1993). The mortality data reported by the mothers, as reflected in Table 8-E, should be interpreted with caution. It seems that many mothers abstained from the very sensitive question about household deaths by conveniently answering "none." Still, the generated data presents some pattern about deaths in the study households during the five years preceding the survey.

Nearly four out of five (78.1 percent) reported household deaths were children of the respondent mothers. The other deaths were husbands (5.2 percent), parents-in-law (5.2 percent), parents (4.2 percent) of the mothers, and assorted relatives (7.3 percent).

Almost one-third of the reported deaths (32.2 percent) occurred in 1991, while the percentage of the other deaths was more or less even for the other years. Of note, the average percentage of deaths for the period 1991-1993 is much higher than the figure for 1990, when Samar Island hugged the national limelight and attention following the publication of newspaper articles that highlighted the poverty, disease, and deaths in this part of Region VIII.

Three out of five reported deaths (61.4 percent) were males, and seven out of ten (70.8 percent) were children 0-4 years old. This child mortality figure is alarmingly high.

The leading causes of death among children children aged 0-4 years are largely preventable with the use of simple and appropriate measures. Measles was the leading cause, responsible for almost one out of five child deaths (13.5 percent of total deaths). This was followed by "miscarriaged delivery" of the mother, reported to have caused one out of eight child deaths (9.4 percent of total deaths). Since the survey question explicitly excluded "miscarriage" (i.e., igin-awak) as a cause, the label presumably referred to children who died within hours or few days after a difficult birth. Nag-aplud (cyanosis) and tigda la (sudden death) as reported causes of child deaths need to be better known.

Table 9-A presents data on health-seeking behavior among the respondent mothers, and Table 9-B presents Barangay Health Station (BHS) services availed of by the mothers and their youngest children.

Latest Illnesses and their Interventions. To determine their health-seeking behavior, the respondent mothers were asked about their latest illnesses and their interventions for these illnesses. The data on latest illness presents a greater variety of reported ailments compared to the answers to the question on present health problem in the previous section (Table 8-D).

Headache (suol ha ulo) was the leading latest illness, suffered by almost one out of six respondent mothers. And, as in a similar presentation in Table 8-D, most of the other reported illnesses were due to aches and pains in various parts of the body. Illnesses belonging to other classifications included cough (batok) and colds (sip-on), which are respiratory infections, and influenza (trangkaso) and fevers.

Nearly one out of five mothers just bore her latest illness and did nothing about this. And about one out of six took drugs, whether prescribed or bought over-the-counter. Many other illnesses were subjected to various locally known remedies including herbal decoctions, massage, pain-killing balms, rubs, etc. Only few latest illnesses were referred for professional care and attention (of the physician or of the rural health midwife).

Last Visit to the Barangay Health Station. To gauge access of the Barangay Health Station (BHS), the most peripheral health facility of the DOH, the respondent mothers were asked to cite the date of their last visit to the BHS. In processing the data for the responses to this question, we excluded those visits within 30 days before the survey, as some of these were feared to have been "induced" by the rural health midwives.

Still the data showed a very high level of contact between the rural health midwives and their client mothers, whether at the BHS or in the homes. Almost half of the respondent mothers (48.1 percent) last visited their nearby BHS during the first to the third months preceding the survey. And at least another one out of ten mothers (11.2 percent) performed this task during the fourth to the twelfth months before the survey. In all, almost three out of five mothers last visited the BHS during the first to the twelfth months prior to the survey.

Two out of five respondent mothers did not visit their BHS during the first to the twelfth months before the survey. Perhaps most of them were subjects of the home visits conducted by the rural health midwives on nearly two out of five households (37.5 percent).

During their home visits, the rural health midwives mainly checked up the children or immunized them. They also weighed a few children in their homes.

Mothers’ Class. Barely one out of six respondent mothers (17.6 percent) has attended a Mothers’ Class, a community-level activity mandated by the DOH. The low attendance coverage among the mothers puts to question the wisdom of conducting this formal activity on a regular basis.

It can be inferred from the data that a similar minority set of mothers has been attending the Mothers’ Classes through the years. Perhaps the Mothers Class should evolve into less formal, tutorial-type sessions, using learning modules suited to the First Year High School average educational attainment of the mothers.

Knowledge gained from the Mothers’ Class includes care of child, family planning, feeding of child, herbal medicine, and balanced diet.

Barangay Health Station (BHS) Services Availed of by the Mothers and their Youngest Children. Pre-natal care and tetanus toxoid injections were the most popular BHS services availed of by majority of the respondent mothers. The other services availed of by a significant percentage of mothers were iron/ vitamins dispensing, consultation, dispensing antibiotics, and post-natal care. The family planning and referral services offered by the BHS had less takers.

Immunization, registration of birth, and child-weighing were the most popular BHS services availed of by majority of the respondent mothers for their youngest children. The other child care services which were also widely availed of were consultation, giving medicine, feeding, food supplementation, and deworming.

Table 10-A presents data on perceived problems affecting community health and development, Table 10-B presents proposed solutions to the perceived problems cited in Table 10-A, Table 10-C presents various vulnerabilities of the households to specific ecological factors, and Table 10-D presents a list of top nominees for women’s representatives on health matters as polled among the respondent mothers.

Perceived Problems Affecting Community Health and Development. The respondent mothers were asked to cite three most important problems that affect the health and development of their communities. Majority of them answered "diri maaram" (I don’t know), which response perhaps reflects their basic indifference towards community problems and issues.

The three leading problems mentioned by some respondents were lack of medicines (16.4 percent), lack of toilets (11 percent), and lack of livelihood opportunities (7.2 percent). The top two problems are health-related. And most of the other cited problems have some influence on the capacities of the households to lead healthy lives.

Proposed Solutions to the Perceived Problems. The respondent mothers were likewise asked to propose three solutions to whatever three community problems they may have perceived. The majority also answered "I don’t know."

The three leading solutions proposed by some respondents tallied with the ranking of the top three perceived problems in Table 10-A. These proposed solutions were: supply of free or cheap medicines (11.5 percent), materials for making toilets (5.9 percent), and jobs or job assistance (5.2 percent). The other proposed solutions address the need for unity and cooperation among the barangay residents, and the general demand for the provision of social services by the government.

Vulnerabilities of the Households to Ecological Factors. The respondent mothers readily answered most of the questions for Table 10-C. This attitude contrasts with their reluctance to respond to the questions on community problems and their solutions.

Majority of the respondent mothers (51.2 percent) reported destruction of their houses (unspecified as to whether the damage was total or partial) due to a typhoon or calamity during the five years preceding the survey. A similar majority (51 percent) also reported that their livelihood were affected by a typhoon or calamity during the same period of time.

Only one out of six respondent mothers (16.1 percent) admitted the existence of peace and order problem in her barangay. When probed further whether the peace and order problem affected the delivery of health care services in the study barangays during the past 12 months, one out of eight mothers (12.6 percent) answered "Yes", while a small majority (50.4 percent) answered "No".

The surprising finding was the fairly high percentage (31.9 percent) of mothers who abstained from answering the follow-up question pertaining to peace and order (i.e., its effect on health services delivery). Majority of the respondents in Balangiga and Oras towns did not answer this question, which is intruiging because some study barangays of both towns were considered "hot spots" during the survey.

Nominees for Women’s Representatives on Health Matters. Each respondent mother was polled to identify a person in her barangay whom she would prefer to represent her on health matters. About 55 names were cited per study municipality, which we cut down to a list of 25 names in Table 10-D.

Three out of five nominees (60 percent) were known to the mothers as Barangay Health Workers (BHWs). This finding underscores the leadership capacities and the continuing health auxiliary roles of the BHWs at the community level, even if the DOH remains ambivalent about their role in health care delivery (Borrinaga; 1991), and has largely neglected them since the fad that caused their recruitment and training in the early 1980s had died out.

The other nominees included three rural health midwives, barangay councilors, and lay women leaders.

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