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IN THE PROVINCE OF SAMAR Antonio M. Tirazona3 and Honorata L. Catibog4 ------------ 1) Associate Professor, School of Health Sciences, University of the Philippines Manila, Palo, Leyte; 2) Executive Director, Tandaya Foundation, Catbalogan, Samar; 3) Chief, Technical Division, Samar Provincial Health Office, Catbalogan, Samar; 4) Provincial Health Officer, Samar Provincial Health Office, Catbalogan, Samar.Paper presented at the RHRDC-8 5th Regional Health Research Forum, Ritz Tower de Leyte, Tacloban City, December 17, 1999. ------------ INTRODUCTION This paper discusses the maternal and child health care components of a multi-indicator cluster survey conducted in the Province of Samar in late 1998. The Samar survey was part of a national survey under the Local Government Unit Performance Program (LPP) of the Department of Health (DOH). LPP is a component of the Integrated Family Planning and Maternal Health Program (IFPMHP), a project assisted by the U.S. Agency for International Development (USAID). It aims to improve the health of the mothers and children through family planning and selected child survival interventions. This paper excludes the family planning component. METHODOLOGY The survey covered 62 barangay clusters in 24 municipalities and one city of Samar Province. The barangay clusters were randomly chosen using the probability proportionate to size (PPS) method. Fifteen women per cluster were chosen for a total of 930 respondents per indicator. RESULTS AND DISCUSSION This paper discusses the maternal and child health care components of the 1998
multi-indicator survey in the Province of Samar.
A. Desire to Have Children
TABLE 1. Number and Percentage of Women by Desire to Have Children
at the
Table 1 presents the number and percentage of the sample mothers by desire to have children at the time of pregnancy with their children aged 0-23 months according to educational attainment. Overall, the data show that more than half (487 or 52.4 percent) of the mothers wanted the pregnancy of their 0-23 months old children. A higher percentage (112 or 59.9 percent) of college-educated mothers wanted their pregnancies, probably because they have lesser number of children (average of 3.1 children per mother) compared to the high-school-educated mothers (average of 3.6 children per mother) and elementary-educated mothers (average of 5.0 children per mother). One-fifth (186 or 20 percent) of the respondent mothers wanted to delay their pregnancies. Again, a higher percentage (24.1 percent) came from among college-educated mothers compared to those with lower educational attainments. More than one-fourth (257 or 27.6 percent) of the respondents no longer wanted the pregnancy of their children aged 0-23 months. Of note, nearly one-third (148 or 32.7 percent) of the elementary-educated mothers no longer wanted their pregnancy, probably because they already have many children. A comparison with the finding of the 1994 Eastern Samar MCH study shows a significant increase in percentage of unwanted pregnancies among mothers in Samar. Only one-out-of-nine mothers (11.1 percent) in the Eastern Samar sample did not want their last pregnancies prior to the 1994 survey. The adverse effects of the economic crisis (i.e., the impact of the Asian currency crisis) on the rural households might have some influence on the increase in unwanted pregnancy perception among the mothers in the present study. TABLE 2. Percentage of Women Who Would Like to Have
Waited for
Table 2 presents the percentage of the 186 mothers who would like to have waited for the pregnancy of their children aged 0-23 months, according to educational attainment and preferred period of delay. The data show that nearly half (88 or 47.3 percent) of the respondent mothers preferred to wait 2-3 years before their next pregnancy. A great majority of the high-school-educated mothers (39 or 63.9 percent) and college-educated mothers (26 or 57.8 percent) preferred this waiting period. More than one-third (69 or 37.1 percent) of the respondent mothers preferred to wait 4-5 years before their next pregnancies. A great majority of the elementary-educated mothers (47 or 58.7 percent) preferred this waiting period. B. Pre-Natal Care A total of 864 mothers (92.9 percent) in the sample, or nearly all respondents, had submitted themselves for pre-natal care during the pregnancy of their children aged 0-23 months. A few mothers (66 or 7.1 percent) did not avail of pre-natal care services. TABLE 3. Percentage of women who received pre-natal
care during pregnancy with child
Note: * multiple responses (N=864). Table 3 presents the percentage (from multiple responses) of the 864 mothers who received pre-natal care by type of pre-natal provider. More than one-fourth (28.4 percent) of these mothers availed of the services of the doctor as pre-natal provider, solely or in alternate basis with one or two other providers at various times throughout the pregnancy with their children aged 0-23 months. The midwife (usually the BHS-based rural health midwife) had provided pre-natal care to more than two-thirds (68.2 percent) of the mothers. Most of these mothers also alternately consulted the hilot or traditional birth attendant, who had seen nearly two-thirds (63.8 percent) of them for similar care during the same pregnancy. TABLE 4. Percentage of women who received pre-natal
care during pregnancy with
Table 4 presents the percentage of the 864 mothers who received pre-natal care during the pregnancy of their children aged 0-23 months by pre-natal provider first seen. The data show that more than one-fifth (185 or 21.4 percent) of the mothers had first seen the doctor for pre-natal care during their pregnancy. Nearly half (384 or 44.4 percent) of the mothers first saw the midwife for pre-natal care, while almost one-third (284 mothers or 32.8 percent) first saw the hilot for similar care. Thus, in the provision of pre-natal care, the leading health workers for the respondent mothers in the study are:
TABLE 5. Percentage of women
who received pre-natal care during pregnancy with child
Table 5 presents the number and percentage of the 864 mothers who received pre-natal care during pregnancy with their children aged 0-23 months by month of initial pre-natal care. The data show that most of the mothers first availed of pre-natal care at 3-4 months (for 353 mothers or 40.8 percent) or 5-6 months (for 305 mothers or 35.3 percent). On the average, the mothers first availed of pre-natal care at 4.18 months of their pregnancy. TABLE 6. Percentage of women who received pre-natal
care during pregnancy with child
Table 6 presents the percentage of the 864 mothers who received pre-natal care during pregnancy of their children aged 0-23 months by number of pre-natal care visits. The data show that more than one-fourth (28.5 percent) of the mothers submitted themselves for seven or more pre-natal care visits. The rest were distributed along a rising-and-falling line with a peak in the three visits category. On the average, the mothers availed of 5.3 pre-natal visits during their pregnancy. TABLE 7. Number and percentage of women who did or
did not receive specific
Table 7 presents the number and percentage of the respondent mothers who did or did not receive specific medications during pregnancy with their children aged 0-23 months. The data show that more than two-thirds (639 or 68.7 percent) of the mothers had received iron tablets/capsules during their pregnancy. Some of these mothers were prescribed commercial, sugar-coated iron tablets/capsules by the doctors they had consulted for pre-natal care. However, most of the other mothers got their supply of iron tablets/capsules from the government public health system (RHU in the town center, or from the BHS-based rural health midwife). More than half (500 or 53.8 percent) of the mothers had received iodine capsules during pregnancy with their children aged 0-23 months. The free distribution of this specific medication, solely by the government public health system, provides a practical indicator of the effective reach of the RHU’s supply support system to the mothers, a few of whom self-reported as already suffering from goiter during the survey. A rough estimate derived from the survey findings is that iron tablets/capsules and iodine capsules distributed by the government public health system effectively reach only a little more than majority of the pregnant women. Assuming that the supply is available, this is one accessibility problem that must be addressed by both health program managers and implementors. pregnancy with their child aged 0-23 months, according to number of tablets/capsules taken.
Table 8 presents the number and percentage of the 639 mothers who received iron tablets/capsules during pregnancy with their children aged 0-23 months. The data show that nearly half (299 or 46.8 percent) of these mothers took less than 10 of the tablets given them. A few other mothers (31 or 4.8 percent, including the "don’t know" answers) received but did not take any of the iron tablets/capsules given them. More than one-third (219 or 34.3 percent) of the mothers had consumed from 11 to 50 iron tablets/capsules during their pregnancy. Only a few mothers (90 or 14.1 percent), or about one-out-of-seven, had consumed more than 50 iron tablets/capsules during their pregnancy. A rural health midwife usually gives a batch of 20-30 iron tablets/capsules to the pregnant mother during a pre-natal visit, a supply probably enough to last till the next visit. But majority of these mothers stopped taking the medication after a few tablets/capsules. Many complained to the field interviewers about the "fishy" (malangsa) odor and after-taste, which induced vomiting among some mothers after taking the tablets/capsules, and about the "rust-like" (matauy-tauy) taste. The pattern presented by the data shows that the prevention of iron deficiency anemia among mothers through intake of government-provided iron tablets/capsules appears to border on failure. The technology is simply plagued by a serious acceptability problem, particularly among rural mothers who need them most. This problem must be addressed by health officials at more central, policy-making levels, to avert further waste of resources. Aggressive promotion of iron-rich food alternatives (i.e., ampalaya, or the bitter gourd) for pregnant women is probably more acceptable and effective in the short-term. C. Maternal Immunization TABLE 9. Percentage of mothers with child aged 0-23 months who received Tetanus Toxoid Vaccinations (TTV) during and/or prior to pregnancy of child by number of doses.
NOTE: Reference child is aged 0-23 months.
TT2+ Coverage ------------------------------------------------------------------ x 100 = 68.7 % reference child. The figure 930 is the total number of respondent mothers.) TT2+ coverage is the percentage of women given 2 or more doses of TTV during and prior to Table 9 presents the number and percentage of mothers who received tetanus toxoid (TT) vaccinations during and/or prior to pregnancy with their children aged 0-23 months by number of doses. The data show that the numbers and percentages were more or less the same for the One, Two, and Three TT doses levels (i.e., 120s, and 13+ percent). The sudden drop (to 7.6 percent) in the Four TT doses level from the usual 13+ percent figure is probably an effect of the nationwide tetanus toxoid scare in early 1995, or about four pregnancies ago. About one-sixth (164 or 17.6 percent) of the mothers never availed of tetanus toxoid vaccinations during and/or prior to pregnancy with their children aged 0-23 months. The fact that some of these mothers without TT vaccinations had doctors as sole pre-natal providers prompted a field interviewer to worry that some doctors did not require this vaccination for the pregnant mothers they had seen. The worry has some basis. As the 1994 Eastern Samar MCH Study had shown, a great majority of the pregnant mothers eventually called the hilots to attend their birthing in their homes, even if these mothers had sought pre-natal care from health professionals (i.e., rural health midwives and doctors). From the above table, we can also derive the Tetanus Toxoid Plus (TT2+) coverage, the percentage of women given two or more doses of TT vaccination during and/or prior to pregnancy of their children aged 0-23 months. The result shows a TT2+ coverage for more than two-thirds (68.7 percent) of the women in the sample. TABLE 10. Percentage of children 0-23 months of age who were protected against neonatal tetanus as a result of mother’s tetanus toxoid vaccination.
Note: Protection at birth - is the level of protection against neonatal tetanus of an infant as determined by the mother’s TTV status. A child is Protected at Birth if mother:
Table 10 presents the number and percentage of children aged 0-23 months who were protected against neonatal tetanus as a result of their mothers’ tetanus toxoid vaccinations, based on the qualification criteria enumerated under the table. The data show that more than three-fifths (575 or 61.8 percent) of these children were protected against neonatal tetanus during pregnancy by their mothers. Nearly two-fifths (355 children or 38.2 percent) were not protected against neonatal tetanus according to the qualification criteria (i.e., received at least 2 or more doses of TT injections during pregnancy with reference child; or, received one TT injection during pregnancy with reference child plus at least 2 TT injections prior to this pregnancy; or, received at least 3 TT injections prior to pregnancy with reference child). TABLE 11. Main Reason for Not Receiving Tetanus Toxoid During Pregnancy with Child Aged 0-23 Months.
Table 11 presents the main reason why 348 mothers did not receive tetanus toxoid vaccinations during pregnancy with their children aged 0-23 months. Nearly one-fourth (81 or 23.3 percent) of these mothers claimed they "never had any pre-natal care or check-up," an answer often qualified to refer to the care provided by the rural health midwife. It seems some mothers intentionally avoided consulting the RHM for pre-natal care, because this usually involved administration of the tetanus toxoid vaccine, which they morbidly fear. One-fifth (72 or 20.7 percent) of the mothers did not receive TT vaccines during their pregnancy because they already "had complete TT immunization" (i.e., at least three previous TT injections). One-out-of-seven mothers (48 or 13.8 percent) claimed they were "unaware of (the) need for tetanus toxoid injection." This answer is usually associated with various fears, including "fear of injection," a non-coded answer given by 35 mothers (10 percent) and ranked No. 4, and "fear of side reactions" given by 25 mothers (7.2 percent). Of note, "advised against tetanus toxoid injection," a coded answer cited by only three respondents, seems to indicate the virtual disappearance of the nationwide tetanus toxoid scare in 1995.
TABLE 12. Main Reason for Not Receiving Tetanus Toxoid
During Previous Pregnancies or During National Immunization Days
or Oplan Alis Disease.
Table 12 presents the main reason for not receiving tetanus toxoid vaccinations during previous pregnancies or during National Immunization Days or Oplan Alis Disease. The data show that "unaware of need for tetanus toxoid injection" was given by 110 mothers (32.4 percent), or almost one-third of the 339 mothers in the category. Again, as cited earlier, this answer seems associated with various fears. The other leading reasons also seem to echo the same fear of TT injections. The morbid fear of injections among many mothers should be factored in the program plans for tetanus toxoid vaccination as a public health intervention. Rural health midwives should be allowed to deload from their performance targets those mothers who already had three or more TT injections. Then they can focus their motivation efforts on the new set of mothers (estimated 13+ percent increment) and the nearly two-fifths (38.2 percent) of the older mothers whose babies were not protected against neonatal tetanus during their pregnancy. After all, more than half of the latter mothers just need to be convinced to complete their second or third tetanus toxoid injections. D. Child Immunization TABLE 13. Number and percent of children 12-23 months of age who had received vaccines at the time of the survey.
Note: A fully immunized child (FIC) must be given at
least one dose of BCG, 3 doses of DPT, 3 doses of OPV, and Table 13 presents the number and percentage of the sample children aged 12-23 months who had received vaccines at the time of the survey. The data show that 859 children (92.4 percent), or more than nine-out-of-ten, had received an initial dose of immunization against disease. Unfortunately, this nearly total coverage could not be sustained for all the immunization doses. The other 72 children (7.7 percent) in the sample had never been immunized at all. Nearly two-thirds (579 or 62.3 percent) of the children in the sample are considered "fully immunized children" (FIC). This meant they had received at least one dose of BCG, three doses of DPT, three doses of OPV, and one dose of measles vaccines before their first birthday. Another 36 children (3.9 percent) completed their immunizations after their first birthday. More than one-fourth (244 or 26.2 percent) of the children had incomplete immunizations. This meant they had missed at least one of the required (BCG, three DPTs, three OPVs, and measles) vaccines. The study sample had not reached the desired "universal coverage" of immunization (at least 90 percent) for any of the vaccines. More than seven-out-of-eight children (808 or 86.9 percent) had been immunized with the BCG vaccine; at least four-fifths had been given one dose of DPT or OPV vaccine (755 children or 81.2 percent for DPT, and 762 children or 81.9 percent for OPV); and seven-out-of-ten children (653 or 70.2 percent) had been immunized against measles. Less than half (395 or 42.5 percent) of the mothers have kept the immunization records of their children, usually a yellow card issued by the DOH. About half (463 or 49.8 percent) of the mothers could not produce records and merely recalled from memory the vaccines received by their children. Many of them claimed to have lost or misplaced their children’s yellow cards at the time of the survey. Some mothers claimed that yellow cards were not issued by their rural health midwives, who seemed to have run out of stock of this record and instead gave out small pieces of paper as alternative immunization records. Several other mothers claimed their yellow cards were kept by their midwives (perhaps until the completion of the children’s immunizations), an action probably influenced by the observable tendency among many mothers to lose or misplace these cards. The above findings raise questions about the cultural fitness and sustainability of the yellow-card as a home-based record in a characteristically oral-and-visual culture. Of some consolation, most mothers who had lost or misplaced their children’s yellow cards had very good recall (and awareness of the importance) of the vaccines received by their children. The data from the yellow cards shown by 395 mothers present patterns of administration of the different vaccines. BCG vaccines were given at a mean age of 2.9 months and a modal age of one month. DPT1 and OPV1 vaccines were also given at a mean age of 2.9 months, but with a modal age of two months. DPT2 and OPV2 were given at a mean age of 4.6 months and a modal age of three months. DPT3 and OPV3 vaccines were given at a mean age of 6.3 months and a modal age of four months. Measles vaccines were given at a mean age of 9.9 months and a modal age of nine months. Immunization coverage as a variable provides a reliable indicator of performance of the rural health midwife, the health professional assigned at the most peripheral level of the government public health system. She has virtually no competition in this task. In contrast, she competes with other health workers for her other tasks: mainly with the hilot (traditional birth attendant) for the care of pregnant, birthing and post-partum mothers, and with her supervisors in the Rural Health Unit (public health nurse, municipal health officer) for health consultations and provision of family planning services. Performance in child immunization determines the rural health midwife’s capacity and capability to maintain good rapport with the mothers in the catchment area of her BHS, and to keep contact with them on a regular or scheduled basis; to keep the barangay health workers under her supervision motivated and be of help and facilitation in her work; and to be able to get adequate supplies and support (i.e., vaccines and medicines, travel allowance) from her RHU or higher offices. Inadequacy in one or several of these aspects, especially the diminished material support to and technical supervision of RHU operations following the full devolution of health services to local government units (LGUs) effective January 1994, appeared to have significant adverse impact on the RHM’s coverage and performance. As a point of comparison, the 1994 Eastern Samar MCH Study showed better RHM coverage and performance just prior to the full devolution of health services to local government units. About three-fourths (74.4 percent) of the mothers had kept the yellow cards of their children, and more than four-fifths (81 percent) of their children aged 12-36 months had complete immunizations. Since the sample mothers in Eastern Samar had the same average educational attainment (i.e., completed first year high school) as the sample mothers in the present study, the education of the mothers cannot be considered as a differentiating factor here. TABLE 14. Reasons for Not Receiving or Not Completing
Immunization before
Table 14 presents the reasons (multiple responses) for not receiving or not completing the immunizations before the first birthday of the children, as provided by 352 sample mothers whose children fell under these categories. A total of 40 different reasons were cited, 14 of them pre-identified and coded. The leading reason, "mother too busy," points to a constraint on the part of the mother. The second leading reason, "child ill - not brought," points to a child-related constraint. Among the 10 answers with the highest frequencies, there were three open, non-coded answers ("irregular/rare visits of the midwife," "out of town," "unaware of schedule"). "Place too far" highlights a real geographic constraint affecting both mothers and health workers in Samar. "Fear of side reactions," mainly fevers after some immunizations, "unaware of need for immunization," and "no faith in immunization" point to the continuing need for health education and information activities related to child immunization. Eight out of the top 10 reasons given had singular effects on the affected children or their immediate families. But "irregular/rare visits of the midwife" and "health worker absent" appeared to have multiplier effects on many mothers and their children, as was revealed by the findings of this study. Since the RHM usually sets the schedule of the mother’s visit for the next round of immunization for her child, the RHM’s absence on or the postponement of the agreed schedule (usually intervals of six weeks to three months) appeared to have often led to confusion or non-return of the mother with her child. The other reasons in the table are more or less related in some way to several of the top 10 reasons. E. Vitamin A Coverage TABLE 15. Percentage of Children (18-65 months of age)
who received
Table 15 presents the number and percentage of the sample children aged 18-65 months who received Vitamin A capsules as supplements within the six-month period prior to the survey (i.e., as of October 1998). The data show that 854 children (91.8 percent), or more than nine-out-of-ten, had received the vitamin supplements, while 73 children (7.8 percent) had not. Three respondents (0.3 percent) gave "don’t know" answers. The finding shows a "universal coverage" (at least 90 percent) of Vitamin A supplementation among the qualified children population in Samar. TABLE 16. Percentage of children 18-65 months old who received Vitamin A according to source.
Table 16 presents the number and percentage of the sample children who received Vitamin A supplements according to source. The data show that 635 children (74.3 percent), or about three-fourths, had received their vitamin supplements in designated Patak Centers of different barangays. More than one-fifth (191 or 22.4 percent) of the children received their vitamin supplements during visits to their homes of a health worker, usually the local BHW who had been left some vitamin supply by the RHM. The 28 respondents who gave "others" for their answer gave specifics of non-health centers as distribution points - e.g., barangay hall, waiting shed, etc. TABLE 17. Main reason for a child not receiving Vitamin A in the last 6 months.
(April 1-15, 1998) Table 17 presents data on the main reason why 73 children in the sample did not receive Vitamin A supplements within the six-month period prior to the survey. The data show that more than one-third (26 or 35.6 percent) of the respondent mothers in this category did not go to the health/patak centers. The assumption here was that these mothers were aware of the need for Vitamin A, not busy, and knew about the days for Knock-Out Polio (April 15, 1998) and Vitamin A (April 1-15, 1998). About one-fifth (14 or 19.2 percent) of the mothers claimed that Vitamin A was not available at the health center. A few mothers claimed they were busy and had nobody to bring their children to the health/patak center (8 mothers or 10.9 percent) or were unaware of the need for Vitamin A (6 mothers or 8.2 percent). TABLE 18. Main reasons why the mother did not bring
her child to the health center for Vitamin A
Table 18 presents specifics for the main reason why 26 mothers did not bring their children to the health/patak centers for Vitamin A supplementation. More than one-fourth (7 or 26.9 percent) of these mothers claimed they live too far from the health/patak centers. REFERENCES Abilar, Antonio A. and Rolando O. Borrinaga (1988). "Monitoring Population, Health and Borrinaga, Rolando O. (1994). "Report on the Maternal and Child Health (MCH) Survey in | . | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||