Eyewitness to a home birth in the city

“Ana, please, one more time,” Ana’s mother exhorted, as she dipped closer to her daughter’s head, clasping tight Ana’s right hand, running her left hand over her daughter’s cropped hair.

“Push one more time, please,” she whispered close to Ana’s ear.

Ana remained still, her eyes closed.

“Just one more time, then the midwife can bathe your child. Please.” This time, it was Ana’s mother-in-law who cajoled her to push. Just one more time.

Ana, 28, had just given birth a few minutes ago and her second child, a boy, was shrieking beside her on a blanket, his skin still smeared with blood and a thin, oily white sheath.

The labor was short, and the baby came out in less than an hour after the pregnant Ana had lain on her bed right by the flotilla of fighter-planes postcards pinned on a corkboard below the sky-blue cotton towel hanging on a rack right next to the 14-inch television set.

As the financial crisis continues to ripple its effects towards the economic peripheries, Ana is one among the increasing number of pregnant women who risk the complications of birthing at home.

But she is not representative of the woman who would usually opt for such home birthing. Neither is she among those who fancy home birthing as a back-to-basics defiant act against established tradition or governmental advice for healthy and safe motherhood.

In the 1900s and at the beginning of the new century, women who gave birth at home were rural residents and availed of the services of the traditional, non-medically trained “hilot”, a traditional birth attendant.

By 2000, 65.3 percent of the total births in the country was attended by doctors, nurses and midwives. The figure is a high jump from that of a 1993 National Safe Motherhood Survey showing that 75 per cent of deliveries in the Philippines take place at home, with a “hilot”, attending 73 percent of the deliveries.

Almost two decades ago, home births used to make up 85 percent of deliveries in the rural areas, and 54 percent in the urban areas. By 2004, the number of women who opt to have medical attendants increased to 67.6 per cent, most of them giving birth in a hospital or clinic.

By 2008, the latest National Demographic Health Survey shows that only 44 per cent of women give birth in health facilities like hospitals while 56 per cent of children are delivered at home.

In urbanized cities like Cagayan de Oro, the figures are much higher, with cities in the National Capital Region at a high of 75 to 82 percent of births at a hospital or clinic.

City-bred Ana is an urbanite at heart. Her family lives in an apartment just a tricycle ride away from the financial district and a mere five-minute brisk walk away from the nearest private hospital.

Ana is schooled and has an accounting degree and so is her husband but the times had been difficult for both them lately. The husband has been jobless for months and she is juggling her hours selling herbal medicines and bookkeeping for small firms.

“I think it is safe to give birth at home. As long as you have prepared well and have gotten pre-natal counseling,” she said, assuring herself a few hours ago as her labor pains began.

She also trusted her midwife, who had assisted at the births of other mothers in the neighborhood in the past seven months previous to her own. “May is a professional and has a lot of experience.”

There was a popular “hilot” in the barangay who got medical training and had delivered births for decades but she had recently died. No one trained under her wing anymore. But Ana noted that several young girls and boys are now taking midwifery courses, a cheaper and shorter route to a medically-related profession than nursing or medicine.

May the midwife works at a public hospital but lately has been accepting requests for home-based deliveries. “It helps me earn more,” she said. She had to ask permission from her supervisor who allowed her to accept appointments as long as it does not interfere with her regular 8-hour day shifts. She earns at least PhilP1,800 (US$43) for each delivery but she also has to provide post-natal care and counseling for both mother and child. A hospital-based delivery could costs between PhilP5-10,000 (US$119-238).

“But really each delivery means a bigger responsibility for me. I have to plan for emergencies,” she said. “I have to make quick decisions. Like bringing the patient to the hospital.”
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Under the Philippine Midwifery Law, midwives like her are allowed to supervise and care for women during pregnancy, labor and normal delivery. But this particular delivery with Ana was unnerving to her, she would confide later when it was over. It could have lead to one of the causes of maternal deaths, post-partum complications like hemorrhage or hypertension

That’s why all the women were coaxing Ana to push once more because the placenta was still inside her. Normally, it should come out with the baby.

“Anybody who took note of the time? How long since the baby came out?” asked the midwife, a slight sign of worry in her otherwise calm voice.

She was still in front of the prostrate Ana, trying to pull the rope-thick sheath connected to the placenta, the way a fisherman would hold a rope tied to a boat being borne away by the high tide, holding it tight and tugging back with all his strength so the vessel could be tied safely to a buoy.

“Tell me when it is past 20 minutes.”

Ana’s mom looked at her watch. About 15 minutes, she said.

“You can make it, one more push and this will be over,” the midwife said. Still Ana won’t move.

“We’ve got to get the placenta out now or else, we have to go to the hospital,” said the midwife, her voice almost a command.

At that moment, as if she had heard some magic phrase, Ana heaved and pushed hard once more and moved the placenta out.

(This is an updated version of a previously published article that appeared in the Philippine Daily Inquirer and allvoices.com)