New status for the hilot
When 75 per cent of births turned out still to be handled by hilots-traditional birth attendants- the Philippines' Department of Health decided to re-train them and bring them into the health team
BY AMANSIA MANGAY-ANGARA
Traditional birth attendants- hi/ots- have probably been practising their skills in the Phil- ippines since the earliest history ... ..,.... of the country's predominantly Malay population. This is suggested by the similarity of hilot practices with those of the bidan of Malaysia and the dukun of Indonesia. Such practices pro- bably emerged out of the necessity for mutual help among womenfolk in the small villages many centuries before modern medicine was introduced to the country.
ln the traditional village society there have always been such categories of indi- genous healers as the herbalist, the bone setter, the faith healer and the hilot. The latter usually confines her activities to attendance at birth and to the care of the newborn child. Her services vary but often include offering such assistance with household chores as is traditionally demanded by good neighbourly practice in the village. It is largely through main- taining this combination of services to the mother, the child and the household that the hilot has survived and continues to be accepted by the local community to the present day even though modern health care has since become available to the rural population.
Unfortunately, the hi lot's practices have time and again contributed to maternal and infant morbidity and mar-
Mrs Rosa Raymundo, a traditional birth at- tendant, dons a plastic apron before bathing a newborn child, as she has been taught during special training. (Photo WHO fl. Abcede)
Traditional Birth Attendants Still the greatest barrier to<~e.alizing the proper potential of traditional birth attendants (TBAs) today is the resistance of some professional health workers.· Bu.t TBAs still deliver two- thirds of the babies in the world. In Asia. Africa and Latin America they are accorded, for the most part very,high prestige in theif villages.
Several countries have already started on-going training programmes for
th,~~~ women. to e..nsure that they offer safe midwife'ry practices where they will be most eff~ctive. Other countries are beginning to encourage them and g,ive them additioqal training so as to >gain for them increasing involvement in primary health care activities.
Several countries have also tried to explore thei{ full potential in family planning programmes. They have proved capable of making useful con- tributions to family planning
com-
munication activities in Indonesia (where they are known as dukuns).
Malaysia ·(as bidans), Mexico (as parteras) and India (as dais). There is probably no reasonable alternative for government maternal health and family planning programmes but to join hands with TBAs. The findings and . recommer)dations of various studies have repeatedly shown that
thei ,enjoy a relatively high' degree
of credibil'ity in ,the eyes of villagers and the urban poor. while their potential for incorporation as partners in public Health vyork is a very
practical reatity. ·
tality. She performs very few manipula- tions during childbirth; the newborn is passively received under cover of a cloth to conceal the mother's private parts.
Although some complications in the mother may result from errors of omis- sion by the birth attendant, such as fai- lure to protect the perineum, others may follow acts of commission such as apply- ing manual pressure on the fundus of the uterus to facilitate expulsion of the fetus, causing a subsequent rupture. In the case of the newborn child, errors of commis- sion are frequent; it is common for the umbilical cord to be cut with a non- sterilized knife or bamboo blade and the application of some powder, chopped tobacco leaves or even dried horse manure on the cord dressing. Practices of this nature are responsible for the high incidence of tetanus of the newborn in the Philippines.
Until around the early 1950s the Government's general attitude had been to discourage hilot practice and to pro- mote their replacement by trained licensed midwives. In 1954, the Depart- ment of Health reviewed the prevailing status of midwifery services and found that a large proportion of births (about 75 per cent) were attended by traditional midwives. While infant and mortality rates were high, available trained health manpower was grossly insufficient to meet the demands for midwifery services, particularly in the rural areas.
Largely as a consequence of these find- ings, and of the realization that while the country's population was rapidly on the increase its health resources were insuffi- cient, a revised strategy was evolved.
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This included some concessions to hilot practice in localities where the services of practising physicians or registered mid- wives were not available. Within this new policy frame, traditional birth attendants would receive such training and orienta- tion on hygienic procedures and routine midwifery practices as would promote the safety of the mother and the newborn child; they would also be given health staff supervision and guidance in the course of their work.
In 1954, with WHO and UNICEF assis- tance, the Department of Health initiat- ed the training of hilots as part of the country's midwifery training pro- gramme. Priority was given first to staff involved in teaching and supervision such as nurse-midwife supervisors at the central level, then at the regional and later at the provincial and local levels.
This was followed by a teaching pro- 20
gramme to make hilot practice safer for mothers and to encourage the birth ·at- tendants to seek guidance and assistance from the trained health personnel.
This training was first conducted by a provincial nurse supervisor who had herself undergone training under the midwifery training programme. Her un- derstudy was a nurse or midwife of the rural health unit or puericulture (mother and child health) centre, who took over as instructor of subsequent hilot classes.
The classes are usually organized in groups of ten, and the course consists of 12 weekly or bi-weekly meetings each lasting three hours. Instruction is given in the local dialect. A hilot who satisfac- torily completes a course is given a
UNICEF midwifery kit and issued with a record book to insert the necessary infor- mation needed to register the birth of the child she has delivered or report any
New status for the hilot
Left: Hilot Asuncion Sag ins in pays a pre- natal visit to a patient. The Philippines' Government has introduced a teaching pro- gramme to make hilot practice safer for moth- ers and to encourage the traditional birth attendants, to seek guidance from trained health personnel when needed.
Right: Nurse Felicitas Bautista graphically explains to a class of hilots-in-training the basic steps to be taken when· attending deliv- eries. (Photos WHOfJ. Abeede)
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...
birth which has not yet been registered.
After training, the birth attendants orga- nize themselves into a local association which holds monthly follow-up meet- ings. At these meetings, the nurse or midwife of the rural health unit inspects their kits and evaluates reports of their activities.
Now that official recognition has been given to the trained hilots, and with the increasing acceptance of the health aux- iliary or aide in providing health care, the hilot is being encouraged to get herself involved in a wider variety of community health activities. These in- clude helping to notify communicable diseases, organizing mothers' classes, registering births, helping to arrange mother and child referrals to the health centre or hospital, participating in the housekeeping at the health centre, assist- ing in community immunization round-
ups and collaborating in the family plan- ning programme by motivating mothers and following up those who accept the services. On the whole, hilot training and the broadening of her participation in community health work have forged stronger links between the traditional birth attendant and the local health staff.
She has thus become an important resource in the local health service even though she is still not a member of the health team. She receives neither com- pensation, honorarium nor daily wages for her services. The remuneration she receives from the mother may be in the form of a gift or sometimes in cash, but more often her services amount to simple acts of goodwill and good neighbour- liness.
The Government's goal of ultimately replacing the hilots with licensed mid- wives remains unchanged. But consider-
ing the limited resources and the magni- tude of existing health problems, it will take some considerable time before the Government's goal can be achieved.
Therefore the stop-gap arrangements for training the hilot and involving her in health services are proceeding with more active Government support as well as the endorsement of various sectors of the local community. Increasing attention is being given to the hilot as a potential health manpower resource capable of being trained and guided to respond to local community health demands, partic- ularly for mother and child care.
With a view to obtaining more accu- rate information about the hilot man- power resources in the country, the Department of Health carried out a nationwide survey in 1974 with the help of a WHO grant. The objective was to obtain information on the number of
traditional birth attendants in practice, where they live and other useful data which would enable central and local hilot registries to be drawn up. More than 31,000 hilots- both men and wom- en- were identified. On the basis of the findings it was calculated that the total number who were in practice was be- tween 38,000 and 40,000, or roughly a ratio of one hilot for every barangay- the smallest local administrative unit with an average population of 1,000 to 2,000. The registries that have since come into existence will help in identifying those birth attendants who need training and in locating their homes, and will thereby facilitate their supervision by the local health personnel. The registries will be kept constantly up-to-date and will furnish other useful information which will help in designing the hilot training courses in the coming years. •
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