Shalom Birthing Center
About an hour’s dusty, traffic-ingested taxi ride out of Manila’s business center, we found ourselves in a bustling jungle town partway up a mountain. As we curved up the winding roads, we could see a bit of Manila’s epicenter rising in the distance, framed by tropical forestry and roadside shops with corrugated tin roofs. After a few navigation errors, we finally came up to the three-story complex that serves as the Shalom Birthing Center, a non-profit clinic designed to provide prenatal, antenatal (during labor), and postnatal care to the surrounding village. This birthing clinic does not exist in a silo; dozens of non-profit (and for-profit) clinics of various types exist around Manila. However, our role in visiting this one was not only to see what resources were available for impending Filipino mothers, but as a first step in better understanding the role non-profit organizations play within the larger international development sphere. Specifically over the course of our trip we will be asking:
- How should non-profits interact with other aspects of an ecosystem such as private industry or government agencies?
- What makes a non-profit effective, and how can the more ineffective ones improve or change?
- How should non-profits work within systems known for corruption, inefficiencies, and under changing regulations?
- How do locals view non-profits, and are they involved in any capacity (working for the non-profit, paying a small portion for any services provided, providing feedback)?
Non-profit organizations make up a key part of the aid and international development ecosystem, and while our trip only scratches the surface of the complex web in which non-profits and public and private organizations exist, I am eager to begin the journey to understand more.
Maternal-Child Health in the Philippines: An Overview
Shalom birthing center was birthed (pun intended) out of the need to provide better maternal-child healthcare in the greater Manila area; while Philippines’ infant mortality rate has decreased by 35% over the last 20 years (33.5 per 1,000 live births in 1995 vs. 21.5 in 2016, according to the World Bank), they are still 102nd out of 221 countries in infant mortality rate. The maternal mortality rate has only dropped by 6% since 1995, making Philippine’s 70th out of 181 countries on this index [1]. Additionally, use of contraceptive methods has barely improved in the Philippines over the last 20 years. However, percentage of births attended by skilled health personnel (doctors, nurses or midwives) has increased by almost 20% over this same time period [2]. “Countdown to 2030”, an organization that tracks progress to universal coverage for women’s, children’s, and adolescent health has a fascinating data graphic for Philippines maternal-child healthcare per year with other interesting ways of breaking down the problem by demographic, policy, nutrition, equity, water and sanitation, and overall health for these populations; below is their 2015 graphic [3]. While the Philippines has made progress, it still has more it can do to make childbirth safer for Filipino mothers and babies.
The Birthing Clinic
We entered a large, humid reception area filled with whirring fans and expectant mothers and were swiftly greeted by a bubbly woman. “I’m Becka,” she told us in her impeccably American accent (we later learned she was actually Swedish, but had grown up in the Philippines herself, surrounded by Americans. Thus the accent). Becka told us that she didn’t have a healthcare background-”If you have any medical questions, you’ll have to ask our interns”-but served as the accountant for the clinic. “I’m training up someone to take over for me when I leave in a few months,” she told us, as she explained her desire to try something different after a long list of accounting jobs. She swiftly showed us the accounting and filing systems she was helping set up as few non-profits have robust finance systems or accounting personnel. When she arrived, many other non-profits approached her to see if she could set up systems for them as well. Becka explained how far the organization of the clinic had come over the past year, with a paper filing system now slowly being replaced by a computer record, which enabled better (albeit imperfect) tracking of patients who missed visits or still needed to pay. At Shalom, patients are required to pay a small fee for services at the clinic; $11 (550 pesos) to give birth, less for their visits beforehand (of note: international development research has shown that it is actually better for people in developing nations to financially contribute rather than just accept aid; for example, at Shalom, it gives them a stake in their own health, and also has been shown to build confidence rather than listlessly developing a “victim-in-need-of-handouts mindset”). While the computer system is growing, Shalom still uses a set of patient chart booklets which the midwives fill out with aspects of prenatal care during each visit, such as date of visit, vitals, date of next visit (see photo). They also use a simple yet ingenious paper clip system to keep track of labs. For example, they put a red paper clip on the book when they need a CBC lab, yellow for urinalysis, and green for ultrasound.
Becka toured us around the rest of the clinic, and we ooh’ed and aah’ed over some small babes that had just been born earlier that day. No labors took place while we were there, so the Filipino midwives buzzing around, checked on the new babies and mothers, provided prenatal check-ups, and educated women on various methods of contraception available to them. Shalom has more than 20 full-time staff including the Filipino midwives, chaplains, janitors, and a missionary nurse/clinical director. Becoming a midwife in the Philippines does not require a university degree, but some of Shalom’s midwives were in school to receive one. A Filipino OB/GYN works part-time at the clinic when she is not at her private clinic in the village. The clinic is able to deal with many small emergencies; the midwives are being trained in neonatal resuscitation, but if larger emergencies (i.e. the need for a C-section) arise, they take the mother to a nearby hospital. “Recently, due to pressure from Western nations, the Philippine’s Department of Health has created stricter rules for childbirth,” Becka told us. “Now, women who have been pregnant four times or more and anyone under 20 is obligated to go to a hospital for delivery.” Becka explained how this was actually more of a problem than a solution, as this rule tended to hit those on the lowest end of the socioeconomic spectrum, who would often opt to give birth at home rather than going into a fearsome and expensive hospital, and she estimated that half of those women actually did stay at home.
Impact of Philippine’s Department of Health Regulations
Despite what it may seem from the DOH’s regulations, the clinic would be able to provide better care in an emergency situation than the hospital, so those “higher risk” patients would have been better off at the clinic. “In the hospital, they don’t have CPAP (a form of respiratory support often used for neonates) and each patient only gets one oxygen tank. Before they can have another one, the family has to go scrounging for money to give to the hospital or else they’re in trouble,” Becka told us. The clinic’s number of births per month, typically 60-100 before the DOH’s new regulations, were now dropping. “Last month we only had 30 births,” Becka said, sighing. I asked her if she knew how other similar clinics had been affected by the regulations. While she knew there were others, Shalom didn’t have any sort of communication or collaboration with them that Becka knew of. I wondered whether, perhaps, the clinics could work together with the Department of Health to create regulations that benefited those who matter most-the patients…but perhaps that is my optimistic naïveté shining through! These questions-how non-profits and government agencies (especially in known highly corrupt nations like the Philippines) can potentially work together-is something I am curious to continue exploring, and if anyone knows of a shining example where this has been done well, I would be interested to hear about it. I was also surprised that Shalom seemed to be unaware of most other non-profit clinics in the Manila area, and I wonder whether collaboration amongst groups with similar missions could be beneficial.
1 https://data.worldbank.org/indicator/SP.DYN.IMRT.IN
Elly & Josh 