Background: One of the strategies adopted by the Department of Health (DOH) to improve maternal outcomes is the systems approach which means understanding extensively how the system operates to determine factors affecting the delivery of services. In 2014, Albay province responded by adapting and implementing the Maternal, Newborn and Child Health, and Nutrition (MNCHN) Service Delivery Network Guidelines. However, no external monitoring and evaluation have been done to assess the compliance of birthing facilities to these guidelines. Objectives: To determine Legazpi city’s obstetric service delivery network functionality and to compare government and private primary level birthing facilities in terms of 1) governance; 2) human resources; 3) protocols; 4) transportation and communication; and 5) emergency drugs and equipment. Materials and Methods: A cross-sectional study using the referral system assessment (RSA) questionnaire translated into a scorecard with a review of secondary data on high-risk pregnancies, referral rates, and maternal mortalities was done on eight facilities in Legazpi City. Results: Overall, none of the health facilities assessed were fully-functional. Privately owned facilities scored highest in emergency drugs and equipment (83.3%) and lowest in human resources (38.9%). Government facilities scored highest in emergency drugs and equipment (88.9%) but lowest in transportation and communication (44.4%). Statistically significant differences were observed for human resources (p-value=0.0180), wherein public facilities garnered higher scores, and in transportation and communication (p-value=0.0294), private facilities showed better scores. Only one maternal death in 418 referrals was reported. Conclusion Overall, the health facilities varied in the level of functionality in terms of SDN guidelines.
Birthing Centers

Background: Teaching clinics provide low-cost health programs while offering valuable learning opportunities for student clinicians, which then contributes to increasing health care accessibility. To date, there is a paucity of literature exploring the satisfaction of patient seen in rehabilitation teaching clinics in developing countries. The Service Quality (ServQual) Scale is a valid and reliable tool that has been used to measure client satisfaction in different work settings and industries.

Objectives: The aim of this study was to demonstrate the usefulness of ServQual
in measuring the satisfaction of clients in a rehabilitation teaching clinic in a developing country.

Methodology: A cross-sectional survey was conducted for three months among CTS-AA (Clinic for Therapy Services- Adult and Adolescent Section) clients who are at least 18 years old; have attended at least three sessions; and can read. Prior to
administration in CTS-AA, the ServQual scale was translated to Filipino, validated
and pilot tested for reliability.

Results: Thirty-two respondents were included in the analysis. there was no
statistically significant difference between the expectation and the perceptions
of the clients for the domains of reliability (z=1.799, p=0.0721),responsiveness (z=0.839, p=0.4013), assurance (z=1.914, p=0.0556) and empathy (z=1.772, p=0.0764). However, there was a statistically significant difference between the clients' perception and expectation for tangibles (z=4.117, p<0.0001) and between the overall client perception and expectation (z=4.086, p<0.0001).The overall ServQual score for CTS-AA is -0.3782.

Conclusion: The ServQual has been shown to be useful in assessing the satisfaction of clients in rehabilitation clinics and the specific areas that needs improvement. The tool can still be further improved by including items on cost, relationship of students with supervisors and outcomes of treatment.

Objectives: To A functioning referral system is critical to the maternal health program, especially in the management of obstetric emergencies. This study explored supply-side barriers affecting the effective implementation of the said service delivery network (SDN) in Legazpi, Albay in the Bicol Region of the Philippines. Methods: Face-to-face in-depth interviews using semi-structured questionnaires were performed with health care providers involved in the SDN in Albay. Extensive note taking was done by the primary investigator while participants were observed during performance of duties from June - November 2018. Interviews were audio-recorded, transcribed, translated into English, and analyzed thematically along with the observation notes using NVivo. A deductive-dominant approach was utilized for the data content analysis. Results: Referral system barriers identified were cross-cutting across the different components of the health system such as governance, human health resource, service delivery and information systems. The barriers were further classified into individual, organizational and external-related factors in relation to the SDN. Examples of barriers included lack of knowledge of protocols and guidelines, lack of coordination between facilities, poor data management, inadequate capacity building opportunities, and constantly changing political landscape and policies. Conclusions The study is the first to explore barriers to effective service delivery network in maternal health in the country. Findings from the study provide significant insight to areas of improvement in the SDN that must be addressed to strengthen local health systems, especially with the country’s movement towards Universal Health Care where local health systems play a key role.
Maternal Health Services ; Referral and Consultation

Background: Since 1976, Bicol Region had higher maternal mortality ratio (MMR) than the Philippine average and became the fourth region with the highest MMR in 2012. Looking at trends of maternal health outcomes and determining risk factors among mothers who died may guide interventions to reduce MMR. Objectives: To determine the changes in maternal mortality ratio (MMR) in the Bicol region from 2004 to 2017 and determine the sociodemographic profile of pregnant women who died from 2015 to 2018. Materials and Methods: A records review of Bicol?s Regional Field Health Services Information System from 2004 to 2017 and maternal death review reports from 2015 to 2018 was done. Changes in MMR was determined using Poisson regression. The sociodemographic characteristics and causes of maternal deaths were analyzed using frequencies and proportion. Results: From 2004 to 2017, MMR of 100.9 remained higher than the regional target of 31.6. Significant reductions in MMR were achieved in 2007 to 2008 and in 2011 to 2012 wherein MMR ranged between 75.3 to 89.3. However, by the end of 2012, maternal deaths again increased which reached 122.5 in 2017. From the maternal death reviews, it was observed that 29.5% of maternal deaths were aged 35 years and above and 7.5% were less than 20 years old. Mothers who had more than five pregnancies were 30.1% of total deaths. In terms of place of death, 15.7% died at home or in-transit to referral facilities. Hemorrhage or hypertension-related causes were the leading reasons for maternal deaths. Conclusion Significant reduction in MMR was not sustained after 2012 and higher deaths were reported in the succeeding years. Maternal deaths can be further reduced by using a systems approach, by promoting family planning, and by strengthening service delivery networks to effectively manage hemorrhage and hypertension-related emergencies.
Maternal Mortality ; Maternal Health

Objectives: The availability of emergency obstetric and newborn care (EmONC) services is one of the key strategies in improving maternal health and achieving Sustainable Development Goal 3. Health staff knowledge and competency on these interventions are crucial to ensure the effective handling and management of obstetric and newborn emergencies. Health workers, despite having undergone formal training, require regular refresher courses to keep up with new, evidence-based information on EmONC intervention; and to ensure compliance with national and local referral guidelines. A two-day workshop was implemented to assess the knowledge and skills of health workers in Legazpi, Albay, regarding obstetric emergency cases and referral guidelines.

Methods: A pretest was conducted on the first day to assess the knowledge of the participants. A series of lectures were given before administering a posttest at the end of these lectures. An Objective Structured Clinical Examination (OSCE) was conducted on the second day, which aimed to assess the skills of the participants.

Results: The pretest findings indicated that the participants are generally knowledgeable about areas such as handwashing and prenatal care. Results of the posttest show that participants had difficulty with the category of referrals. Moreover, comparing the pretest and posttest scores, there is strong evidence that there is a difference in the median values of the pretest scores as compared to the posttest scores. The results of the OSCE also indicate the need for further training on partograph use and adherence to an EINC protocol. More than half of the participants passed all five parts of the OSCE.

Conclusion: The workshop contributed to an improvement in the knowledge of health care workers in obstetric emergency cases. Skills-wise, more frequent training may need to be conducted to improve other competencies such as partograph utilization and the practice of EINC interventions.

Key Words: emergency obstetric care, training, skilled birth attendants, knowledge, skills