Now that a deadly disease is eliminated, childbirth is safer in the Philippines

January 2018

Nurse Mica Kaddaring doesn’t let muddy and slippery terrain stop her from immunizing women and newborns in the remote Autonomous Region of Muslim Mindanao of the Philippines — even when it means losing a shoe along the way.

“My shoe got stuck in the mud, and I walked barefoot until we found a house whose owner lent me his slippers,” says Kaddaring, who goes door-to-door providing antenatal care and vaccines to women in remote areas. “It felt like a really long walk.”
Nurse Mica Kaddaring in an immunization outreach activity in Basilan province, the Philippines. Credit: Basilan Provincial Health Office/UNICEF

However, her patients walked even further, without complaint, to be immunized as part of the Philippines Department of Health’s campaign to eliminate maternal and neonatal tetanus, in collaboration with WHO, UNICEF and other partners.

“Whenever I think of the people in remote areas that could die of diseases that can actually be prevented –and I as a nurse know how to help them — I am inspired to work hard,” says Kaddaring.

Through the support from countless health workers and partners, the Philippines eliminated maternal and neonatal tetanus — a disease that can be prevented through hygienic birth practices and immunization — in November 2017. WHO defines elimination as achieving an incidence rate of less than 1 case of tetanus per 1000 live births in every district in the country.

A more than two decade elimination effort

The country began its elimination efforts in the early 1990s when vaccination coverage reached 70%. But a few years later coverage plummeted due to false allegations that the vaccine caused miscarriages and sterilization. In Manila, tetanus vaccination was banned entirely from 2003 to 2006.

By 2003, the country’s elimination programme was off-track. A review by WHO, UNICEF and the Philippines Department of Health found that an estimated 25% of pregnant women were still not vaccinated; antenatal care, skilled birth attendance and promotion of clean birth practices were limited; and surveillance need to be strengthened to understand where to target their efforts.

A field investigation in Negros Oriental, Philippines, in 2009 as part of an intensive survey to determine tetanus risk in the province. Credit: DOH Region VII

It was clearly time to act. The country, with UNICEF support, launched intensive immunization campaigns and worked on strengthening routine immunization in high-risk areas. WHO worked to train midwives, who provide the majority of vaccines, to discuss vaccine concerns with patients and educate them on clean cord practices.

In 2015, WHO and UNICEF were able to validate that 16 out of 17 regions had eliminated maternal and neonatal tetanus. Only one region remained — the Autonomous Region of Muslim Mindanao (ARMM) and elimination required ensuring that 80% of its pregnant women had received at least three doses of tetanus-containing vaccine.

Nurse Mica Kaddaring administers the Tetanus-diphtheria vaccine to one of the women in ARMM region, the Philippines. Credit: Basilan Provincial Health Office/UNICEF

Targeting the very last region

Challenges included geographical isolation, armed conflict, tribal wars and other security concerns. Health education approaches required area-specific adjustments considering the wide population diversity in terms of ethnicity and dialect. Likewise, engagement of men as heads of the family and as ethnic and religious leaders was crucial for successful implementation.

Between 2016 and 2017, UNICEF funded three rounds of immunization campaigns targeting more than 300 000 women aged 15 to 49 years. The funding supported logistics, training of vaccination teams, transport to isolated communities and community mobilization activities.

The government also created the Midwives in Every Community in ARMM programme (MECA), so more midwives could go door-to-door providing health education and strengthen maternal and child care especially in the hard-to reach communities.

Following immunization activities, another team of health workers check women’s vaccination records to ensure that coverage targets are met in each community. Credit: Basilan Provincial Health Office.

“Though ARMM is a very challenging area to work in, the health department and local government staff really went the extra mile to achieve maternal and neonatal tetanus elimination,” says Dr. Gundo Weiler, WHO Philippines Representative. “I want to congratulate all health workers and mothers who have made this feat possible”.

In November 2017, WHO and UNICEF conducted the final desk review and found every region in the Philippines had now eliminated maternal and neonatal tetanus. The validation meant the Philippines became the 44th country to eliminate the disease.

“While the MNTE status has been achieved, now the goal is to sustain this remarkable achievement. This is possible through a concerted effort to enhance access to quality antenatal care, skilled attendance at birth and tetanus vaccination for all pregnant women, including those living in the remotest areas of the country, ” says Ms. Lotta Sylwander, UNICEF Philippines Representative.

Countries still facing the threat

Worldwide, 15 countries still face the threat of maternal and neonatal tetanus. The Maternal and Neonatal Tetanus Elimination initiative, launched by WHO, UNICEF and UNFPA in 1999, aims to make the disease a public health problem of the past. Unlike polio and smallpox, tetanus cannot be eradicated, but through immunization and promotion of clean birth practices the disease can be eliminated.

Women in Sulu province in ARMM proudly show their vaccination cards, proof that they received protection against tetanus. Credit: Sulu Provincial Health Office