Philippines: barriers impeding reproductive health and rights.

Before the ICPD Programme of Action (POA), women's reproductive bodies and functions were viewed by health and development planners in a fragmented and instrumentalist way, disassociated from women's own agencies. Women's wombs were important for propagating family and race. In the opposite vein, women's wombs were instrumental to bringing down fertility rates, viewed as key to the economic development of poor countries. Furthermore, sexuality and abortion, vital aspects of a reproductive being, were considered subversive of 'Filipino culture' and kept out of public policy and discourse.

In the Philippines, initiating an approach with the POA's health, gender and rights framework meant confronting contrary mindsets and social barriers on three fronts. First is the pro-natalist, anti-contraceptive and anti-condom Catholic Church hierarchy that first came to power in 1986 with the ascension to the presidency of the first woman president, Corazon Aquino. By 1993, the Church lobby had successfully kept women and their children from the government's immunisation campaign by charging--falsely--that the anti-tetanus vaccine caused infertility. Other tactics of the Church included protesting against, and eventually closing down, an NGO cafe that promoted condoms for HIV/AIDS prevention. Smear campaigning against senatorial candidacy of Dr Juan Flavier, a strong advocate of family planning and HIV/AIDS programme fortunately failed. Nevertheless, it demonstrated the tenacity of the Church lobby.

Secondly, the economic technocrats and donor agencies who are fixated on population growth control as the key economic strategy. This group views family planning almost exclusively as an economic remedy with little consideration of reproductive health and rights. Third factor is the debilitated state of the Philippine public health system which subsists on expenditures of 1.5% of gross domestic product and which had been fragmented since 1993 by devolution into over 1,600 totally autonomous local government units.

In spite of these barriers, implementation of the reproductive health approach was embraced with optimism. The United Nations Population Fund (UNFPA) under its Fourth Country Programme actively supported NGO innovations in the area of gender-sensitive programmes, holistic and integrated services, patients' rights, sexuality awareness and education, male involvement, adolescent-centred care, and humane and non-judgmental post-abortion care. Moreover, the Department of Health (DOH) led by the first woman health secretary, Dr. Carmencita Reodica, initiated the 'life-cycle approach' which departed from the traditional focus on women-of-reproductive age. This programme was further strengthened in 2000 by the succeeding DOH administration which laid down the administrative order piloting PMAC (the prevention and management of abortion complications) and introduced the emergency contraceptive pill, Postinor, in government crisis centres for women.

Unfortunately, this favourable environment ended abruptly towards the end of 2000 when the sitting president was ousted by people's protest actions and replaced by the then vice-president, a devout Catholic. Since her presidency in 2001, Gloria Macapagal-Arroyo has banned Postinor, pushed natural family planning and has refused to allocate a single centavo for artificial contraceptives. On the supposition that 'reproductive health' entails the use of abortifacients, she had the term removed from the medium term development programme of the national women's commission and publicly announced her intention to veto the Reproductive Health Bill, a proposal that aims to institutionalise the current reproductive health programme and ensure its regular budgetary appropriations. These retrogressive developments compound a contraceptive supply shortage already triggered by the scheduled phase-out of USAID contraceptive subsidies beginning this year until 2007.

Bad News on the Ground: Likhaan' Likhaan's s Findings

From the period 2000 and 2001, under the above climate, Likhaan undertook two qualitative studies to assess women's reproductive health and rights, specifically with regard to abortion and maternal mortality. The abortion study inquired into the reasons, processes and psychosocial effects of women's experience(s) among 30 interviewees, all of whom came from women organised communities in the poorest sections of Metro Manila. The maternal mortality study, on the other hand, inquired into the social conditions and processes that mediate women's responses to obstetric emergencies. This latter study involved in-depth interviews with women or their surviving relatives and friends involved in 30 cases of emergencies, 12 that led to death and 18 that resulted in survival.

The following are some of our major findings:

* Maternal mortality ravages women at a rate that national policymakers have underestimated up to this day. In the city of Malabon, Metro Manila, which was the site for this particular inquiry, we had up to three deaths every year from 1999 to 2003 for two areas that comprised only 18% of the population of the entire city. The official figure for Malabon in 2001 and 2002 based on field reports was one death per year, estimates that are now deemed unreliable by WHO and most health authorities because maternal deaths are often misclassified and under-reported.

* The maternal mortality study points out the critical role of birth attendants and the functional state of the healthcare system, including maternal care delivery, especially during emergency situations. Nine of the 12 deaths were due to scientifically uninformed and erroneous management by traditional birth attendants (TBAs). Eighteen of the 19 survivors were managed in secondary and tertiary facilities, 15 of which were in public hospitals. Admission to public hospitals was the major hurdle for the patients, some of whom were shuttled between three and four facilities. This access barrier is the result of a severely strained hospital system suffering from patient overload. This dire access situation is bound to worsen when the government starts to implement the corporatisation of government tertiary facilities as part of the DOH's Health Sector Reform Agenda, formulated in 2000.

While government referral facilities are overloaded, the primary healthcare structures, which are now under the authority of the local government executives, are functioning poorly. The primary hospital in Malabon could not provide basic emergency care, such as intravenous fluids and dilation and curettage for patients suffering from miscarriages. The public maternity centre was operating on a budget of Peso 5,000 a year (less than US$100), and midwives working in the health centres were occupied with family planning and other administrative duties, instead of assisting deliveries.

* Care for poor women in government facilities was substandard. Patients in both studies complained of being ignored, neglected, scolded and shamed. The treatment is particularly worse for women consulting for complications of abortion, whether induced or spontaneous.

* Factors like the ability to make informed decisions and level of assertiveness affected women's lives and chances of survival. In the maternal mortality study, the women who survived were those who persisted to overcome the many-layered barriers of hospital admission and their own lack of funds, or those whose relatives persisted for them.

In the abortion study, many of the abortions undergone were to explicitly reduce or limit the number of children. These women could have benefited from the use of contraception as utilisation of artificial contraceptive was low and sporadic. These women either did not see the need for proactive contraception or relied on ineffective methods.

Continuing the use of risk assessment--which supposedly predicts who are likely to face delivery complications and who would not-is dangerous given the weight of evidence supporting the statement that most life-threatening obstetric complications cannot be predicted or prevented, but they can be treated. Strengthening Emergency Obstetric Care in the healthcare system, which includes intravenous fluids, manual removal of the placenta, blood transfusion and caesarean section, will involve upgrading facility and personnel capacity, redefining the roles of midwives and TBAs, and reinventing the power relationship between women and their healthcare providers.

Educating health professionals and students about the medical ethics of abortion including respect for patients' dignity and autonomy, is critical. Another strategy is to help women optimise the use of contraceptives to reduce unwanted pregnancies and the recourse to abortion. Unfortunately legalisation of abortion, the one option that would reduce women's death and disability due to unsafe abortion, is a remote prospect in Catholic Philippines.

* By Junice Melgar, MD, Executive Director, Likhaan, 92 Times St., West Triangle Homes, Quezon City 1104 Philippines. Tel: [phone] Fax: [phone] Email: [e-mail]

* Endnotes Likhaan. 2004. "Country NGO monitoring report, Philippines", in ARROW (ed.). Monitoring ICPD Ten Years On. Kuala Lumpur: ARROW [unpublished] Website: www.arrow.org.my

Likhaan. 2004. Study on maternal mortality. Manila. Likhaan. [Unpublished]