Women in the Philippines speak on reproductive health services.
The main reason women gave for choosing the hospital was its low cost or free service. Other reasons included referrals by other hospitals and service providers, availability of equipment and facilities, competence of doctors and proximity. In terms of the cost of health services, public transport and ambulance costs were significant barriers to accessing health care. Although treatment was free, women had to purchase medication, blood for transfusions and other supplies. Doctors interviewed said at times doctors themselves gave money to patients to purchase medical supplies. Said one woman:
"We are financially constrained. Even if I prefer a private hospital, we could not afford it. We know it is free here because this is a public hospital". Many women felt the waiting time before receiving medical care was unreasonably long. Said one woman:
"After the interview at the emergency room, they sent me to the delivery room. There I waited again for a long time because there were just too many women on the delivery tables and in the labour room."
Women living in remote places with inadequate transport were particularly at a disadvantage, as often lack of evenly distributed equipped health facilities, poor roads and long distances have serious consequences for these women.
Quality of Services
Quality of care explored the quality of health services in terms of interpersonal relations, extent of family planning services available, security and safety and clients' satisfaction. Women complained about the poor and impersonal treatment meted out by staff during labour and delivery. "They should understand that labour pains can be very painful. So I shouted every time I could not bear the pain. Women are not the same, some women can bear the pain but some cannot. The doctors covered my mouth with a diaper cloth. I really felt very bad with this insensitive treatment," said a rural housekeeper of 23 years who had three children through normal delivery.
"I felt like I was a pig in a slaughterhouse where women fall in line for every procedure. We wait in line for the interview at the front desk, medical history by the doctor, internal examination (IE) and other procedures. At the IE room everything is rushed and the doctor is insensitive. Why don't you spread your legs wider? ... move fast, because there are still others waiting! ... okay you're done, next! The procedure is painful, but their rude treatment is even more painful. I don't want to be treated like this", said one woman.
Doctors interviewed said both doctors and nurses are over burdened with workload. "We are institutionally abused and not given proper working conditions with too many patients per doctor, inadequate facilities and support staff. We push the stretcher and try to secure the medicine and blood supplies, while the husband just looks on and asks us to take care of his wife as he has no money," said one doctor.
Apart from a challenging workload, doctors cited other problems, including lack of supplies, inadequate equipment, shortage of staff and 'difficult clients'.
"It is difficult to handle women who have never been hospitalised. They are shocked at the lack of personal care and privacy, very unlike what they find at home or in private hospitals," said one doctor.
"There are patients who are 'maarte' (demanding). They move a lot on the delivery table, which is really high. I tell them they might fail but some just refuse to listen. Sometimes there's no use talking to the patients. I shout at them when they become unreasonable. There are patients who shout really loud because of the pain. We explain to them that they should not lose their energy by shouting because they need to bear down. Some doctors would give patients a diaper cloth to bite on. When they concentrate on biting the diaper cloth, the delivery room will be quieter," said one doctor.
Women interviewed generally cited negative and unpleasant experiences with regards to care and services at the hospital. Women often hesitated to express feelings and complaints to health providers for fear of rejection or rude treatment. Their views were confirmed by the attitudes of doctors who were often judgemental.
"I can't understand why women resort to abortion. There are people who want a baby and yet there are women who have no qualms having abortion. And when a woman comes here, she has no money, "said one doctor.
Doctors interviewed tended to emphasise the criminal aspect of abortion to the women. Most women interviewed had not received family planning counselling from health providers. Women complained while they were cautioned by doctors against getting pregnant, they received no information about family planning methods.
"I told the doctor that I want to have tubal ligation and that I might regret it in the future as aft my kids are girls. She declined saying that I was too young. And yet, she did not even give me information about other family planning methods, not even pills," said one woman.
The gender-sensitivity of the service was assessed using variables such as spousal support, consent for ligation and hospital bed allocation. Researchers noted that the obstetric ward was always full and it was not uncommon to see three women and their babies sharing two beds. The delivery room lacked privacy as it was open to doctors, nurses, midwives, medical students, cleaning staff and nursing aides.
"After the interview at the emergency room, they sent me to the delivery room. There I waited again for a long time because there were just too many women on the delivery tables and in the labour room. I think dilation and curettage cases had to give way for delivery cases," said one woman.
An important aspect of gender-sensitive health care is that women, individually and collectively, are treated with dignity and respect, able to make informed decisions, allowed to become equal partners in decisions about their own health care and allowed to contribute their views to health planning and research.
The study revealed that women were given limited decision-making powers with regards to reproductive choice. There was evidence of deficiencies in informed consent and choice relating to medical interventions. For example, two rural women underwent tubal ligation during caesarean section. Their husbands made the decisions while both were unconscious and both women remain confused as to why the doctors chose to perform the tubal ligation procedure based solely on their husband's consent.
Furthermore, in cases of abortion, a husband's consent was mandatory and in emergency circumstances, only the husband's consent was required. This finding indicates that there is gender bias or gender stereotyping regarding spousal consent for tubal ligation.
Findings from the research were discussed at training sessions on gender-sensitive health care and ethics of care for health providers at the hospital. Meetings with management to disseminate findings led to the eventual setting up of a client suggestion box, curtains in the delivery room and a special area for relatives at the birthing place. Doctors are also now more involved in the women's crisis unit on violence against women at the hospital and in advocacy and capacity building on issues related to women's health.
Sanchez, Rosena; Ingente, Regina; 2003. "Women's access to reproductive health services in a public hospital in the Philippines", in The Asian-Pacific Resource and Research Centre for Women (ARROW). 2003. Access to Quality Gender-Sensitive Health Services: Women-Centred Action Research. Kuala Lumpur: ARROW. p61-80
ARROW. 2000. "Gender-sensitive health care". ARROWs For Change. Vol. 6, No. 1. Kuala Lumpur: ARROW.
Osteria [et al.]. 1997. Gender, Sexuality and Reproductive Health. The Life Cycle Approach. Manila.
WHO. 1996. Qualitative Research for Health Programmes. Geneva: Division of Mental Health and Prevention of Substance Abuse, World Health Organisation.
Sanchez, Rosena [et al.] 1996. Abortion and Reproductive Health Among Women in Davao. Philippines: Ateneo de Davao University, Davao City.
Rosena Sanchez, Social Researcher, Ateneo Davao University, Jaconta St., Davao City 8000, Philippines. Tel/ Fax 63 82 224 2955. E-mail: firstname.lastname@example.org
Regina P. Ingente, Medical Doctor, Davao Doctors Hospital. Quirino Avenue, 8000 Davao City. Tel: 63 82 222 8898/6898. E-mail: email@example.com