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CONTEXT: In the Philippines, abortion is legally
restricted. Nevertheless, many women obtain abortions—often in unsafe
conditions—to avoid unplanned births. In 1994, the estimated abortion rate was
25 per 1,000 women per year; no further research on abortion incidence has been
conducted in the Philippines.
METHODS: Data from 1,658 hospitals were
used to estimate abortion incidence in 2000 and to assess trends between 1994
and 2000, nationally and by region. An indirect estimation methodology was used
to calculate the total number of women hospitalized for complications of
induced abortion in 2000 (averaged data for 1999–2001), the total number of
women having abortions and the rate of induced abortion.
RESULTS: In 2000, an estimated 78,900
women were hospitalized for post-abortion care, 473,400 women had abortions and
the abortion rate was 27 per 1,000 women aged 15–44 per year. The national
abortion rate changed little between 1994 and 2000; however, large increases
occurred in metropolitan Manila
(from 41 to 52) and Visayas (from 11 to 17). The proportions of unplanned
births and unintended pregnancies increased substantially in Manila,
and the use of traditional contraceptive methods increased in Manila and Visayas.
CONCLUSION: The increase in the level of
induced abortion seen in some areas may reflect the difficulties women
experience in obtaining modern contraceptives as a result of social and
political constraints that affect health care provision. Policies and programs
regarding both postabortion care and contraceptive services need improvement.
Summary from: International Family Planning Perspectives,
2005, 31(3):140–149
Illegal or clandestine
abortion has been a relatively neglected issue, in spite of being recognized as
an important component of reproductive health and rights since the 1994
International Conference on Population and Development. An estimated 19 million
unsafe abortions take place worldwide each year—almost all of those occurring
in the developing world.1 The conditions under which such abortions take place
result in serious consequences for women and societies: For example, 13% of
maternal deaths in the developing world are attributed to unsafe abortions.2 In
addition, large costs are incurred by public sector health care systems because
of the provision of medical care to women suffering from abortion
complications. However, insufficient information at the country level
perpetuates the invisibility of the problem and results in governments giving
little priority in policy decisions to improving services for postabortion care
or to expanding contraceptive services to reduce unplanned pregnancy.
In countries like the
Philippines, where induced abortion is against the law,3* many women
nevertheless seek an abortion—despite conditions that may put their health at
risk—rather than give birth to children they cannot care for or do not want. A
study using an indirect methodology estimated that in 1994, there were 400,000
induced abortions in the country and 80,000 women hospitalized for
complications of induced abortion.4 The Department of Health of the Philippines
reported that 12% of all maternal deaths in 1994 were the result of illegal
abortion.5
Studies from the 1970s
onward have shown that despite the law's severity, abortion appears to be
widely practiced.6 Evidence from the mid-1990s indicates that Filipino women of
all social classes and backgrounds are having induced abortions.7 They do so
under varying circumstances, ranging from safe medical procedures performed for
better-off women by trained personnel to procedures in extremely unsafe
conditions for poor women who cannot afford to pay for a surgical abortion. The
evidence of a survey of health professionals in the mid-1990s suggests that
about one-third of women seeking an abortion obtain it from a doctor or nurse,
but a high proportion of women consult traditional practitioners or attempt to
induce the abortion themselves.8
Regrettably, because
induced abortion is punishable by law in the Philippines, the subject tends to
be masked by silence and consequently, public attention to the issue is
minimal. The general secrecy surrounding induced abortion does not mean,
however, that the subject has not been of concern over the past 30 or more
years. A number of medical professionals, lawyers, social scientists,
legislators and women's health advocates, among others, have written on the
subject and worked toward improving health policies and services. In addition,
the Philippines Department of Health provided official guidelines for a
postabortion care program, Prevention and Management of Abortion and its
Complications, and pilot tested such programs in 17 government hospitals by
late 2003.9
Given the likelihood of
changes over the past 10 years in fertility preferences, contraceptive use and
abortion methods, it is of great relevance to know how these changes have
affected the levels of unintended pregnancy and induced abortion, as well as
the safety of induced abortion in the Philippines. For example, has the level
of unintended pregnancy increased over the past decade? What have been the
national and regional trends? And has the number of women hospitalized for
abortion complications declined as abortion methods have changed? In addition,
national survey data show that contraceptive use increased only moderately
between 1993 and 1998, and that in some regions, use of modern methods hardly
increased.10 The proportion of all live births that are unplanned remained at
about 45% between 1993 and 2003, while the gap between actual family size and
wanted family size remained at about one child per woman.11 Might these trends
be related to an increase in unintended pregnancy and abortion, as women
continue to experience difficulties in obtaining modern contraceptive methods
and in achieving the family size they want?
The aim of this article
is to address some of these questions by providing new estimates of abortion in
the Philippines
for the year 2000, and by assessing abortion trends between 1994 and 2000. We
provide estimates of the number of women who were hospitalized in 2000 for the
treatment of complications following unsafe induced abortions; the total number
of women who had induced abortions each year, including both women who
experienced no complications from the procedure and those who did; and the
incidence of induced abortion at national and regional levels. We apply the
same indirect estimation methodology used for our earlier study and, therefore,
have comparable estimates for 2000, allowing assessment of change in the level
of induced abortion between 1994 and 2000.
Also, for the first time,
we estimate unintended pregnancy rates for the Philippines by combining our
estimate of induced abortion with an estimate of the number of unplanned births
based on available national survey data on the planning status of recent
births. We provide estimates of unintended pregnancy rates and the proportion
of pregnancies that are unintended for both 1994 and 2000, nationally and for
the four major regions of the country. These data provide insights into trends
in the root causes of unintended pregnancy and abortion, and increase our
understanding of the factors underlying the level, differentials and trends in
induced abortion, including contraceptive use.
METHODS
Estimating the level of
abortion in the Philippines
involved several steps: collecting information on the number of women
hospitalized due to abortion complications, adjusting this number for
incompleteness, separating out women treated for complications of induced
abortion and calculating the total number of women having an induced
abortion—safe or unsafe—based on the number of women hospitalized. We arrived
at these assumptions after considering all available information concerning the
safety of abortion practice and access to hospitals. These data were then used
to estimate the abortion rate and the abortion ratio. Data on abortion were
combined with survey-based data on total births and unplanned births to
estimate total and unintended pregnancy rates.
Data
As part of licensing
regulations, all hospitals in the Philippines are required to submit
an annual report to their regional Department of Health office that includes
the number of patients treated for each of the top 10 causes of hospital
admission. Although regional health offices are expected to submit these forms
to the national office in Manila,
not all do so. Furthermore, the regional offices that do submit the forms
sometimes have not received records for all hospitals in their region. Although
they are used for basic summary findings on health care provision, the hospital
reports are not compiled, processed or tabulated at the national level to allow
for a detailed analysis of abortion-related hospitalization. As a result, part
of the work of the present study was to collect available forms for all
hospitals in the Philippines
between 1996 and 2001, starting with the records available at the central
Department of Health office, and then obtaining those from each of the 16
regional health offices. Between May 2003 and February 2004, we identified a
total of 2,039 hospitals in the Philippines
and obtained usable reporting forms for 1,658 facilities. Reports were obtained
for 81% of hospitals, representing 89% of hospital beds, indicating that
coverage was very high (not shown).
The sources of data on
contraceptive use, planning status of births and unmet need for contraceptive
services are two national surveys, the 1993 National Demographic Survey (1993
DHS) and the 1998 National Demographic and Health Survey (1998 DHS). In the
1993 DHS, 15,029 women aged 15–49 were interviewed, and in the 1998 DHS, 13,983
women were interviewed. Also, we cite recently released findings for the 2003
DHS survey, in which 13,633 women were interviewed.
Estimating
Abortion Incidence
Several methodological
approaches have been developed to estimate levels of abortion, but all suffer
from high levels of underestimation.12 We chose to use the indirect methodology
developed for the 1994 study based on hospital records13 for several reasons.
First, this methodlogy allows assessment of trends by providing comparable
measures of incidence for both points in time. Second, it provides estimates
not only at the national level, but also for the four major
regions—metropolitan Manila (also known as the
National Capital Region), the rest of Luzon, Visayas and Mindanao).†
Third, it provides an estimate of serious abortion morbidity (that is, the
number of women hospitalized for abortion complications). Finally, it provides
for adjustment for underreporting, unlike most other methods. To account for
some years' incomplete data and for likely actual year-to-year fluctuations, we
calculated estimates based on averaged data for 1999–2001, producing estimates
for the central year, 2000.
•Calculating the total
number of women hospitalized for abortion. We used a three-step methodology to
estimate the number of women treated for abortion complications in all
hospitals, including those for which these data were not directly reported. For
hospitals that reported abortion as one of the 10 leading causes of admission,
we obtained the number from the hospital reports. For hospitals at which abortion
did not rank among the top 10 reported causes, we assumed that admissions for
abortion complications accounted for half as many patients as the number
hospitalized for the lowest or 10th-ranking cause.‡ For all other hospitals
(i.e., those that did not file a report or omitted data on abortion
complications), we entered hospital characteristics§ into a logistic regression
to impute the number from hospitals with information.
In 478 hospitals—about
one in four—abortion was one of the 10 main causes of admission, so a direct
count of the number of women hospitalized for abortion complications was
available from their official reports. For these facilities, there were
approximately 71,500 annual hospitalizations for complications of induced and
spontaneous abortion;** the average annual number of cases treated was 150, and
the range was 1 to 3,748. We estimated that 26,500 women were hospitalized for
abortion complications each year in the remaining 1,180 hospitals at which
abortion was not among the top 10 causes, and 7,000 women were hospitalized in
the 381 hospitals that had no submitted report. Therefore, we estimated that a
total of 105,000 women were hospitalized for abortion complications in 2000
Estimating the number of
women hospitalized for induced abortion. Some of the women hospitalized for
abortion complications had been admitted after having a spontaneous abortion.
We needed to subtract these women from the total to estimate the number
hospitalized for complications of induced abortion. Data reported by hospitals,
however, typically do not distinguish between induced and spontaneous
abortions, both because symptoms are often similar and because of a reluctance
to expose patients to possible legal action. For these calculations, we used
data on the biological pattern of spontaneous abortion, established by clinical
studies,14 and assumed that late miscarriages (those at 13–22 weeks) are likely
to require hospital care.†† Miscarriages at 13–22 weeks account for about 2.9%
of all recognized pregnancies, and are equal to 3.4% of all live births.‡‡ A
final adjustment is needed because only a certain proportion of all women who
need hospital care for the treatment of late spontaneous abortion will have
access to a hospital or use hospital services for this condition. We assumed
this proportion to be the same as the proportion of women giving birth who
deliver in a hospital: Nationally, 37% of women delivered at a health facility,
73% in Manila, 36% in the rest of Luzon, 29% in Visayas and 23% in Mindanao.15
Applying these assumptions within regions, we estimate that 26,100 women were
hospitalized for complications of spontaneous abortion in 2000.
•Estimating the total
number of induced abortions. Next, we derived a multiplier, or inflation
factor, to estimate the total number of women who had an abortion in the Philippines
in 2000. This total would include women who had a complication but did not
obtain hospital care (whether due to poor access to hospitals or to a
reluctance to seek treatment), those who obtained care from a private doctor,
those who died before obtaining hospital care and those who had an
uncomplicated abortion. Multiplying the number of women hospitalized because of
an induced abortion by the inflation factor would provide an estimate of the
total number of women who had an abortion in 2000.
In general, the safer
abortion services are, the higher the multiplier, because for every woman
hospitalized, many have abortions that do not result in complications or
hospitalizations. Concomitantly, the more risky the abortion services are in a
given setting, the lower the multiplier, because a higher proportion of women
have serious complications that need hospital care. Safety is not the only
consideration, however. The multiplier is also a function of the accessibility
of hospital services. Where such services are easily accessible, the proportion
of women with complications who receive hospital treatment will be higher. In
poor regions or in underdeveloped rural areas, on the other hand, where there
are few hospitals, some of the most seriously affected women may not get the
treatment they need.
Unfortunately, there have
been no recent large-scale, community-based surveys in the Philippines that might provide a
reasonable estimate of the proportion of all women having induced abortions who
are hospitalized. Therefore, we used existing estimates. We drew upon two
sources: the body of evidence used by the 1997 study by Singh and colleagues
that developed estimates of the level of abortion in the Philippines in 199416 and anecdotal
evidence of changes in abortion service provision since the mid-1990s. Two
Philippine community surveys provided relevant information. In one, conducted
in 1978 in Cavite province, 12% of women who reported having had one or more
abortions had been hospitalized for complications.17 The other, conducted in
1994, found that among 170 women in Manila who reported ever having had an
abortion, about 36% had been hospitalized for complications.18 Still, neither
of these studies is likely to be generalizable to the whole country or to
1999–2001, the time period of the present estimate.
A third source of
information is a 1996 survey of health professionals suggesting that about one
in four women who had had an induced abortion were expected to be hospitalized
as a result of complications.19 On the basis of this body of data, the 1997
study by Singh and colleagues concluded that a multiplier of five was
appropriate for the Philippines in the mid-1990s, given the conditions of
abortion service provision that existed at that time.
However, in estimating
the multiplier, it was important that we consider evidence of increasingly safe
abortion services in the 1990s, even within the highly legally restricted
context. There is anecdotal evidence that the number of clinics offering safe
surgical procedures has increased.20 In these clinics,
obstetrician-gynecologists train and supervise nurses and midwives in
performing abortions, and almost all patients come through referral.21 In
addition, the trend in the 1990s of increased use of misoprostol and other
drugs to cause abortion is apparently continuing.22 Misoprostol is highly
effective,23 and has been available inexpensively on the Philippine black
market for some years now.24 Preliminary results from a 2004 qualitative study
in Manila and suburbs show that use of misoprostol was indeed very common, with
20 out of 66 abortion attempts being made with this method, either alone or in
combination with other methods.25
The limited information
available on recent trends and current conditions of abortion service
provision, including the cost constraints faced by poor women, leads us to
conclude that the safety of abortion has likely improved over the last decade.
As a result, the proportion needing hospitalization among all women obtaining
an abortion has probably declined, thus increasing the multiplier used to
estimate the total number of abortions from the number of women hospitalized
from complications of such abortions. We estimate, therefore, that for 2000 the
multiplier likely ranges between five and seven (that is, between one in five
and one in seven women having an induced abortion were hospitalized for
complications).
We present estimates for 2000 based on three multipliers—5, 6 and 7. To assess
trends over the recent period, 1994–2000, we base estimates for 2000 on the
medium estimate, calculated using a multiplier of 6, and compare them with the
medium estimates for 1994. It is important to bear in mind that access to safe
abortion and to hospitals varies across areas and subgroups, thus requiring a
higher or lower multiplier to produce a reasonably accurate estimate; however,
available information does not permit estimation of regional-level multipliers.
Estimating
Unintended Pregnancy
Calculation of unintended
pregnancy numbers and rates involved several steps. We estimated the annual
number of births by applying age-specific fertility rates for each major region
(calculated from 1993 and 2003 DHS data) to population estimates for five-year
age-groups of women for 1994 and 2000, respectively. The population estimates
are from the National Statistical Office of the Philippines, and were either
interpolated between censuses (for 1994) or directly obtained from the census
(for 2000). We obtained the number of births for 2000 by prorating the rate of
change in fertility between 1993 and 2003, and adjusting the 2000 numbers based
on fertility levels from the 2003 survey. Separately, we obtained the
proportion of births that are unplanned—mistimed or unwanted at the time they
were conceived—from national surveys for 1993 and 1998, and applied these to
the fertility estimates to obtain the rate of unplanned births. These are
combined with the abortion rate to provide an estimate of the rate of unintended
pregnancy for 1994 and 2000.
RESULTS
Abortion
Morbidity
By subtracting the
estimated annual number of women hospitalized for complications of spontaneous
abortions (26,100) from the estimated annual number of women hospitalized for
complications of abortions (105,000), we calculated that in 2000, approximately
78,900 women were hospitalized for complications of induced abortion (Table 1).
That translates to a national rate of 4.5 per 1,000 women of reproductive age
per year (not shown). Manila
had a much higher rate (8.6), probably because of better access to hospitals.
The rate in the rest of Luzon was the same as the national average, whereas the
rates in Visayas and Mindanao were lower (2.8
and 3.0, respectively), most likely because of poor access to hospital care.
The national abortion hospitalization rate declined between 1994 and 2000, from
5.0 to 4.5 per 1,000 women—a change most likely resulting from increased use of
safer abortion methods rather than a decline in abortion incidence.
Abortion Incidence
in 2000
The medium 2000 estimate
for the total number of induced abortions in the Philippines is 473,400 (Table 1);
the low estimate is 394,500, and the high estimate is 552,300. The medium
estimate for the abortion rate is 27 induced abortions per 1,000 women aged
15–44 per year (Table 2); the low estimate is 22, and the high estimate is 31.
There is considerable variation in the medium estimated abortion rate for the
different areas of the country. Manila and the
rest of Luzon, which are more urban than the other regions, have higher
abortion rates (52 and 27, respectively) than do Visayas and Mindanao
(17 and 18, respectively).
Using the medium
multiplier, we estimated that the national abortion ratio in 2000 was 18,
meaning that 18 of every 100 pregnancies (live births and abortions) ended in
abortion; the low estimate is 16 and the high estimate is 21. Thus,
approximately one in five pregnancies is terminated by induced abortion.
According to estimates for the four major regions, Manila has the highest
proportion of pregnancies ending in abortion (one in three), compared with
about one in five in the rest of Luzon and about one in eight in Visayas and
Mindanao.
Trends in
Abortion, 1994–2000
Nationally, the annual
number of women hospitalized due to induced abortion declined by 2.5% between
1994 and 2000, from about 80,100 to 78,900 (Table 3); however, the numbers for
Manila and Visayas increased by 11% and 35%, respectively, during that time.
Based on medium estimates, 400,500 women nationwide had an induced abortion in
1994; this number increased to 473,400 in 2000. Although the absolute number of
induced abortions increased in all regions, Manila
and Visayas had much larger increases (34% and 63%, respectively) than did the
rest of Luzon and Mindanao (5% and 10%,
respectively).
The national induced
abortion rate remained nearly stable between 1994 (25 per 1,000) and 2000 (27
per 1,000). Nevertheless, a relatively large increase in the abortion rate
occurred in two regions. In Manila,
the abortion rate rose by 25%, from an already high rate of 41 to 52 per 1,000.
And in Visayas, the rate increased by 54%, from 11 to 17 per 1,000.
Abortion in the
Context of Unintended Pregnancies
To portray the broader
context in which induced abortion occurs in the Philippines, we estimated the
proportion of births that are unplanned, the overall pregnancy rate, the
proportion of pregnancies that are unintended and the unintended pregnancy
rate. First, we drew estimates from the 1993 DHS and the 1998 DHS of the proportion
of live births that were unwanted or mistimed at the time the women became
pregnant. In 1993, 16% of births in the Philippines were unwanted (Table
4); this proportion increased to 18% in 1998. The proportion of mistimed births
was virtually unchanged between 1993 and 1998 (28% and 27%, respectively), as
was the proportion of unplanned births (44% and 45%, respectively).
In 1993, the proportion
of unplanned births varied widely across regions, from a low of 31% in Manila to a high of 55% in
Visayas. However, between 1993 and 1998, trends were quite different by region,
and by 1998, the proportion of unplanned births was similarly high across
regions (42–48%). In Manila,
the proportion of unplanned births increased by 50% during the period, from 31%
to 47%. By comparison, Mindanao and the rest of Luzon
had small increases in unplanned births (8% and 1%, respectively), and Visayas
had a moderate decrease (14%).
The estimate of unplanned
births combined with the estimate of abortions can be used to calculate
unintended pregnancies. The proportions of births that are unplanned based on
the five-year period before each survey year were applied to the total number
of live births in 1994 and 2000. We assumed that this proportion remained
approximately the same from the early 1990s to 1994 and from the mid- to
late-1990s to 2000. Nationally, the unintended pregnancy rate remained stable
between 1994 and 2000 (83 and 81 unintended pregnancies per 1,000 women per
year, respectively—Table 5). The rate for Manila,
however, increased by 43% during that time (from 68 to 97 unintended
pregnancies per 1,000 women per year), whereas other regions' rates declined.
The proportion of all pregnancies that are unintended changed little in the Philippines
between 1994 and 2000 (53% and 55%, respectively). Again, the largest change in
the proportion of pregnancies that are unintended occurred in Manila, rising from 54% to 65%, whereas the
proportions in the other regions changed more modestly or remained about the
same.
Finally, we calculated
the overall pregnancy rate for the Philippines. The pregnancy rate
declined by 6% between 1994 and 2000—from 156 to 147 pregnancies per 1,000
women per year. Manila
experienced a substantial increase (18%) in the pregnancy rate—from 127 to 149,
resulting from an increase in both fertility and abortion during the 1990s.
Because of these trends, Manila
went from having the lowest pregnancy and unintended pregnancy rates of the
regions in 1994 to having the highest of both in 2000. The other three regions
experienced 8–10% declines in the pregnancy rate. With these different trends,
the pregnancy rate by 2000 was similar across the four regions, ranging from
145 to 149.
Factors
Underlying Trends in Pregnancy and Abortion
The observed differences
in levels and trends among the four major regions in unintended pregnancy and
abortion may be explained by factors such as increased exposure to the risk of
pregnancy, decreased contraceptive use, a shift toward use of traditional
contraceptive methods instead of modern methods or decreased effective use of
contraceptives. One indicator of an increased risk of conception—the gap
between age at menarche and age at first union—has changed little between the
early 1990s and 2003, although the change is in the direction of increased
risk.26 And although trend data are not available, reported levels of sexual
activity among unmarried women are low: About 9% of single women 15–24 report
having ever had intercourse, according to a 1994 nationally representative survey.27
Available data, however,
suggest that changing levels and patterns of contraceptive use may have
affected levels of unintended pregnancy and abortion. Current contraceptive
prevalence among married women 15–49 increased from 40% in 1993 to 48% in 1998 (Table
6, page 146); however, use of modern methods increased from 25% to 28% during
that time, while use of traditional methods—which are likely to have high
failure rates—rose from 15% to 20%.§§ In addition, contraceptive users are
experiencing increased difficulties in maintaining continuous protection, given
that 44% of pill users discontinue the method within a year of adopting it (an
increase of 33% from 1993).28
Regional trends sometimes
differ from the national trend. Between 1993 and 1998, the level of modern
contraceptive use in Manila remained relatively
unchanged, whereas the rest of Luzon and Mindanao
experienced increases of 4–5 percentage points, or almost 20%. The proportion
of women using traditional methods increased in all regions, but most
substantially in Manila
(from 15% to 22%), followed by Visayas (from 17% to 23%).
However, the proportion
of married women with an unmet need for effective contraception in the late
1990s was extremely high: One of every two married women did not want a child
soon or wanted no more children, but were not using a contraceptive method. The
overall proportion of married women who have an unmet need for contraception
dropped slightly between 1993 and 1998 (from 54% to 50%); however, this was due
to substantial declines in the proportions in the rest of Luzon and Mindanao,
while the proportions in Visayas and Manila
changed little.
DISCUSSION
The consequences of
unsafe abortion for women's health and survival in the Philippines are evident from the
large numbers being treated each year for abortion-related complications.
Moreover, this number increased in Manila
and Visayas during the 1990s.29 Given the fact that substantial proportions of
women who have complications do not receive treatment at a medical facility,
the estimated annual rate of 4.5 per 1,000 women most likely underestimates the
size of this problem. In addition, treatment of abortion complications absorbs
scarce medical resources and incurs large costs to the public health system.
Furthermore, studies suggest that the quality of such postabortion care is
poor: Women seeking care at hospitals for complications of induced abortions
are often viewed as criminals and verbally admonished. In some cases, they are
denied anesthesia and made to wait longer than other patients thought to be
suffering from spontaneous abortion.30
The almost half a million
induced abortions occurring each year in the Philippines cannot be understood
in isolation from the generally restrictive social and political climate surrounding
the delivery of modern contraceptive services. In addition, decentralization of
health service provision most likely contributes to Filipino women's
difficulties in obtaining contraceptive information, services and supplies.
Moreover, husbands' negative attitudes toward family planning31 and women's
misperceptions about the side effects of methods32 may prevent women from
practicing contraception.
One factor that has
serious implications for the risk of unintended pregnancies and abortions is
Filipino women's heavy reliance on traditional contraceptive methods.
Withdrawal and periodic abstinence—which are commonly used in
Philippines33—typically have higher failure rates than do modern methods such
as sterilization and the pill.34 Also, the majority of women using periodic
abstinence do not know the timing of their fertile period, thus further
increasing their risk of unintended pregnancy and possibly of induced
abortion.35
Another factor
contributing to unintended pregnancy and abortion is the deficiencies in the
family planning services available in the Philippines.36 According to a study
focusing on the quality of family planning services for new mothers in 28
provinces across the country, a surprisingly large proportion of clinics did
not provide any advice on contraception to women who wished to stop having
children, and that proportion increased between 1994 and 1997.37 In addition,
service providers incorrectly informed clients that the duration of the
protective period from breastfeeding (i.e., lactational amenorrhea) is longer
than it actually is.
The Catholic Church in
the Philippines
is likely to have had a strong influence on the provision of contraceptive
services, given that it opposes use of modern contraceptive methods. The church
accepts only periodic abstinence as a method of family planning.38 It was
critical of the Ramos administration, which promoted the use of artificial or
modern birth control methods, and have campaigned against politicians who
support modern family planning. Under President Macapagal-Arroyo, the national
population and reproductive health program has endorsed traditional family
planning methods on the grounds that they promote family values.
Another important factor
that may have negatively influenced the provision of family planning services
is the process of decentralization (i.e., the transfer of power from the
central government to local levels of administration) that began in 1991. Until
this study, there had not been any assessment of the likely effect of devolution
on provision of contraceptive services. However, it is possible that variation
in support for family planning services at the local level may partly explain
our findings of decreased use of modern contraceptives, increased use of
traditional methods and an increased level of induced abortion in some regions.
In particular, the unexpected finding that women living in Manila—the most
urbanized area of the country, where family planning services would be expected
to be widely available and accessible—have high and increasing levels of
unintended pregnancy and abortion than other regions may be partly because of
reduced supplies of modern methods and declines in access to contraceptive
services. The explicit position taken by the Atienza administration in the City
of Manila banning any artificial methods of contraception from being offered in
any public clinic under its direct control and supervision likely also
increased barriers to services.
According to newly
available data for 2003, the level of contraceptive use in the Philippines
increased only slightly between 1998 and 2003;39 a small but important shift
toward increased use of modern methods occurred during that time, accompanied
by a decline in use of traditional methods. Thus, while overall use was 48% in
1998 and 49% 2003, the proportion using modern methods increased from 28% to
33%.40 In Manila, overall use remained stable at 49–50%, but modern method use
increased from 29% to 32%, similar to the national pattern.
This study has several
policy and programmatic implications. An estimated 78,900 Filipino women are
hospitalized each year for abortion complications. Given that many more women,
particularly those in the rural regions of Visayas and Mindanao,
are probably in need of postabortion care but cannot obtain it, services should
be made more widely available, especially in rural and isolated areas, and
health care providers should receive comprehensive training in postabortion
services and family planning counseling. Adequate postabortion care services
and counseling should be offered at all public provincial and district
hospitals. Also, in light of reports of judgmental behavior toward postabortion
patients,41 training programs should include sensitization of health providers
about the context and realities of women who obtain unsafe abortions.
The second important area
in which improvements in policy and programs are needed concerns provision of
contraceptive services and information to the general population and to
specific subgroups, such as adolescents and men. Better services would improve
the ability of women to prevent unintended pregnancy and thereby reduce the
level of induced abortion overall, as well as reduce unsafe abortion and its
consequences on women's health in the Philippines. Not only do women
hospitalized for abortion complications need contraceptive counseling and
services, but the approximately one in two married women of reproductive age
who have an unmet need for effective contraception need improved contraceptive
services—including an expanded range of contraceptive methods and improved
quality of services.
REFERENCES
1. Åhman E and Shah I, Unsafe abortion: worldwide estimates for 2000,
Reproductive Health Matters, 2002, No. 19, pp. 13–17.
2. Åhman E and Shah I, Unsafe Abortion: Global and Regional Estimates of the
Incidence of Unsafe Abortion and Associated Mortality in 2000, fourth ed., Geneva: World Health
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Published by the Reproductive Rights
Resource Group – Philippines
(3RG-Phils.); October 2005
Link: http://www.guttmacher.org/pubs/journals/3114005.html
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