Key Points

• Many women in the Philippines are unable to achieve their desired family size, and have more children than they want. Unintended pregnancy is common, in part considering of the high unmet need for contraception.

• The Philippine government has made efforts to amend access to contraceptive services, but abortion is illegal nether all circumstances and is thus highly stigmatized. Nonetheless, ballgame is common, but is oftentimes performed in unsanitary conditions and using outdated techniques.

• Unsafe abortion carries significant risks for Filipino women: About 1,000 die each year from abortion complications, which contributes to the nation's high maternal bloodshed ratio. Tens of thousands of women are hospitalized each year for complications from unsafe ballgame.

• Poor women, rural women and immature women are particularly probable to experience unintended pregnancy and to seek ballgame under unsafe weather condition.

• Because of the risks of dangerous abortion, many women demand postabortion care, merely they face barriers in obtaining such care, including the stigma around abortion and the high cost of medical intendance.

• Policymakers and regime agencies should educate the public nigh contraception, ensure acceptable funding for contraceptive services and eliminate barriers to obtaining methods, peculiarly among disadvantaged populations. To help destigmatize postabortion care, the government should train more providers in the employ of safer and less invasive methods of care.

July 2013

The Philippines, with a steadily increasing population that is approaching 100 million, faces significant challenges in the area of reproductive health.1 Most 25 million of its citizens are women of reproductive age, and they experience high levels of unintended pregnancy, accept relatively low levels of contraceptive use, and frequently feel dangerous ballgame and consequently high levels of mortality and morbidity.ii–four This report summarizes existing evidence on the context and consequences of unintended pregnancy and unsafe abortion in the Philippines—particularly amid vulnerable populations such as poor, rural and young women—and highlights key areas in which policymakers and reproductive wellness advocates can focus efforts to improve the health and well-beingness of Filipino women and their families.

Admission to services is opposed by influential groups

Women's access to reproductive health services faces challenges or outright opposition from various—often powerful—segments of Filipino social club. While contraception is legal in the Philippines, until mounting pressure to reduce maternal mortality and morbidity and to combat poverty in the country arose in recent years, the government had shown merely weak support for access to modern contraceptives.5 Since 1971, much of the free contraceptive supply had been funded past the U.S. Bureau for International Development (USAID) and other international donors, but in 2008 USAID discontinued its support to encourage the Philippine regime to become self-reliant.vi Local bans on contraceptives—such as the mayor of Manila'south executive order in 2000 to remove contraceptives from public clinics, and the 2001 ban by the Department of Wellness on the emergency contraceptive Postinor—created nonetheless more than barriers to access, and particularly affected poor women who rely on public services.7

In the Philippines, the Catholic Church hierarchy wields potent influence on society and on government officials. The church not only condemns abortion, merely forbids the use of modern contraceptives.vi Despite this opposition, recent legislative developments have been supportive of reproductive health.5 In contrast to one-time president Gloria Macapagal Arroyo, who opposed public provision of modern contraceptives in favor of promoting natural methods approved past the Vatican, the electric current president, Benigno Southward. Aquino Iii, endorsed the highly debated Responsible Parenthood and Reproductive Health Act of 2012 (commonly known as the Reproductive Health Law),viii which provides modernistic contraceptive services, counseling and sex education, especially for rural and poor Filipinos.9 This policy was (and still is) strongly opposed past the church hierarchy; still, it is generally supported by the Philippine public. In December 2012, lawmakers passed the bill and President Aquino signed information technology into law. As of early 2013, implementation of the law was delayed by the Philippines Supreme Courtroom. Yet, passage of the beak represents a historic milestone.

In contrast to the liberalizing trend in contraceptive policy, the Philippines' abortion law is amongst the strictest in the earth. Abortion remains illegal in the Philippines under all circumstances and is highly stigmatized. While a liberal interpretation of the law could exempt abortion provision from criminal liability when done to relieve the woman'southward life, in that location are no such explicit provisions.v,10–12 There are likewise no explicit exceptions to allow abortion in cases of rape, incest or fetal impairment. The Penal Code considers abortion to exist a criminal criminal offence punishable by up to six years in prison for doctors and midwives who perform abortions and by 2‒6 years in prison for women who undergo the procedure, regardless of the reason. A separate ready of laws under the Midwifery Deed, Medical Act and Pharmaceutical Deed allow the revocation or intermission of the licenses of whatsoever practitioner who performs abortions or provides abortifacients.

Unmet need is widespread and unintended pregnancy is mutual

In 2008, there were 1.ix 1000000 unintended pregnancies in the Philippines, resulting in 2 chief outcomes—unplanned births and unsafe abortions.xiii In the Philippines, 37% of all births are either not wanted at the time of pregnancy (mistimed) or entirely unwanted (Table one),three and 54% of all pregnancies are unintended.xiii On average, Filipino women give birth to more than children than they desire (3.3 vs. ii.4 children—Figure 1), highlighting how difficult it is for a woman to run across her fertility desires. This is especially hit among the poorest Filipino women, who accept most two children more than they intend to take (5.two vs. 3.3 children).


Table 1

Amid married women using whatever method of contraception in 2011, one in 4 used a traditional, less effective method such as periodic forbearance.14 Though married women showed a small-scale increase in modern method use between 1998 and 2011 (from 28% to 37%), this latter rate was withal essentially lower than the comparable subregional average in Southeastern Asia (55%) and rates in other populous countries in the subregion, such every bit Indonesia (57%), Vietnam (68%) and Thailand (79%).15

Much of the gap between women'due south total and wanted fertility rates in the Philippines can exist attributed to low contraceptive employ and high levels of unmet need for contraception: In 2008, more than 90% of unintended pregnancies occurred among women using traditional, ineffective methods or no method at all.13 In 2011, but 49% of married women of reproductive age were using whatsoever contraceptive method, and this represented a negligible increase since 1998 (Tabular array 2).14 Poor women are less likely to use a contraceptive method than nonpoor women (43% vs. 51%), and in regions where poverty is common, contraceptive use is substantially lower than the national boilerplate—for example, 38% in the Zamboanga Peninsula and 24% in the Autonomous Region in Muslim Mindanao.14


Table 2

The proportion of married women with an unmet need for contraception did not refuse between 1998 and 2011: At the time of both surveys, one in five married women did non want a child soon or wanted to stop childbearing altogether, but were not using any contraceptive method. In 2011, poor women had much higher levels of unmet need than their nonpoor counterparts (26% vs. 17%).xiv Single women who were sexually active had fifty-fifty more than dramatic levels of unmet need for contraception: In 2008, about 50% of these women wanted to prevent pregnancy but were not using a family planning method, and nigh lxx% were not using a modern method.iii

There are many reasons why, and circumstances in which, Filipino women exercise not practice contraception. Co-ordinate to the 2008 Demographic and Wellness Survey,3 afterward excluding women who were unable to carry children and those who wanted children soon, the ii virtually usually cited reasons were fear of side effects or broader health issues (36%) and difficulty obtaining a method (27%). The lack of governmental support for contraceptives, widespread local bans on contraception and the USAID phase-out of contraceptive supplies are major reasons for women'south inability to obtain modern methods and accurate data nigh their safety and efficacy.3,7 Despite the potent influence of the Catholic Church hierarchy on policies regarding family unit planning, few women cited religious or personal opposition every bit reasons for nonuse (two–4%). Poor women are specially vulnerable to barriers to access, as the public-sector provision of modern contraceptives has shifted to private, and often more expensive, sources: In 2003, two-thirds of women using a mod method obtained it at a public facility, but by 2008 the proportion had dropped to less than half.iii Furthermore, more recent data show that 56% of poor women who employ hormonal pills (the nearly commonly used method) obtained them from the public sector in 2006, while 32% did and so in 2011.16

Adolescents and young women and are particularly vulnerable

Sexual activeness among young people is becoming more common in the Philippines. The proportion of women aged 15–24 who were sexually experienced increased from 25% in 1998 to 32% in 2008.three,17 Despite the taboo against premarital sexual activity, many women study such behavior: In 2008, the median age of wedlock among young women was most a year after than the median age at first sexual feel (22.1 vs. 21.three years).3 Filipino women are also giving nascency before: Among kickoff-time mothers, the proportion who were teenagers increased from 20% in 2000 to 27% in 2010.eighteen Boyish females are specially at risk of unintended pregnancy because they lack access to comprehensive sex educational activity and contraceptive supplies.v

Ballgame is common in the Philippines

Of the hundreds of thousands of Filipino women who have unintended pregnancies each year, many confront a hard selection: either give nascency to a child they are not prepared or able to treat, or obtain a underground, and often unsafe, abortion. Considering ballgame is highly stigmatized and punishable by law, it is extremely challenging to directly gauge the number of abortions in the Philippines, as both women and providers are probable to not report the procedure. The most recent report on national abortion incidence in the Philippines used indirect estimation techniques and hospital records to estimate a charge per unit of 27 abortions per 1,000 women of reproductive age in 2000, with lower and upper estimates of 22 and 31 abortions per one,000 women.xix Notably, this rate was considerably higher than a more than recent estimate of the dangerous abortion charge per unit in Southeastern Asia every bit a whole (22 abortions per ane,000 women), indicating that the Philippines may have more unsafe abortions than some neighboring countries.20 Projections based on the 2000 national abortion rate, and taking into business relationship population increases, estimated that 560,000 abortions occurred in 2008 and 610,000 abortions in 2012.ii,5,19


Figure 1

Who has abortions in the Philippines, and why?

According to a national 2004 survey of women of reproductive age, individuals who have abortions are similar to Filipino women overall: They are typically Cosmic, are married, are mothers and take at least a high schoolhouse education.4 The most common reason women identified for having an abortion—cited by virtually iii in iv—was the inability to beget the price of raising a kid or an additional kid. More than half of those who had had an abortion said they underwent the process considering they felt they already had plenty children or that their pregnancy came besides soon after their last nascence. Nearly ane-3rd of women felt that their pregnancy would endanger their health, and another third believed that their partner or another family fellow member did not desire or support the pregnancy. Perhaps about disturbingly, 13% of women who had had an abortion cited pregnancy equally a result of forced sex as their reason for getting an abortion.

Not surprisingly, larger proportions of poor women than of their nonpoor counterparts cited economical reasons for having an abortion, and roughly two-thirds of women who had had an abortion were poor.4 Women younger than 25, who accounted for 46% of ballgame attempts in the 2004 survey, also cited reasons related to their age—they wanted to avoid interrupting their schooling, had bug with their partner or considered themselves too immature to have a baby. Among all the women interviewed, economic reasons and being unmarried or likewise young were cited as the about important reasons for why women obtain abortions, illustrating that many Filipino women who have not had an abortion understand why other women choose to take i.21

Near women who had had an abortion had discussed the thing with at to the lowest degree ane person, merely fewer than half had discussed information technology with their partner, suggesting that in many cases women feel that their partner will non be supportive of their situation or decision.4 Nearly one-third of women who get an abortion do not tell anyone, highlighting how stigmatized abortion is in the Philippines.

The cloak-and-dagger nature of getting an abortion oft leads to unsafe procedures

The process of obtaining an abortion in the Philippines is oftentimes non straightforward, and may involve many methods and attempts, some of which may take serious health consequences. While the skill and training of providers and the safety and effectiveness of methods vary widely, virtually all abortions are underground and therefore deport associated risks. Some women seeking pregnancy termination may be able to obtain medically recommended procedures such every bit manual vacuum aspiration (MVA) or dilation and curettage (D&C), merely the providers may exist untrained or the settings unsanitary.22 Conversely, a woman may go through a series of ineffectual methods and steps, but to find herself however pregnant and at a more advanced indicate in gestation.

According to the 2004 national abortion study, about women who obtain an abortion do so in the start trimester, merely a substantial proportion—nearly one in four—exercise not terminate their pregnancies until later, when risks are greater.4,23 A college percentage of poor women than of nonpoor women have abortions after the starting time trimester, which could be a issue of failed or ineffective attempts to terminate the pregnancy or inability to secure the money to pay for the process. Surgical methods that are considered relatively safe and constructive (when performed past a trained provider) are often expensive, and poor women may resort to dangerous, painful or ineffective means (Figure 2). Particularly dangerous methods include the insertion of a catheter or other object into the uterus, which often causes infection and perforations, and heavy abdominal pressure level or "massage" to expel a fetus, which a traditional practitioner (hilot) may administrate.iv,10,23 An estimated 22% of poor women used massage or a catheter in an ballgame attempt, while no nonpoor women employed such methods. Moreover, poor women were far less likely than the nonpoor to use safer methods such as D&C or MVA (13% vs. 55%).4


Figure 2

Furthermore, poor women are much less likely than nonpoor women to obtain an abortion from a doctor (17% vs. 55%), or seek an abortion in a wellness facility (21% vs. 60%); instead, they are more probable to self-induce or to employ the help of a friend, associate or partner (44% vs. 30%).4 In many cases, women are able to cocky-induce by taking misoprostol (too known past its brand proper noun Cytotec) obtained through street or Internet vendors; still, the drug is expensive and the right dosage may non be dispensed, which lowers the effectiveness of the method.4,24 A pocket-sized report that interviewed young people well-nigh their experiences and perceptions regarding abortion found that many bug were involved in both the choice of a method and the perceived level of efficacy.24 Some participants felt that a method'south effectiveness was due to the position of the fetus, the "will" of the fetus or God's will.

The health consequences of unsafe abortion are significant

In 2008, an estimated i,000 maternal deaths in the Philippines were owing to abortion complications.thirteen Co-ordinate to the Philippines Department of Health, the state'south maternal mortality ratio increased from 161 to 221 deaths per 100,000 live births betwixt 2006 and 2011.25 This ratio is well above the regime's Millennium Development Goal 5 target of 52 maternal deaths per 100,000 live births for 2015.26 The Department of Health acknowledges that high maternal mortality is preventable through the provision of effective family planning methods to gainsay unmet need, specially among poor women, and that access to antenatal intendance and to care for pregnancy- and abortion-related complications would also aid to reduce maternal mortality.

Tens of thousands of Filipino women are hospitalized each yr equally a issue of complications from unsafe ballgame, at a charge per unit of 4.v individuals per 1,000 women, and countless others accept complications but exercise non receive treatment.iv,19 In Manila, the hospitalization charge per unit was nearly double the national average, likely because of better access to care than in rural areas of the country. Projections based on information from 2000, assuming that the rate stayed the same and taking into account increases in population, indicate that ninety,000 Filipino women were hospitalized for ballgame complications in 2008, and over 100,000 women in 2012.13,xv,xix Furthermore, well-nigh 1-quarter of the two,039 hospitals included in the abortion incidence study recorded ballgame (induced and spontaneous) every bit amidst the top 10 causes for admission in 2000.19 More than recently, abortion-related surgeries (surgical completion of incomplete ballgame and D&C) were amidst the fifteen most common surgical claims submitted to the national wellness intendance organisation, PhilHealth, in 2011.27

Women may experience a range of complications from unsafe abortion. More than 80% of Filipino women in the 2004 study who terminated their pregnancies experienced a complexity, and 46% of those women (more than than one-3rd of all women) experienced a astringent complication.iv By and large, the about common complications of unsafe abortion are incomplete abortion or retained products of conception, excessive blood loss and infection.22,23 Less common but more serious complications include septic shock, peritonitis, cervical or vaginal lacerations, and abdominal perforations. In the Philippines, certain methods and providers bear more than risk of serious complications: 70 percent of women who used a massage or insertion of a catheter experienced a severe complexity, compared with thirteen% of those who received a D&C or MVA.4 As discussed earlier, larger proportions of poor and rural women use unqualified providers or riskier measures than exercise nonpoor and urban women, and they therefore disproportionately feel more severe complications. Finally, if postabortion care is delayed, inadequate or not administered at all, mild complications can become more serious or astute, and eventually touch long-term health and well-being. Studies have shown that long-term problems may include anemia, chronic pain, pelvic inflammatory disease and infertility.20,22,23

Providing postabortion care poses serious challenges

Considering so many Filipino women experience postabortion complications, the need for early on and adequate postabortion care is particularly urgent. However, many women who develop wellness issues after an unsafe abortion may be reluctant to seek help; near i in three women with complications practice not receive postabortion care.4 Cost can be a pregnant barrier, particularly for more serious complications in which women may accept to receive multiple procedures and medications or stay overnight in a wellness facility.five Some women leave the infirmary prior to completing treatment considering they fearfulness they volition be unable to pay the final beak, leaving them to manage their complications through other ways. At the time of the 2004 national study, it was estimated that regime hospitals typically charged ₱1,000–four,000 (US$24–94) for postabortion care, and private hospitals charged substantially more, upwards to ₱15,000 (US$375).4 In a country in which one in seven people live on less than The states$2 a twenty-four hours, postabortion care may be entirely out of reach for many women.28

In the Philippines, the stigma surrounding abortion is another gene that makes it difficult for a woman to seek postabortion care. Some women written report feeling shamed and intimidated past health intendance workers, and in some cases women are not provided with pain relievers and anesthesia, or treatment is delayed or denied altogether.4,5 Others report being threatened that they would be turned in to the police. Doctors themselves report having a bias against postabortion care patients, with some assertive that these women have committed punishable crimes. Other health care providers may accept difficulty properly managing complications when women conceal the cause of their medical emergency.

The Prevention and Management of Ballgame Complications programme was established by EngenderHealth in 2000, under the approval of the Philippines Section of Wellness, to strengthen the capacity of the health intendance system to manage ballgame complications by training providers in techniques, counseling and sensitization.4,29 The pilot programme ended in 2002, however, and it was never fully integrated into the health intendance arrangement.thirty The Department of Health subsequently replaced it with the Prevention of Abortion and Direction of Pregnancy Complications plan, thus effectively deemphasizing care specific to abortion complications. Currently, postabortion care is subsumed under Bones Emergency Obstetric and Newborn Intendance guidelines, notwithstanding information technology is non known whether training in counseling and sensitization has been incorporated. A study that interviewed gynecologists who provide postabortion care in Manila found that many preferred using sharp curettage instead of the recommended MVA for terminating early pregnancies, even though it is associated with higher risks and greater pain.31 The study besides found that some doctors were using improper doses of misoprostol, and a small proportion were not using analgesia for surgical uterine evacuation.

Illegal and unsafe abortions carry social and economic consequences

Physical complications are not the simply consequence of dangerous abortion. The social and economic costs of hole-and-corner ballgame and postabortion care are substantial, to both individual women and the wellness organisation equally a whole. Because abortion is illegal, many providers charge high fees to recoup for the hugger-mugger nature of the procedure,4,5 and hence obtaining a relatively condom abortion in a clinic is out of reach for the boilerplate Filipino woman. Many women with an unintended pregnancy therefore resort to cheaper and often less rubber methods, which may result in complications that ultimately incur pregnant costs to the woman and to the health care system. Recent costing studies of postabortion intendance in countries with highly restrictive ballgame laws accept plant that the costs to the health systems, including drugs, supplies and staff fourth dimension, are substantial.32–34

In addition to the directly costs of intendance for abortion-related complications, another cost is the time that women spend in recovering from injuries and ill wellness. During recovery, women are prevented from fulfilling other responsibilities, such equally making a living, attending schoolhouse and caring for their families.iv,35 The cost of this lost time, when added to the health care costs of treating complications, means that dangerous abortion takes a substantial cost on guild as a whole, every bit well equally on individuals and families.

Legal advances and hereafter investment in reproductive health care

The Reproductive Wellness Law mandates several provisions, including supplying a full range of contraceptive methods, especially to the poor and marginalized; providing "humane and nonjudgmental post ballgame intendance"; ensuring that wellness facilities have adequate and qualified personnel to provide emergency obstetric and newborn care; and offering reproductive wellness education to adolescents.36 (All the same, the police force offers modernistic contraceptive methods to minors only if they have parental consent or have had a child or miscarriage.) The law also prohibits individual providers, local government officials and employers from banning, restricting or coercing the use of reproductive wellness services. Overall, these legislative advances accept the potential to greatly improve women'due south health by reducing maternal mortality and morbidity.

Another recent advance in reproductive rights is the landmark 2009 Magna Carta of Women, which promises to protect Filipino women from measures or practices that have "greater adverse furnishings" on women than men.37 This provision could be used to identify and address barriers to the full admission of reproductive health services, such as contraception and postabortion intendance. Furthermore, in 2012, the Philippines Section of Health pledged ₱500 meg toward family planning supplies nationwide.25

Regarding the critical touch of reproductive health care, a 2009 written report of the benefits of meeting contraceptive needs concluded that if all Filipino women at risk of unintended pregnancy used a modern method, unplanned births would refuse past 800,000 per year and there would be 500,000 fewer abortions.13 Achieving this goal is not possible without increased fiscal commitment; yet, the reduced need for medical care for those unintended pregnancies and abortions that could exist averted would result in a net economic savings and immeasurable social benefits. This study highlights how investing in family planning and contraceptive supplies and services would promote the health and welfare of Filipino women, their children and lodge.

Recommendations for addressing unsafe ballgame and its consequences

The passage of the Reproductive Health Police is a milestone that will help to reduce maternal mortality and better the overall health and lives of Filipino women and their families. With full implementation of the law, nearly all Filipino women—including immature, single, poor and rural women—should have access to reproductive health information and services that assistance them to plan and care for their families.

To fully realize the potential of the law and to further promote women's health, Filipino national, regional and local policymakers, as well as government agencies, should:

• Educate the public almost modern contraceptives and the risks of unintended pregnancy and unsafe abortion.

• Ensure adequate funding for the full range of contraceptive methods, as well equally counseling, so that women can find and use the methods that are most suitable to their needs.

• Eliminate barriers to contraception amid vulnerable populations—such equally poor women, rural women and adolescents—by making clinics more accessible and youth-friendly and by providing family unit planning at low or no price.

• Integrate contraceptive services with other reproductive health services, and provide contraceptive counseling and services for women in postpartum and postabortion intendance settings.

• Destigmatize postabortion care among providers, to ensure fair and humane handling, and among the population as a whole, to encourage women to seek timely postabortion intendance.

• Railroad train more than medical providers, including midlevel personnel, in the use of safer and less invasive methods of postabortion care (such as MVA), and ensure availability of these methods in relevant wellness facilities.

• Ensure that all women have admission to emergency obstetric and neonatal care.

• Study the impact of the electric current abortion ban, and explore assuasive abortion at least in infrequent cases, such every bit to save a woman's life or preserve her health, in cases of rape or incest, and where there is gross fetal deformity incompatible with life.

In the Philippines, most unintended pregnancies resulting in ballgame are preventable, as is nigh all ballgame-related mortality and morbidity. Amend information on sexual and reproductive health, as well equally access to effective contraception, can lower the incidence of unintended pregnancy, thereby reducing the number of Filipino women who resort to unsafe abortion and experience the related wellness consequences. Investing in women's wellness yields enormous benefits not only to women's condition and productivity, merely likewise to their families and society every bit a whole.

CREDITS

This In Brief was written by Rubina Hussain and Lawrence B. Finer, Guttmacher Found. Information technology was edited by John Thomas. The authors are grateful for comments provided by Junice Melgar and Mina Tenorio of Likhaan, Quezon City, Philippines, and for contributions made by the post-obit Guttmacher colleagues: Akinrinola Bankole, Jessica Malter and Gustavo Suarez.

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