BEYOND NUMBERS
Recognizing women's reproductive rights-and ensuring their health
By Deedee Sta. Cruz-Espina
Correspondent
I help girls out." So says Vera Drake in 1950s England, in that thought-provoking film that shows her as an old cleaning lady who induces abortions on the side, using a crude procedure done by using carbolic soap, a cheese grater, and a syringe, among other things. Only when one of the girls lands in the hospital due to complications, is Vera arrested and charged.
"Are you sure?" Father Amaro asks young Amelia after telling him she is pregnant with his baby in another movie, The Crime of Padre Amaro. The young priest, assigned to a church in a small rural village in Mexico, falls in love with Amelia, becomes pregnant with his baby, and asks for his help in getting an abortion. Amelia bleeds to death while the priest tries to rush her to a hospital. Eventually, the news breaks out and becomes a scandal that rocks the nation and the very foundations of the Roman Catholic Church.
Vera Drake, Padre Amaro, and Amelia are certainly just characters borne out of their writers' imagination, but they should probably give a glimpse of what the picture is beyond the silver screen. And real-life stories would prove stranger, even here.
Reproductive realities
Although illegal, about 400,000 abortions a year are performed in the Philippines, according to a survey done by the University of the Philippines Population Institute, with teenagers accounting for 17 percent of these cases.
It is estimated that 100,000 women each year are hospitalized because of serious postabortion complications.
The Department of Health (DOH) says that 12 percent of all maternal deaths in 1994 arose from complications related to abortion, making it the fourth-leading cause of maternal deaths in the country.
Ten women die every 24 hours in the country from causes related to pregnancy and childbirth, according to a 2000 report by the Population Commission and the United Nations Population Fund (UNFPA).
This is not surprising given that only three out 10 deliveries are assisted by a doctor, one by a nurse, and two by a midwife. The rest are assisted by traditional hilot (2003 National Demographic and Health Survey, NDHS).
Still, with the odds stacked against their well-being, Filipino women bear more children than they want or consider ideal.
On the average, every Filipino woman of childbearing age gives birth to four children. But when asked in the 2003 NDHS how many children they considered ideal, their answer was "three." In fact, six out of 10 women who already had two children at the time of the survey said they don't want any more children.
Yet, only one of every two married women uses any family-planning method and only one in three uses any modern method.
Principles of reproductive health and rights
The International Conference on Population Development (ICPD) defines reproductive health as the state of complete physical, mental, and social well-being in relation to the reproductive system and to its functions and processes.
The ICPD, held in Cairo in September 1994 under the auspices of the United Nations, was attended by representatives from governments, intergovernment organizations, UN programs and specialized agencies, nongovernment organizations, and the news media from more than 180 states, including the Philippines. Delegates took part in the deliberations and negotiations to finalize and approve a Program of Action in the area of population and development for the next 20 years.
One of the primary goals of the ICPD program of action is to make family planning universally available by 2015 as part of a broadened approach to reproductive health and rights.
The ICPD is not an international treaty, but rather a set of 15 principles to which countries party to it, the Philippines included, have expressed their commitment. According to the summary of the ICPD program of action, the set of 15 principles "provides a careful balance between the recognition of individual human rights and the right to development of nations."
Further, it read: "The implementation of the recommendations contained in the program of action is the sovereign right of each country, consistent with its national laws and development priorities, with full respect for the various religious and ethical values and cultural backgrounds of its people, and in conformity with universally recognized international human rights."
Dr. Junice Melgar, executive director of Linangan ng Kababaihan (LIKHAAN), a center for women's health resources and health-nurturing services, in a paper titled "Grounding Reproductive Health Programs on Human Rights and Human-Centered Development" writes: "Embedded in the complete definition are references to the ability to be pregnant; to deliver safely a healthy offspring; to have a satisfying sex life; and to decide whether to be pregnant or not." The definition, she adds, "connotes a condition of the mind and body, people's ability to decide, and the state of attendant social factors."
Melgar explains that reproductive health conditions include pregnancy, childbirth, abortion, infertility, infections, side effects of contraception, tumors, sexual dysfunction, sexual violence and abuse, and others. Most of these happen during the reproductive age, but they also happen before and after. "Men and women are both affected, but the onus of risks are borne by women," she says.
For instance, Melgar explains, "Only women die from pregnancy, childbirth, and unsafe abortion; women are more frequently the victim of sexual violence and abuse; more women contraceptive users bear the methods' inconvenience and side effects; women's reproductive cancers are more deadly compared to the reproductive cancers of men."
Women's reproductive rights are human rights, according to Women's Legal Education, Advocacy and Defense (WomenLead) Foundation, a resource institution committed to advancing women's rights and empowerment through feminist strategies in the critique and analysis of the law and the legal system.
"WomenLead engages in feminist legal interventions," says Hope Abella, executive director of WomenLead. Abella explains that WomenLead is centered on empowering women through the legal process so that they can continue with their lives after their rights had been violated.
The advocates
LIKHAAN and WomenLead are just two members of a network of women's groups in the Philippines that have been actively advancing and lobbying for reproductive health and rights, and taking part in international initiatives such as the ICPD. The two women NGOs, though separate in their missions, are closely intertwined into a network of groups that push for reproductive rights. Both, however, advocate a rights-based approach to achieving a reproductive-health system in the country.
Reporting on the status of initiatives of reproductive health and reproductive rights in the Philippines, Melgar says that the Philippines was among the countries that "warmly embraced the ICPD, at least in policy, and at least up to 2000."
She reports that in 1998, the 10-point Reproductive Health Program of the DOH showed how reproductive health was valued then--it was placed under the office of special concerns directly attached to the office of the secretary. From 1999 to 2000, the Estrada administration maintained the reproductive-health program but placed it in the bigger cluster of family health. In the same period, the DOH issued guidelines for the implementation of the program on the prevention and management of abortion complications, which required service providers to treat postabortion patients in a humane and nonjudgmental manner.
However, Melgar says, 2001 saw the start of the steady erosion of reproductive health and reproductive rights in Philippine policies. "The first reversal came in the form of the subtle push for natural family planning against artificial contraceptives in national budget allocation and DOH programs."
"[Former health] secretary [Manuel] Dayrit at that time even joined a TV debate where he championed the superiority of the [natural method] over artificial methods," Melgar recalls, adding that "overlooked and pushed aside by this policy was the substantial and consistent preference of women for artificial rather than natural scientific family-planning methods as reflected in demographic surveys."
In her report, Melgar supposes "the inspiration for this biased policy derives from President Gloria Arroyo herself who laid out the 'four pillars' of her population policy--birth spacing, respect for life, responsible parenthood, and informed choice."
Pending bills
To get at their meaning, Melgar adds, these policy measures can be juxtaposed with the President's other remarks: "The best contraceptive is electrification." "My use of contraceptive pills made me irritable." "National government will not pay for Family Planning; NGOs will." "I will veto any bill that attempts to smuggle in abortion."
According to Melgar, the last remark was a reference to the Reproductive Health Bill that was pending in both houses of the 12th Congress (2001-2004), which aimed to institutionalize the integrated reproductive-health program as initially conceived by DOH and to ensure funds for it. "It explicitly stated that the measure was not changing the law that completely outlaws abortion," Melgar adds.
Reproductive-health bills are still pending in Congress, including Senate Bill 1546 introduced on July 29, 2004 by Senator Panfilo Lacson; Senate Bill 1280 filed by Senator Rodolfo G. Biazon on July 2, 2004; House Bill 16 introduced by Representative Edcel Lagman on July 1, 2004; and House Bill 2029 introduced on August 3, 2004 by a group of representatives. They are either in the committee level or scheduled for reading in the plenary.
On February 22, 2005, House Bill 3773 or "Responsible Parenthood and Population Management Act of 2005" was filed by Lagman, which "sets in place a national policy that assures adequate and continuing information on reproductive health and a full range of family planning methods (excluding abortion)." House Bill 3773 substituted bills filed earlier including House Bills 16 and 2029. The Bills Summary Report of Congress reveals that the bill has been referred to the Committee on Women and has been calendared on June 7, 2005. No further update is given.
The case of the emergency-contraception pill
According to Melgar, the 1999 to 2000 health administration was also the administration that initiated the registration of the emergency contraceptive, levonorgestrel 750 mcg or Postinor, for use in cases of rape. Postinor is listed by the WHO as an essential drug and credited with significantly reducing the rate of unwanted pregnancies.
Emergency contraceptive pills (ECPs) are a type of hormonal contraception designed to prevent pregnancy after unprotected sexual intercourse.
Postinor, a brand of ECP (indicated for emergency use) got DOH approval and in principle was already supposed to be available in government-run women- and child-protection units in cases of sexual abuse, according to WomenLead. It was in place for over a year between April 24, 1999 and May 2000.
However, Melgar reports that under President Arroyo, the DOH through the Bureau of Food and Drugs (BFAD) banned Postinor.
The BFAD claimed that the drug "has abortifacient effect and contravenes existing provisions of the law." According to WomenLead, this decision was prompted by a letter of complaint from Abayfamilya, a church-based organization.
On May 24, 2002, WomenLead, representing Reproductive Health Advocay Network (RHAN), filed a petition to reopen the DOH case on Postinor, arguing that women and women's-reproductive-health advocates were denied due process when the DOH decided to ban levonorgestrel 750 mcg.
The legal battle ensued. DOH convened a seven-person technical committee made up of doctors and lawyers to rule on RHAN's petition. In 2004, the technical committee voted five to two in RHAN's favor and recommended reregistering Postinor.
"Yet, [former] Secretary Dayrit chose to ignore the recommendation and maintained the ban ostensibly for technical reasons, i.e., the distributor had withdrawn the product," Melgar says.
"The DOH experts committee actually already upheld our position by making the recommendation to re-register Postinor. However, the DOH secretary had refused to act on [this] since the original applicant for the license had withdrawn their application," says lawyer Carolina Ruiz Austria, program-development consultant of WomenLead.
"So instead of questioning the DOH move on a mere technicality at the Supreme Court level, we would rather test the case on the merits by arranging for service providers within RHAN to apply for the license to import Postinor," Ruiz-Austria reveals. "We already have willing applicants interested in qualifying. As far as we are concerned, the experts committee recommendation was not overturned," she adds.
It was avoided at all costs by Dayrit, she says. "He sat on the decision until it was time for him to go. Raising technicality issues at the Supreme Court level will only delay the importation, and expose the merits to a very conservative court."
The most contentious issue
Abortion is still the most contentious issue in reproductive health and rights, according to Melgar. The sad part of it all is that it is impossible to detach abortion from the question of women's reproductive rights, according to international reproductive-rights advocates.
But there are realities to contend with--400,000 abortions per year have raised alarms in the face of unsafe abortion practices, as one-fourth of these land in hospitals because of complications.
"Where abortion is illegal, it is likely to be unsafe and harmful," says Melgar. She adds though that legalizing abortion does not guarantee against unsafe practices.
Some argue that making abortion legal and safe makes it too easy and leads to high abortion rates. However, the Netherlands, which allows abortion, has the lowest abortion rate in the world. Advocates say it is an irony of ironies. The reason for this, they say, is the extensive use of reliable contraception.
Melgar says that an examination of abortion laws around the world shows an abortion-tolerant environment: 117 countries, where 74 percent of the world's population live, allow abortion for various reasons. These include considerations of women's physical and mental health; rape, incest and other forms of sexual abuse; and when there is great likelihood of severe fetal defects and deformities incompatible with life, Melgar explains.
Melgar continues that religious fundamentalism is a common feature of countries with very restrictive laws, which number 74 and where 26 percent of the population lives.
Philippine laws, specifically Articles 256 to 259 of the Revised Penal Code makes abortion a crime. Article II, Section 12 of the 1987 Constitution provides that the state "shall equally protect the life of the mother and the life of the unborn from conception," one of the few legal frameworks that accords the fetus with rights, and to the same degree as the mother, explains Melgar.
According to Melgar, some legal writers argue that the phrasing of this provision allows abortion to save women's lives, and yet there is no Supreme Court ruling on this matter.
Without this explicit language, the Philippines is thus categorized among the countries with the most restrictive laws on abortion, says Melgar.
Recommendations
The current state of affairs on the reproductive-health front requires major changes in government policies and programs. Among many other bold steps that need to be taken, Melgar says, enacting enabling legislation would require reviewing for timeliness and conformity with the evolved universal standards.
One of such laws, she says, would be the Philippine Constitution of 1987, which equated the unborn with living women, and the Revised Penal Code, which punishes all abortion without consideration for the life and health of women.
"To overcome the opposition of national and local-government executives to the reproductive-health program, it is necessary to enact a law along the integrated and rights-based approach. This law should, among other things, stop all manner of coercing women for or against certain family-planning methods, be [it by] providers, spouses, religious leaders, [or] government officials," Melgar explains.
And while everything is still up in the air, "women can continue dying," says Melgar.
Hormone injection can prevent death during delivery
STOCKHOLM
Some 600,000 women die in childbirth each year, 99 percent of them in countries south of the Sahara, but many of those deaths could be prevented with a hormone injection, according to a new Swedish study.
The most common cause of death for mothers in childbirth is heavy blood loss occurring between the birth of the child and the placenta's discharge.
According to the study, conducted in Angola where maternal mortality rates are among the highest in the world, an injection of the hormone oxytocin, which stimulates uterine contraction during birth, can help reduce postpartum bleeding by almost 50 percent.
"Reducing bleeding is particularly important in a poor country where many women have low blood levels even before the delivery," said Roland Strand, a gynecologist who conducted the study as part of his doctor's thesis at Sweden's Karolinska Institute.
He said that a three-pronged approach of an oxytocin injection, together with rapid cutting of the umbilical cord and active removal of the placenta--called active management of the third stage of labor (AMTL)--greatly increased women's chances of survival during childbirth.
Strand studied postpartum blood loss in 782 women whose birthing process followed a natural progression and 814 women who delivered their children under the AMTL method. AMTL reduced postpartum blood loss by almost 50 percent, and by 80 percent in women with severe blood loss exceeding one liter.
In addition, "around two-thirds of uterine ruptures were judged to be avoidable at the hospital level," Strand said.
The AMTL method is already widely recommended in many industrialized countries.
Strand noted that in the Angola study, the oxytocin was provided in a special one-time package consisting of a disposable needle and the hormone.
"This is very important. The needle can't be reused and therefore you don't risk spreading diseases such as HIV/AIDS, which is a major problem in poor countries because of the lack of hygiene surrounding needles," Strand said.
AFP
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