Practicing what they preach
Through evidence-based medicine, a group of clinicians and researchers dispels many myths about reproductive health
By Jin Paul S. de Guzman
Associate Editor
In the 2003 National Demographic and Health Survey (NDHS), nearly three-fifths of all married Filipino women who already have two kids don't want to have any more. And yet, the national fertility rate remains high at 3.5--which means that a large number of women are having one or more children than they really want.
In relation to that, a 2000 Pulse Asia survey showed that almost every Filipino sees the significance of planning the size of his or her family. And yet, not even half (48.9 percent) of married women use any family-planning method at all.
These numbers speak of at least two issues facing reproductive health in the Philippines--how the actual size of the average Pinoy family doesn't match the desired size, and how controlling the size of the family is mostly left in the hands of women.
Evidence-based medicine
Of course, birth control is just one of the many issues under reproductive health. Dr. Mario Festin, deputy director for health operations of the University of the Philip-pines-Philippine General Hospital and professor of clinical epidemiology and obstetrics and gynecology at the UP College of Medicine, explains: "People usually equate [reproductive health] as a means to highlight family planning when actually there are many things related to that." These include maternal and child health, the prevention of complications associated with induced abortions, breast and cervical cancers, issues of sexuality, infertility, and adolescent sexual health--all as important as family planning.
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Misconceptions about reproduction are common not just among people in the community but also among a number of health-care professionals. These misconceptions obviously affect people's health as well as their health-seeking behavior---and these definitely have to be addressed. One way of addressing these misconceptions is by working the concept of evidence-based medicine into clinical practice.
Evidence-based medicine (EBM) has gained significant following in the medical world in the past few years, making it a crucial tool in decision making in clinical, even public-health situations. It integrates three concepts---best research evidence, clinical expertise, and patient values.
The application of EBM is composed of five steps: "converting the need for information into an answerable question; tracking down the best evidence with which to answer that question; critically appraising that evidence for its validity, impact, and applicability; integrating the critical appraisal with our clinical expertise and with our patients' unique biology, values, and circumstance; and evaluating our effectiveness and efficiency in executing [the earlier steps], seeking always to improve them both for next time" (Sacket et al., 2000; cited in Evidence by the Philippine Evidence-Based Reproductive Medicine Network).
The application of EBM in reproductive health, therefore, will not only dispel the misconceptions related to it, but also improve the reproductive health of Filipinos. "Usually we make our decisions based on a singular event," explains Festin. "Actually we can make decisions based on science. [There are] already good research out there. We don't need to repeat [them], we just have to find out whether the research can be applied to us."
EBM in reproductive health
With this in mind, Festin, together with colleagues from the PGH and Philippine Obstetrical and Gynecological Society (POGS), formed the Philippine Evidence-Based Reproductive Medicine Network (PEBRMNet) in 2003. A study group under the UP-National Institutes of Health (NIH), the PEBRMNet is also able to expand their membership to include various other academics and practitioners in obstetrics and gynecology through a grant from the United States Agency for International Development (USAID). The network, says Festin, aims to guide clinicians in making clinical decisions with the support of evidence generated by high-quality scientific research. The PEBRMNet now has 17 members.
When the PEBRMNet was still a small group, it was able to come up with clinical practice guidelines on antenatal care, normal labor, and on screening in pregnancy, which they endorsed to POGS, says Festin, who is a former head of the NIH.
One of the PEBRMNet's major efforts in promoting EBM in reproductive medicine came with the publication of Evidence: PEBRMNet Critically Appraised Topics in 2004. Focusing initially on contraception, the publication sifted through available scientific evidence that will provide health providers "more and better information to address their own misconceptions as well as those of their clients." The group added: "Providers need to be armed with the facts, based on solid, documented evidence, and they need that information to be packaged in a way that directly addresses patients' concerns and providers' own misconceptions, specific to the Philippine context."
Dispelling myths
The affiliation of most Filipinos with the Roman Catholic Church is frequently pointed as the main barrier to the use of modern contraceptive methods and devices. This is not true. As shown in the 1998 NDHS, only 2.3 percent of married women who don't use any form of contraception at all cite religious reasons. A staggering 29 percent cite "method-related reasons," which involve questions of side effects and other health-related consequences.
As earlier mentioned, even health-care providers have inaccurate understanding of various contraceptives. A 2004 survey of 1,200 ob-gyns, general practitioners, midwives, and drugstore clerks by the USAID-Commercial Market Strategies and IMS Health-Philippines showed a few of these, chief of which being 28 percent of the ob-gyns and GPs involved in the survey believed that the pill causes infertility---even if none of them encountered a single case of pill-induced infertility.
In the Evidence series, the PEBRMNet looked for scientific proof to back up---or correct---certain perceptions about six kinds of contraceptives; oral contraceptives, injectables, intrauterine devices, barrier methods, natural family planning, and surgical methods.
While the 2002 Family Planning Report of the Department of Health pointed out that oral contraceptive has the most number of current users (42.5 percent) among the modern contraceptive methods and devices, it is surrounded by the most number of questions regarding health-related consequences. Following are the answers to common pill-related questions.
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The use of oral contraceptives does not raise the risk of breast cancer (Marchbanks PA et al., 2002).
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The risk of stroke for women with migraine and who are using oral
contraceptives increases (Chang CL et al., 1999).
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Women with human-papillomavirus infection and taking oral contraceptives for under five years do not have an increased risk for cervical cancer. However, the risk increases if they take the pill longer than five years (Moreno VM et al., 2002).
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The risk of having a baby with Down syndrome does not increase if a woman gets pregnant after using oral contraceptives (Martinez-Frias ML et al., 2001).
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Women on oral contraceptives or fitted with an IUD for under four years
regain fertility faster than those who have an IUD for more than six years
(Doll H et al., 2001).
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Third-generation-oral-contraceptive use is not associated with an increased
risk for a heart attack (Lewis MA et al., 1996).
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No evidence is available showing that the use of combination oral
contraceptives leads to weight gain (Gallo MF et al., 2003).
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The risk for epithelial ovarian cancer is lower for those who have take oral contraceptives than those who never have (Bosetti C et al., 2002).
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Mood changes and negative affect during specific portions of the menstrual cycle are experienced less often by those on the pill (Oinonen KA and Mazmanian D, 2002).
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The risk of developing liver cancer does not increase with the use of oral
contraceptives (Collaborative MILTS Project Team, 1997).
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Using low-dose contraceptives can help clear moderate acne (Leyden J et al., 2002).
More work
Through workshops and lectures, the PEBRMNet is disseminating the results of the studies to doctors, nurses, and midwives, as well as train them to critically look at scientific data on their own. The PEBRMNet has trained as many as 100 professionals "to get familiar with the methods" of EBM, says Festin.
At present, the PEBRMNet is looking for funding for their plan to look closely into the reasons for doing a cesarean section. "In PhilHealth (Philippine Health Insurance Corporation), that's the number-one cause of reimbursement," says Festin. "We should find out which of the indications for cesarean section are really valid … because we have to regulate the practices of doctors somehow. And one way of regulating is through reimbursement of insurance."
ADDRESSING UNCERTAINTIES
As shown in their publication Evidence, the Philippine Evidence-Based Reproductive Medicine Network (PEBRMNet) provides the correct answers to many questions about contraceptives---and backs up their assertions with high-quality research. Following are several contraceptive methods and devices and the right answers to frequently asked questions.
Intrauterine devices (IUD)
Natural family planning
Surgical methods
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The risk of an ectopic pregnancy in women who underwent tubal ligation is highest if the technique used was bipolar coagulation, but lowest if partial salpingectomy or other techniques was used (Peterson HB et al., 1997).
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The risk of abnormal menstrual bleeding is reduced with tubal ligation (Petersen H et al., 2000).
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Sexual desire and pleasure are not affected by interval tubal sterilization (Costello C et al., 2002).
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Sexual and marital satisfaction of men is not affected by a vasectomy (Hofmeyr DG and Greef AP, 2002).
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It is likely that there is no increased risk or association between prostate cancer and a vasectomy (Dennis LK et al., 2002).
Barrier methods
Injectable contraceptives
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The use of depot-medroxyprogesterone acetate (DMPA) does not raise cervical-cancer risk (Thomas DB et al., 1995).
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Breast-feeding women are more likely to continue using DMPA than nonlactating women to control their fertility. In addition, side effects are less frequent in breast-feeding women (Sun DL et al., 2000).
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The overall increased risk for breast cancer in women using DMPA does not increase, even if they are using it for more than five years (World Health Organization and New Zealand pooled studies).
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Episodes of hot flashes in menopausal women on DMPA are decreased (Barton D et al., 2002).
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Some decrease in bone-mineral density is associated with DMPA use, but it is clinically insignificant and easily reversible after stopping (Scholes D et al., 2002).
NIH spearheads telemedicine network
The National Telehealth Center (NTC) of the University of the Philippines-National Institutes of Health launched in August BuddyWorks, a program that applies web-based technology in telemedicine services for community partnership programs.
With a PhP50-million grant from the e-Government Fund, the project was conceptualized by the NTC and approved by the Commission on Information and Communications Technology. The NTC coordinates with the Department of Health (DOH) to reach the different provinces and with the different units of the Philippine General Hospital to provide experts for teleconsultations. Other institutions will help provide a pool of mentors for the program as well as to develop a wider referral system.
"A key factor in this project is that it will provide medical services to underserved areas in the Philippines," said Dr. Inocencio Maramba, NTC director and BuddyWorks project coordinator.
Functioning like electronic mail, BuddyWorks' interface has been modeled after a hospital chart, in which health professionals from far-off areas may enter important information that they wish to discuss with their colleagues in Manila. Based on the clinical data they provided, the colleagues can make a management suggestion.
This will be especially beneficial to rural communities that are without access to specialists and subspecialists. The network is also being developed to allow specialty societies and academic health institutions expansion of their database for research and training purposes.
BuddyWorks also aims to promote a sense of teamwork in the Philippine medical community, and eventually contribute to the equitable distribution of health services all over the country.
With support from the DOH, Philippine Health Insurance Corporation, Advance Science and Techonlogy Institute, UP Information Technology Training Center, Leverage Systems Technologies, and Microserv Inc., BuddyWorks currently coordinates with 10 hospitals, medical schools, and rural health units all over the country.
W. Sevilla, MD
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