Hard Evidence to Justify the RH Bill

Hard Evidence to Justify the RH Bill

Josefina V. Cabigon

The UP Forum Volume 9 Number 5 September-October 2008

In his column “Justifying a wrong end”(The Philippine Star, October 6, 2008, p. 17), Jose C. Sison says “The debate on H.B. 5304 (RH bill) would have been very informative and enlightening to our legislators and the public in general if the issues raised by those against its passage are met head on, directly refuted and clearly shown to be erroneous.”

This remark merits attention. Three issues raised by the anti-RH bill are directly refuted here using scientific findings and facts and logical reasoning to strengthen the arguments.

Dr. Josefina V. Cabigon

First Issue raised by the RH Bill opponents: The RH Bill is a culture of death.

The RH Bill is a culture of life, very much pro-life as it is for healthy mothers and children. It addresses the problems of the underprivileged poor women and children in terms of health status, access to and utilization of health services to complement the health and other social and development policies in the country. It responds to related issues of under-funding of maternal and child health services, lack of policies and programs addressing the major causes of maternal and infant, perinatal and neonatal deaths, one of which is poor maternal health associated with poverty, low education, poor access to health care and services.

Countless poor Filipino women and families paid and continue to pay dearly for the absence of a clear and effective reproductive health and population policy. Independent studies are consistent in revealing that close to 200 Filipino mothers per 100,000 live births are dying on the average around 2000.1 Maternal mortality ratios were consistently very high, way above the national 200 point estimate in most of the poorest or bottom 10 provinces in the country.2

Based on the 2006 Family Planning Survey (FPS),3 poor infants were 1.35 times more likely to die compared to their nonpoor counterparts. The risk of dying among poor under-five children was 1.56 times that among nonpoor children under five years old. Even if other important variables were simultaneously considered, the children in the poorest wealth index quintile were 154 and 161 times more likely to experience an infant and child mortality in the first five years of life, respectively, compared to those in the richest quintile.4

Disparities between the poor and the rich in access to health facilities are consistently revealed by various sources (e.g. 2006 FPS, 2003 National Demographic and Health Survey (NDHS), Social Weather Station Survey for the World Bank Filipino Report Card and 2002 Annual Poverty Indicators Survey). For example, the 2003 NDHS5 showed that 77 per cent of women had problems in accessing health care when they were sick. The rich Filipino mothers were 4 times more likely to have skilled delivery attendance than the poor during maternal delivery. Thirty five rich mothers for each poor mother deliver at private facilities.

Eastern Visayas, Cordillera Administrative Region, Bicol, and Central Mindanao are the regions where the poorest 10 provinces chalk up the highest percentage of mothers with obstetric complications during pregnancy, delivery and after childbirth according to the 1993 Safe Motherhood Survey.6

The RH Bill prevents conception; it does not promote abortion and therefore saves lives from abortion. Issues of unintended pregnancies, unmet need, abortion and improving maternal and child health through family planning belong to family planning policy which is a component of the RH bill. The RH Bill is an effective family planning policy that ensures freedom of choice and access to a full range of safe and effective family planning methods (natural and artificial). It does not reflect the politically sensitive term ‘fertility reduction policy’; instead, it aims for a reduction of unintended pregnancies in a healthful manner to capture the health and survival of mothers and children.

According to WHO when restrictions on access to contraception are enforced and other pronatalist policies are put in place, unsafe abortion-related maternal morbidity and deaths increase. In Romania such restrictions were imposed in 1966, resulting in increased maternal morbidity and mortality due to unsafe abortion, but these declined sharply after the restrictions were withdrawn in December 1989.7

Given the restrictive law on abortion in the Philippines, it would be harmful from both a public health and human rights perspective to do anything that would decrease use of contraception and increase recourse to abortion.8

Research collaborators from the Guttmacher Institute (GI), New York and the UP Population Institute (PI) revealed that six in 10 Filipino women report that they have experienced an unintended pregnancy at some point in their lives.9 About 1.43 million pregnancies each year in the Philippines are unintended. Fifteen percent of these unintended pregnancies result in induced abortions.

The same GI-PI study indirectly estimated that 473,000 induced abortions in 2000 and 800 women per year die from complications of unsafe abortion. Most women who have had an abortion are married, Catholic and poor. A larger proportion of poor than of wealthy women reported the financial cost of raising a child which emerged as the top leading reason for having an abortion.

Moreover, close to 5 per 1000 Filipino women aged 15-44 were hospitalized for abortion-related complications. Eight in 10 women who succeed in ending their pregnancy have health complications, and more than half of these women report having severe complications. Poor and rural women experienced higher rates of severe abortion complications than did their wealthy and urban counterparts.

Furthermore, nearly half of all married women of reproductive age have an unmet need for effective contraception. Such women are sexually active, are able to have children, do not want a child soon or ever, but are not using any contraceptive method or are using traditional methods, which have high failure rates.

My birthspacing study10 showed that the poor who were current users of traditional methods manifested consistently and substantially much higher proportions of subsequent births and much shorter average birth intervals at second to next higher order births than their nonpoor counterparts. The poor remain disadvantaged even with the use of artificial methods. Poor current users of artificial methods exhibited higher proportions, moving to the next higher order birth and shorter average birth intervals than their nonpoor counterparts who were using artificial methods.

The investigative report “Imposing Misery: The Impact of Manila’s Contraception Ban on Women and Families” documented women and families in physical, mental, economic and social crises due to the total suppression of contraceptive supplies, services and information.

Second issue raised: The RH Bill promotes the use of artificial contraceptives which are abortifacient.

The pill, Depo Provera, and IUD which are popular artificial methods among Filipino women are not abortifacient.

As detailed in the physician package inserts for these contraceptives (which must be approved by government drug regulatory authorities), most contraceptives have multiple mechanisms of action, the most important of which all occur before fertilization is complete. The impact of contraceptive steroids on endometrium could, in theory, interfere with implantation of a fertilized egg, just as the IUD could, in theory, interfere with implantation. But it is unlikely that contraceptives ever actually work this way, since the other mechanisms of action (for hormonal methods suppression of ovulation, thickening of cervical mucus, impact on the movement of sperm and egg through the fallopian tubes) occur earlier to prevent pregnancy. Any impact on the endometrium would be moot.

As succinctly put by the World Health Organization after reviewing pertinent studies,11

“There has been a growing body of evidence for more than four decades indicating that administration of combined oral contraceptives (COC) inhibits follicular development and ovulation, and that this is their primary mechanism of action (Mishell et al. 1977; Killick et al. 1987; Rivera et al. 1999). They also affect cervical mucus, making it thicker and more difficult for sperm to penetrate. This effect may also contribute to their high efficacy (Rivera et al. 1999). Although it is known that there are changes in the endometrium during combined oral contraceptive (COC) use, no evidence to date has supported the hypothesis that these changes lead to disruption of implantation. Given the high efficacy of COCs in preventing ovulation, it is very unlikely that “interference with implantation” is a “primary mechanism” of contraceptive action.…

Progestin-only methods also inhibit follicular development and ovulation although the level of this effect varies for different progestin-only methods and among individuals. For Depo Provera, the level of ovarian suppression is very high; therefore inhibition of ovulation is the primary mechanism of action (Rivera et al. 1999)…

The major effect of all IUDs is to induce a local inflammatory reaction in the uterine cavity. During the use of copper-releasing IUDs the reaction is enhanced by the release of copper ions into the luminal fluids of the genital tract, which is toxic to sperm (Ortiz 1978; Seseru and Carnacho-Ortega 1972; Ullman and Hammerstein 1972). In these users, it is likely that few sperm reach the tubes and those that do reach them have low fertilizing power…

In addition, studies on recovery of eggs from women using copper-bearing IUDs and from women not using any method of contraception show that rates of embryos formed in the tubes are much lower in copper-bearing IUD users than those not using contraception (Alvarez et al. 1988). Thus, the hypothesis that the primary mechanism of copper-bearing IUDs in women is destruction of embryos in the uterus (i.e., abortion) is not supported by available evidence.”

The Population Council12 has data that indicates that the copper T IUD never acts by preventing implantation, but always works to prevent fertilization. The exception would be when the IUD is inserted post-coitally as an emergency contraception. Then it can indeed prevent implantation in the first five days or so after unprotected sex.

Third issue raised: Poverty is not caused by rapid population growth but by a combination of many factors particularly greed, government corruption and inefficiency, uneven distribution or misuse of resources, lack of technology, waste and even natural disasters or wars.

Population affects poverty and at the same time poverty affects population. The RH Bill seriously considers population and poverty as policy issues that cannot be dismissed or treated lightly. It is aware that poor families are the most affected, demographically entrapped in a cycle of poverty and ill health. Sustained economic growth is essential to eradicate poverty. Rapid population growth is an obstacle to sustained economic growth. Hence, finding the intersections between population policy and poverty alleviation policy is crucial.

Poverty and the components of population growth (fertility especially) refer to individual- or family-level characteristics and behaviors. They are reachable by policies that yield welfare gains across income distribution and gender lines; or by government, only through broad scale extension services.

Even for philosophers in ancient times, population did matter13. Confucius (551-478 B.C.) and his school argued that excessive growth of population may cause poverty. Aristotle (384-322 B.C.) contended that poverty, civil strife and ineffective government are the results of un-curtailed population growth.

Through the years, several scholars have held the view that population matters. Malthus argued that population grows geometrically but food supply grows arithmetically14. For Notestein, rapid population growth complicates the process of modernization15. For Hardin, increasing population without limit in a limited world brings ruin to all16. For Ehrlich and Ehrlich, too many people, too little food and degrading environment cause the earth as a dying planet17. For King, population is the critical component in all major human problems18.

It has been the prevailing argument of demographers that in the early stages of demographic transition, per capita income declines because of large youth dependency burden and a small proportion of working age adult working and saving (demographic onus); however, as the transition proceeds, per capita income increases as the share is reversed with relatively more workers and savers (demographic bonus).

According to the latest surveys19 the ratio is a little above 3 children per woman; this implies that the population still grows at a rate of a little more than 2 percent because of the population momentum or the tendency of a young population to continue growing for a number of years. If a population is young, even two-child families will mean a growing population for several generations.

Poverty incidence increases with family size (a family size of 1 with about 10 % in poverty to a family size of 8 with about 55% falling in poverty over time)20. For 2007, an average Filipino family of five members needed PhP 6,195 monthly income to stay out of poverty21.

In a nutshell. the RH Bill realizes that population is the foundation of the state. It is for a wealthy, healthy, and educated population which in turn means a wealthy, healthy, and educated Filipino nation. If each cooperates in achieving a healthy, developed, and wealthy population, the reward will be a healthy, developed and wealthy state.

__________
The author is a Professor at the UP Population Institute. She holds a PhD in Demography and is coordinator of the CSSP Graduate Program and the Tri-College Philippine Studies Program.

Notes
1 AbouZahr , Carla and Wardlaw, Tessa, “Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF and UNFPA” (WHO/UNICEF (n.d.). The 1998 National Demographic and Health Survey (NDHS) reveals an estimate of 172 per 100,000 births but it is also within the 95 percent confidence interval of 120 to 224 (in the order of 30 percent). This implies stability of maternal mortality.

2 Data sources: National Statistical Coordination Board (NSCB) “Highlights: Poverty incidence 1997 and 2007”; “Highlights of the Report of the 1997 Philippine Human Index; and Highlights of the Report of the 2000 Philippine Human Index”. Accessed on line at http://www.nscb.gov.ph; NSCB (1995). Recommended Infant Mortality Rates, Child Mortality Rates, Under-five Mortality Rates and maternal Mortality Ratios National, Regional, Provincial and City Levels, 1990-1995, Submitted to the Technical Committee on Population and Housing Statistics by the Technical Working Group on Maternal and Child Mortality. November.

3 National Statistics Office (NSO), 2006 Family Planning Survey Philippines Fact Sheet (Manila: NSO, 2007), 3.

4 Alcantara, A.A., Rodriguez, M.V. and Cabigon, J. V (2000). ‘Determinants of child mortality and morbidity. In Cabigon, JV. (ed.) PSSC Social Science Information: Papers on the 1998 National Demographic Survey: A Special Issue of the University of the Philippines Population Institute. 28(2):1-32.

5 NSO (Philippines) and ORC Macro, National Demographic and Health Survey 2003 ( Calverton, Maryland: NSO and ORC Macro, 2004).

6 NSO (Philippines) and Macro International Inc., National Safe Motherhood Survey 1993 ( Calverton, Maryland: NSO and ORC Macro, 1994).

7 World Health Organization (WHO). Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000. Fourth edition. Geneva: WHO, 2004.

8 WHO “Expert Opinion on House Bill 4643 on abortive substances and devices in the Philippines’. Geneva:UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, 7 November 2006 citing Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet, 2006 Sexual and Reproductive Health 3. Published online 1 November 2006.

9 Singh, Susheela et al., Unintended Pregnancy and Induced Abortion in the Philippines: Causes and Consequences (New York: Guttmacher Institute, 2006).

10 Cabigon, Josefina V. “Revisiting Birth Spacing in the Philippines,” (Final Report submitted to the Commission on Population, Quezon City: University of the Philippines Population Institute, December 2006), Table 10, 36.

11 WHO, 2006, op.cit. (see reference 8) citing the following: Alvarez F, Brache V, Fernandez E. New insights on the mode of action of intrauterine contraceptive devices in women. Fertil Steril, 1988;49:768-773; Killick S, Eyong E, Elstein M. Ovarian follicular development in oral contraceptive cycles. Fertil Steril, 1987;48:409-13; Mishell DR, Kletzky OA, Brenner PF, Roy S, Nicoloff J. The effect of contraceptive steroids on hypothalamic-pituitary function. Am J Obstet Gynecol, 1977;128:60-74; Ortiz ME, Croxatto HB, Bardin CW. Mechanism of action of Intrauterine Devices. Obstet Gynecol Survey, 1996;51(Supp):S42-S51; Rivera R, Yakobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. Am J Obstet Gynecol, 1999;181:1263-9; Seseru E, Carnacho-Ortega P. Influence of metals on in vitro sperm migration in the human cervical mucus. Contraception,1972;6:231-240; and Ullman G, Hammerstein J. Inhibition of sperm motility in vitro by copper wire. Contraception, 1972;6:71-76.

12 Accessed on line at http://www.popcouncil.org/biomed/cut380.html.

13 Ebenstein, William and Ebenstein, Alan, Great Political Thinkers, Plato to the Present, 6th ed. (Thomson Wadsworth, 2000); Estrella D. Solidum, /Outline of Readings in Political, Social, and Economic Thought/ (Quezon City, 1994), 67pp.

14 Thomas Malthus, Essay on the Principle of Population as it Affects the future Improvement of Society, with Remarks on the Speculations of Mr. Godwin, M. Condorcet, and Other Writers (1798); also from Matt Rosenberg, “Thomas Malthus on Population,” http:/geography.about.com/od/populationgeography/a/Malthus.htm.

15 Notestein, Frank W. “Economic Development Would be Helped by a Reduction of Fertility,” UNESCO Courier, 1974.

16 Hardin, Garrett, ‘The Tragedy of the Commons, “ Science 162 (1968):1243-1248.

17 Ehrlick, Paul and Ehrlick, Anne, The Population Explosion. New York: Doubleday. 1990.

18 King, Maurice, “The US Department of State is policing the population policy lockstep,” BMJ 319 (9 October 1999): 998-1001. His paper presents the following points; a tight taboo prevents demographers and United Nations (UN) agencies from confronting demographic entrapment; defections from this taboo are apt to be policed by the US Department of State; the presumed reason for this is that radical reduction in number of births in the south (one child families) would question resource consumption in the North; the major health programme of the new millennium has to be a one child world, linked to moderation in resource consumption in the North; entrapment is merely the worst of many problems (poverty, malnutrition, etc) in which population plays a large part; to make it taboo is to hinder the resolution of these other problems also. Lockstep is a mode of marching in very close file in which the leg of each person moves with, and closely behind, the corresponding leg of the person ahead—with the result that if one person breaks step the whole squad falls over. The lockstep is the practical manifestation of the hardinian taboo. Population policy lockstep means the closely coherent population policies currently in vogue in academia, the foundations, and the UN agencies. These are tightly bound by the hardinian taboo and deny that entrapment exists.

19 NSO, op.cit. (see references 3 and 5).

20 Reyes C. “The poverty fight: have we made an impact. PIDS Discussion Paper No. 2002-20. Makati City: Philippine Institute for Development Studies. 2002; Orbeta A. “Population and poverty: a review of the links, evidence and implications for the Philippines. Philippine Journal of Development 30(2): 195-227. 2003.

21 National Statistical Coordination Board, June 2007.

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One Response

  1. Well discoursed! Kuddos!

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