What Choice?: Abortion in the Philippines

What Choice?: Abortion in the Philippines
Celeste Ann Castillo Llaneta

The UP Forum Volume 9   Number 5    September-October 2008


Stories leak out, as they always do.

Thirteen young women, including a pregnant 16-year-old, rescued from an alleged abortion clinic in San Andres Bukid (The Manila Times, July 2002). Two suspected abortionists, an 82-year-old woman, and her 18-year-old granddaughter, arrested by NBI agents in Caloocan City (The Philippine Daily Inquirer, August 28, 2008). A 70-year-old alleged abortionist entrapped by NBI operatives in her house in Bacolod City (The Manila Times, February 4, 2007). Another alleged abortionist in Pagsanjan, Laguna, arrested after a police operative posed as a client in need of her services (The Philippine Daily Inquirer, January 12, 2007).

Some stories land in the pages of newspapers; some even make headlines. Some crop up in debates, forums, and opinion essays as case studies offered in support of or against abortion. And some are simply stories you know. The college student impregnated then abandoned by her boyfriend. The single woman in hot pursuit of a career and far from interested in settling down. The exhausted mother of ten living under a bridge, facing the prospect of bringing another life into a world of poverty and hunger.

All of these women will make a choice. And according to The Incidence of Induced Abortion in the Philippines: Current Level and Recent Trends (2005), a study conducted by Fatima Juarez, Josefina Cabigon, Susheela Singh, and Rubina Hussain for the Guttmacher Institute, while some stories end well, others—approximately 473,000 out of 3.1 million pregnancies, or 27 out of every 1,000 pregnancies occurring each year in the country by 20001—end in blood, pain, physical and psychological trauma, a prison sentence, and in some cases, death.

Abortion vs. miscarriage
The word upon which all of these stories hinge is choice. Unfortunately, choice has become just another of the catchwords being tossed about in the debate over House Bill 5043, or the Reproductive Health and Population Development Act of 2008, right up there with /pro-life, safe motherhood, family-friendly, and culture of death,/ the last term being the apocalyptic outcome envisioned by some conservative religious groups should the bill be passed. HB 5043 will pave the way toward legalizing abortion, these groups say, adding that all the artificial contraceptives mentioned in the bill are abortifacients.

At this point, some clarification is necessary, beginning with the definition of abortion. “The word abortion has been misused, misinterpreted, and maligned,” says Dr. Lourdes B. Capito, chair of the UP-PGH Department of Obstetrics and Gynecology. The medical definition of abortion, such as that used by MedicineNet.Com, is simply the termination of a pregnancy through “the premature exit of the products of conception (the fetus, fetal membranes, and placenta) from the uterus.”

There are two major types of abortions. Spontaneous abortion, otherwise known as a miscarriage, occurs due to abnormalities in the development of the fetus, and is clearly beyond the woman’s control. Induced abortion, which is the type of abortion that has the religious groups up in arms, takes place “when a procedure is done to end a pregnancy.”

There’s a move now, especially in Europe, to promote the use of the word ‘miscarriage’ as the politically correct term to refer to spontaneous abortions, although ‘miscarriage’ does not sound very medical,” Capito adds. “‘Abortion,’ which people automatically take to mean induced abortion, has become such a bad word.”

Contraceptives vs. abortifacients
To clarify further, medical science has ruled that contraceptives are not abortifacients. Capito stresses that “artificial contraceptives make the environment in the uterus and fallopian tubes unfavorable for the sperm and the egg cell to meet, so no fertilization takes place. Either that, or the woman is kept from ovulating.”


Dr. Lourdes B. Capito

“That life begins at fertilization is also stated in the ethics manual of the Philippine Obstetrics-Gynecology Society (POGS),” continues Capito. There are various ways to prevent fertilization and pregnancy from happening. These include abstinence from sex; the fertility awareness or natural family planning method; the withdrawal method; barrier methods that use physical or chemical barriers to stop sperm from entering the uterus (e.g., condom, spermicide, diaphragm); hormonal methods using manufactured forms of estrogen and/or progesterone to prevent ovulation, thicken the cervical mucus to prevent the entrance of sperm, and thin the lining of the uterus to reduce likelihood of implantation (e.g., the pill, injectables, IUD); and sterilization (e.g., tubal ligation, vasectomy).

“Artificial contraception does not mean abortion. Studies have shown that these [contraceptives] are not abortifacients,” emphasizes Dr. Josefina V. Cabigon of the UP Population Institute. Some time ago, Cabigon adds, in response to a claim to the contrary made by certain religious groups, the World Health Organization (WHO) released a statement to confirm that the pill is not an abortifacient. The WHO has also released guidelines on contraceptive use, and has included artificial contraceptives among its list of essential medicines for reproductive health.

“There is some conflict regarding what constitutes life,” says Dr. Carolyn I. Sobritchea, former director of the UP Center for Women’s Studies. “Still, some religious factions have stretched the meaning of abortion. They even say that condoms are abortifacients, which is crazy because with a condom the sperm and the egg would never meet.”

The law vs. numbers
The law is uncompromising toward abortion. Article 2, Section 12 of the Constitution upholds the right of the unborn to the protection of the State, and Article 256 of the Revised Penal Code criminalizes abortion, giving the Philippines the distinction of having one of the most stringent anti-abortion laws in the world.2 Moreover, nearly 90 percent of Filipinos are Catholics; thus, the prevailing attitude is distinctly pro-life. With these legal and moral walls rigidly in place and the women themselves understandably reluctant to talk about their experiences, carrying out research on abortion can be difficult.

Nevertheless, stories leak out and somehow a picture emerges. According to a 2005 study /The Incidence of Induced Abortion in the Philippines,/ 91 percent of women who have abortions are or have been married or with a partner, 57 percent have three or more children, 87 percent are Catholic, 71 percent are high-school educated, and 68 percent are poor. Abortion is also equally rampant in the rural areas.

The root cause of abortion? Unintended pregnancy. The Guttmacher Institute publication titled Unintended Pregnancy and Induced Abortion in the Philippines: Causes and Consequences (2006) by Singh, Juarez, Cabigon, Hussain, Haley Ball and Jennifer Nadeau, states that six in 10 Filipino women ages 15-49 have experienced an unintended pregnancy. In 2003, the average Filipino woman wanted 2.5 children but had 3.5. The study also notes that roughly two-thirds of Filipino women are poor, which, when paired with the difficulty in managing the number and spacing the births of children, can only result in a bad situation. “Despite the common perception that abortion occurs primarily among women who wish to conceal the ‘dishonor’ of a nonmarital pregnancy, women’s…reasons for having attempted to end an unintended pregnancy show that this is not the case,” the paper goes on. “The most common reason is an inability to afford the economic cost of raising a child, a reason cited by 72 percent of Filipino women who have attempted to have an abortion.”

Pro-choice vs. no-choice
The reality is this: a Filipino woman dealing with a pregnancy she doesn’t want considers, and at times, actually turns to induced abortion, despite all the blood, gore, guilt, fear, risk, and subterfuge associated with it. “Well-off women can go to doctors in Hong Kong,” says Cabigon. Methods used in a hospital or health center include medication with mifepristone or RU-486, dilation and curettage (D&C), or manual vacuum aspiration (MVA). But for the many who cannot afford doctor’s fees and trips abroad, obtaining an abortion from a doctor, nurse, or trained midwife is not an option. They have no choice but procedures that are crude and dangerous.

A stroll along the streets of Quiapo will offer a glimpse into the choices available to poor women: clandestine abortion clinics manned by hilots. These hilots offer herbal concoctions that can be drunk or inserted into the vagina; misoprostol or Cytotec tablets (which Capito says are likely fake), ingested and inserted into the vagina in order to induce bleeding and uterine contractions; and for pregnancies past the first trimester, deep abdominal massage or the insertion of a catheter or other objects into the cervix.

Life vs. death
The effects are always grave, no matter how the abortion is done. According to the Guttmacher Institute paper, “more than eight in 10 women who succeed in ending their pregnancy report a health complication due to their final abortion attempt…46 percent of women who succeed in having an abortion experience severe complications (defined as severe bleeding, severe pain, moderate or severe fever, or any injury); 35 percent experience a lesser complication, including mild to moderate bleeding or pain or mild fever. Morbidity due to unsafe abortion is not limited to those who succeed in having an abortion; some four in 10 women whose abortion attempt fails also experience complications.”

“No induced abortion is safe, especially induced abortion through instrumentation,” Capito points out. “First, you have the risk of infection. These abortions are not done by legitimate doctors, nor are they done using sterile procedures. Second, there is the risk of perforating the uterus. When the pregnancy is  advanced, the blood vessels are larger and the uterine walls are thinner, so there is greater risk of tearing the uterus. We get a number of such post-abortion patients here [at the PGH], and some of them arrive already in septic shock. A number of them die.”

Morality vs. reality
The stories that leak out are pieces of a bigger story whose central conflict involves a prevailing unmet need and a powerful moral force. “The proliferation of these clandestine abortion clinics tells you that there really is a demand for contraception,” says Sobritchea. “Women will not go to these lengths if they had access to their choice of contraception. The problem is religious groups are opposing contraception on the grounds that it promotes promiscuity.”

“It’s difficult to argue with these groups because they’re coming from a moral standpoint, and morality is relative,” Cabigon adds. “But there are realities these groups just don’t understand.”

Surveys show that most Filipinos want to practice family planning and believe in the need for a law legalizing the distribution of contraceptives3. It is hard not to draw correlations between overpopulation—88.57 million by 2007, according to the National Statistics Office—and widespread poverty.

Sobritchea recalls the experience of NGOs and the women of Barangay Baseco, a depressed, densely populated compound attached to the seawall of Manila port, during the time of Manila City Mayor Jose Atienza Jr. and his EO No. 003, which pushed for natural family planning as the city’s only family planning method.

“Atienza had every clinic distributing contraceptives removed, and the number of unwanted pregnancies shot up. These women live in shanties on stilts, which are almost perpetually flooded—you find yourself unable to sleep at night after seeing how these people live. The PGH had a difficult time handling the number of pregnancies, and the women had to go to clinics in Quezon City.”

Urban poor women are not the only ones paying the price for government’s caving in to the Catholic Church’s pressure regarding contraceptives, Sobritchea continues. Sex workers—both male and female—are also at risk, not only from unwanted pregnancies that end up in abortions, but also from the threats of HIV and other sexually transmitted infections (STIs). Similarly, female overseas workers are put in a kind of double jeopardy. “These women who go abroad suddenly find themselves outside the gaze of our traditional, conservative society. There are no restrictions, so they feel free to explore their sexuality.” Stories abound of Filipino women hooking up with Filipino seafarers, of two or three women sharing one boyfriend, same-sex relationships, and part-time prostitution. “Many of these women don’t know how to protect themselves. So they end up going home to have clandestine abortions, or contracting STIs or HIV.”

In the rural areas, where people have even less access to family planning information and maternal health care, the stories are the same, says Cabigon. The husbands are fishermen who spend two weeks to one month on their fishing boats at sea. When they come back to their wives…well, human nature asserts itself. The women end up pregnant, and since they would rather buy food for their families than spend what little they have on contraceptives, they end up having abortions.”

Another reality is that whenever these men indulge in drinking sessions—a favorite pastime—they come back home to their wives drunk and feeling frisky. “What can the woman do when she isn’t empowered to act on her own? She ends up pregnant again.”

Natural vs. compatible
Natural family planning, the only fertility management method allowed by the Church, can be an effective method if certain conditions are met. “As long as a woman’s menses are regular, which allows her to compute when her fertile period is, the natural family planning method is effective,” says Capito. These methods require a careful recording of a woman’s menstrual cycles, and for the Billings method, checking the cervical mucus. “However, this also requires the husband’s cooperation,” Capito adds. “If your husband presses you to have sex and you happen to be fertile, what can you do?”

College-educated women are more likely to use the natural family planning method, as shown in the 2003 National Demographic and Health Survey. “They know how the method works,” says Cabigon. “They are empowered enough to tell their husbands when sex is not advisable. They have maids, so they have time to chart their cycles every morning.” The woman in the rural areas wakes up, cooks for her family then she goes out to the fields and works all day. When will she have time to do her charting?”

There is also the risk of infection if the woman checks her cervical mucus with unsanitary hands. “The natural family planning method is not compatible with the lives of the poor,” says Sobritchea, who adds that the pill, with its 99 percent effectivity rate, or better yet the IUD, with its five to ten-year period of effectivity, might be more appropriate options for the urban and rural poor.

Ignorance vs. information
For many Filipino women, the choices are limited: they either deny their sexuality or risk getting pregnant. When they do get pregnant, they either see the unexpected pregnancy through, committing the rest of their lives to the consequences of the unforeseen, or get an abortion, risking death. Is it any surprise that, according to the Guttmacher Institute paper, although nearly all Filipino women want children, they spend most of their reproductive years (between the ages of 20 and 45) wanting to postpone or avoid pregnancy?

But choice arises from knowledge, and for the most part, Filipinos are either uninformed or misinformed about sex and sexuality. “Disseminate information by passing the Reproductive Health Act,” Capito says bluntly. “It’s not forcing the women to embrace contraception; it is informing them of the variety of options available to them. This is patient education. We want women to be able to make a fully-informed choice.”

Sobritchea, who is pushing for a bill on the right to information, says the foolproof way to prevent clandestine abortions is to educate Filipino women about sexuality and contraception. “Respect the individual’s right to know. Inform them about all the options suitable to their health needs, context, and economic status. There cannot be one formula for everyone. We have the right to information, and all the information the people need to protect themselves and promote their own well-being should be laid out in the open.”


Dr. Carolyn I. Sobritchea

Despite all the vitriol hanging in the air, the Church and bill’s proponents actually share a common goal: preventing clandestine abortion. And one way to do this is to show women that they have many choices, not just one. “[The bill is not promoting] a culture of death,” says Cabigon. “It’s actually promoting life, not just for the rich and educated minority, but for the poor majority.”

__________
Notes

1 See International Family Planning Perspectives, vol. 31, no. 3, September 2005, http://www.guttmacher.org/pubs/journals/3114005.html.

2 See http://www.pregnantpause.org/lex/world02.htm

3 See http://www.abs-cbnnews.com/nation/10/15/08/majority-filipinos-want-law-contraceptives-sws

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