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Wednesday, August 15, 2007

GMA Legacy May Include More Mothers At Risk

Feature Story / Philippine Center for Investigative Journalism


UBAY, BOHOL — Antonia Quirino sits with a dazed look on top of the stairs of her bamboo house amid a large swath of cornfield. She speaks laconically, as if every word is a labor. Filth surrounds her; debris of past meals remain on the dirty kitchen and table, the clotheslines display tiny clothes too grimy and stained to be considered ready for wear. Nearby, a few of her children sleep the day away.

At 40, Quirino is a mother of 10 children, and is four months away from giving birth to her 11th. She delivers at home and has known no prenatal or postnatal care, yet her nipa hut is just a few meters off the main road that leads to Bohol’s tourist-drawing resorts. She is a mother at risk, but she is below the radar of the government, which has sworn off providing free contraceptives, and which does not encourage information about their use.

About a 90-minute plane ride away, in Malacañang, sits a woman whose family planning policy, many say, has directly or indirectly consigned Quirino to her fate.

When she first took power in 2001, President Gloria Macapagal Arroyo initially issued confusing statements on her family planning policy. She once admitted using pills in her early years as a mother and wife, but said that as a Roman Catholic, it made her go to confession. In 2002, in an apparent effort to woo the Church, which supported her predecessor’s ouster, she ruled out the purchase of contraceptive materials and tossed the responsibility of buying these supplies to local governments. She has since fortified that policy to placate the Church as her government battled numerous threats to its survival. It has also resulted to the undue delegation of official power and handing over of state funds to a private group allied with the Church.

Government health workers and nongovernmental organizations (NGOs) exposed to the realities in the field say Arroyo’s position has deadly effects on numerous fronts. They say it keeps the poorest women uninformed of all the options available to them to limit or space their children. It deprives women of the free contraceptive materials previously available to them in barangay health centers. Worse, private groups like Couples for Christ (CFC), using government funds, preached against artificial contraception. This has prompted a longtime government health expert, who spoke on condition of anonymity, to warn of a rise in abortion rates because of the dearth of contraceptives, formerly available but now absent, in health centers.

“When the census numbers are out next year, this government will be shocked by the high incidence of abortion,” says the government health official. The same official is aghast at how women’s health is being regarded as just another political issue.

Dr. Junice Melgar, head of the NGO Linangan ng Kababaihan or Likhaan, also says that women’s health is now being sacrificed for political expediency. “This is her legacy,” she says, referring to President Arroyo. “Women will remember her harshly for this. This is a woman who has been very unkind. She is pushing women into unsafe pregnancies, and probably even death.”

In a paper that reported the effects of the contraceptive ban in the city of Manila, Likhaan noted that Arroyo “is the first president since 1969 to weld its policies not to medical standards, but to the moral standards of the (Roman) Catholic Church.” (See sidebar) Melgar also asserts, “The major battle is the president herself. It’s not just the Church, but the president’s own attitude toward women.”

Rise in Unintended Pregnancies

It was particularly the memory of youngest sister Elisa who died at seven years old from peritonitis, an abdominal infection, that firmed up her resolve to become a doctor. “She kept a little notebook where she wrote that she wanted to take up medicine,” recalls del Mundo. “When she died, I decided to take her place.”

A 2006 study done by Josefina Cabigon of the University of the Philippines Population Institute (UPPI) and five other experts at the Alan Guttmacher Institute, an international NGO that focuses on sexual and reproductive rights worldwide, says that six in 10 Filipino women had an unintended pregnancy at some point in their lives because of lack of access to and knowledge of modern contraceptives. That fraction, says the study, translates to some 1.43 million unintended pregnancies each year, a third of which end in abortion.

It also says that while the women who had abortion come from all classes, the majority are “married, poor, and Catholic.” The study adds that poor women tend to use unsafe methods because they cannot afford safe procedures by trained providers. These unsafe methods include massage, insertion of a catheter, and the use of Misoprostol, which is prescribed by doctors to treat gastric ulcers. Eight of 10 of the women who use such methods suffer complications, says the study.

A July 2007 World Bank report on population issues also says that the main reason women in developing countries like the Philippines seek abortion is “often due to difficulties in obtaining access to an appropriate method of contraception, incorrect or inconsistent use of contraceptive methods, and contraceptive method failure.”

Meanwhile, the Department of Health (DOH) says it has reduced maternal deaths from 172 per 100,000 births in 1998 to 162 per 100,000 in 2006. But that still means 10 to 12 women die everyday, or around 3,650 to 4,380 every year, because of pregnancy and related cases. Originally, too, DOH had aimed to reduce the maternal mortality rate to 100 per 100,000 births by 2004.

Tomas Osias, head of the Commission on Population (Popcom), the state agency that determines the direction and implementation of the government’s family-planning programs, traces the maternal death rate to women being “too young (less than 18 years old), too old (over 34 years old), or having babies too close or unspaced (less than two years).”

Suneeta Mukherjee of the United Nations Population Fund (UNFPA) has also said that 99 percent of maternal deaths are preventable, adding that promoting family planning in places with high birth rates could help cut the maternal mortality rate by as much as 35 percent. Media reports last March also quoted her as saying that it is unlikely that the Philippines will meet its target of reducing the maternal mortality rate to 52 per 100,000 births by 2015 without “political will.”

As it is, NGOs even doubt the data on maternal health now in use by the DOH. Melgar explains that the maternal mortality rate of 162 per 100,000 is not the result of the regular census conducted every five years. She says it is the result of a survey, which has an error margin of plus or minus 30. This is because the president, whose much-vaunted field of expertise is economics, was not able to fund a census in 2005, because the budget was again re-enacted. A census is a basic requirement in economic planning, as well as in goal- and policy-setting.

Melgar says that veteran health department officials know it is critical to provide family-planning materials to women who want to plan how many children they will have and when, but who are unable to afford these materials on a regular basis. But Melgar asks, “How can you do that, (provide supplies) if your boss does not allow it?”

No Buying of Artificial Contraceptives

Last year, in fact, Albay Representative Edcel Lagman was able to insert a P180-million budget for contraceptives for 2007. But that money remains unspent, and Health Secretary Francisco Duque says it certainly will not be used for artificial contraceptives.

“We are not buying,” he told PCIJ recently. According to Duque, DOH’s policy against government spending on contraceptives will remain, and that his department aims to just “strengthen the scientific, natural family planning methods” it has espoused under the Arroyo administration.

In 2004, DOH even awarded P50 million to the religious group Couples for Christ to fund a government program called Responsible Parenthood-Natural Family Planning (RP-NFP). According to its own website, the CFC considers sex education, contraception, sterilization, in vitro fertilization, and population control as “anti-life.”

Couples for Christ was one of the first groups to mobilize its members during Edsa II, which resulted in the ouster of then President Joseph Estrada and Arroyo’s ascension to power. In a June 2004 report to then Health Secretary Manuel Dayrit to cover the first tranche of the money, CFC said it used the fund to conduct almost a hundred lectures on natural family planning, “chastity education” campus tours, and media and public relations expenses.

Lawyer Rhodora Roy Raterta, executive director of the Family Planning Organization of the Philippines (FPOP), says the deal violated the principle of separation of church and state, “as the CFC is known to have links with the Catholic Church.” But what made it worse, she says, were reports that CFC also used its trainings to denounce artificial contraception.

“The bottom line is, it’s wrong,” says Raterta. She also says that funding natural family planning alone violates the Constitutional provision that says the government will protect the right of spouses to found a family in accordance with their personal religious convictions.

Then Senator Luisa Ejercito, Estrada’s wife, was so incensed by the agreement between the DOH and the CFC that she filed a resolution demanding an investigation into its legality. She said the P50-million deal should have gone through bidding, like all other government contracts.

But health experts are also unhappy over CFC’s claims regarding the efficacy of natural family planning (NFP). Melgar says CFC does not tell its clients that “going natural” has a high failure rate of seven per 100 cases.

In a 1995 study by four experts led by Haishan Fu for the Alan Guttmacher Institute, abstinence, the core of natural family planning, was found to have a 22-percent failure rate while withdrawal had 26 percent. (The Standard Days Method, which the Church promotes, requires abstinence of up to 12 days.)

In comparison, says the study, implant and injectables have the lowest failure rates (two to four percent), followed by the pill (nine percent), the diaphragm and the cervical cap (13 percent), and the male condom (15 percent).

“It’s okay if women choose natural family planning methods,” says Melgar, who is Catholic. “But they should be advised that they could get pregnant, that it has a very high failure rate.”

Yet the CFC, in a letter to its members in October 2004 stated, “NFP is the most reliable, with 99-percent efficacy rate, proven in more than 100 countries and no side effects, except greater marital love and joy.”

Strategic Appointments

Last year, Geraldine Padilla, wife of CFC director Frank Padilla, was appointed to the Popcom board, which is made up of 10 Cabinet members led by the health secretary, the UPPI director, and three private-sector representatives.

As a state agency with almost four decades of experience, Popcom has built a strong network in all provinces, which could effectively reach all households, given enough funding and support. But Popcom has found itself unable to provide the whole array of options it used to offer women. In keeping with Arroyo’s ban on modern methods, its trainings are now limited to explaining women’s fertile periods and the natural methods of contraception. No lessons on artificial means are taught; should a woman ask for these, she is “referred to health centers,” says Popcom chief Osias.

What frustrates women’s rights advocates is the lack of a written, official government policy directive on the ban on contraceptives. This would have afforded them the right to question the policy in the courts. “Our problem is that our hands are tied,” says Likhaan’s Melgar. “There’s no executive order and it’s all verbal. GMA says ‘I am not funding,’ and it becomes the law.”

In 2002, however, the DOH did issue Administrative Order 125, which mandates government health workers to promote natural family planning as “the only acceptable mode of birth control.” It promotes the program under the battle cry of “responsible parenthood.”

Arroyo’s political accommodations in favor of the Catholic Church are also clear and out in the open, leaving even career government officials in fear of losing their jobs should they go against the anti-contraceptives policy.

Thus, they have kept their mouths shut even as the likes of Padilla were named to the Popcom. Padilla is also one of the commissioners of the National Commission on the Role of Filipino Women (NCRFW). (Weeks of efforts to interview her for this piece proved difficult, however, as no one at CFC, Popcom, and NCRFW seemed to know how to get in touch with her.)

Five years ago, Arroyo also appointed Jose Sandejas, who has a doctorate in materials engineering, as presidential adviser on family matters. Sandejas, aside from being a close adviser of Archbishop Paciano Aniceto of Pampanga, has been a trustee of Pro-Life Philippines since 1987. In 2006, he was also named commissioner of Popcom.

Sandejas says that for 37 years, the country pushed artificial contraception, which he says only benefited big pharmaceutical companies. He says that by promoting just the natural methods, the Arroyo government is merely trying to balance the equation. “The pharmaceutical companies make a lot of profit,” he says, “let them push it (artificial contraceptives).”

“It’s really the work of the devil,” he says of artificial contraceptives. “The devil’s main strategy is to create divorce, contraception, homosexuality. The enemy is really winning out so much.”

Rich and Poor Realities

Sandejas dismisses the notion that men tend to leave the responsibility of contraception to women, and that men find it difficult to comply with the abstention required of couples who opt for natural contraception. “I think the men would resent the accusation that they are like animals,” he says. He says most men are responsible, “even those who live in the slums, even the uneducated.”

Sandejas warns of a “demographic winter,” of a graying society with no young blood, of the “human race becoming extinct,” should all countries aggressively try to limit their population. With sadness in his voice, he notes that 50 years ago, Filipino families had an average of seven children; now the average is inching closer to just two children per family.

But experts say that average does not capture the reality of poorer households having more children than higher-income families. While the poorest 20 percent of Filipino women have an average of six to seven children, the richest 20 percent have an average of two.

The 2007 World Bank report on population issues also highlights the correlation between the number of children a woman gives birth to and her capacity to earn. “In the Philippines, the average income growth for women with one to three pregnancies was twice that of women who had undergone more than seven pregnancies,” it says. “Accordingly, the number of children a woman gives birth to affects her subsequent employment and income prospects, with the risk of further driving gender inequalities and perpetuating poverty.”

The report says that since a large family is unable to adequately invest in education, the setback “can create inequities in education and perpetuate poverty.”

With the odds stacked against women who belong to the poorest of the poor, the World Bank report calls on policymakers and development agencies to address inequities in the area of reproductive health.


Jaileen Jimeno, PCIJ / LAST OF TWO PARTS

DATU PAGLAS, MAGUINDANAO — Prayers echo from the minaret of a mosque through a vast banana plantation. Owned by a company called La Frutera, the 1,000-hectare land used to be a “killing field.” At the time, men in the area wound up either as members of secessionist groups or in the middle of a “rido” or clan war.

But since 1997, when La Frutera set up shop in this town, men have ditched their guns to help grow the Cavendish bananas the firm exports. Benefiting from the peace that has taken over the land, many of them now own houses, and most of those houses have TV sets. Those among the men who are married also practice family planning.

“Parang tao rin ang saging, pag masyadong marami, maliliit lang ang bunga (Bananas are like people, when there’s too much, the fruits are tiny),” says a farm supervisor, in explaining why they limit the number of “hands” in each plant.

La Frutera runs a family planning-education program for its 2,000 employees, 95 percent of whom are Muslim men. As a result, the community it calls home has become a pocket of hope in Maguindanao, which is one of the country’s poorest provinces and where many girls are still being married off at an early age and giving birth at home. In 2005, the United Nations Children’s Fund (UNICEF) placed the province’s maternal mortality rate at 300 per 100,000 births.

In Muslim Mindanao, family planning was endorsed by the Assembly of Darul Iftah (Religious Leaders Assembly) on November 23, 2003. The assembly produced a document that said, “Islam has encouraged its people to increase and populate the earth with the proviso that their quality should not be compromised.” Stressing the principle of non-coercion, responsible parenthood, and informed choice, the assembly adopted family planning as a method to birth spacing. It also endorsed all methods of contraception.

Muslims make up five to nine percent of the Philippines’ population of about 88.7 million people, who are all covered by a Constitution that guarantees freedom of faith and the separation of church and state, among other things. But since 2002, Filipinos of all faiths have been subjected to a national family planning policy that pushes only natural methods — a policy that echoes the beliefs espoused by the Roman Catholic Church, which claims some 80 percent of the country’s population as its followers.

The government, of course, stresses that those who want to use artificial contraceptives are free to do so. Health Secretary Francisco Duque says, though, that it is up to local government units to procure such supplies for their constituents. Those who are short on funds “can go to the USAID (US Agency for International Development),” which, he says, has a supply that is “good up to the end of 2008.”

The USAID has been providing contraceptive supplies to the Philippines since the 1970s. But it has been scaling down its donation in recent years; by the end of next year, it will shut down the program completely. A recent study by the United Nations Population Fund (UNFPA) estimates that the country needs at least $2 million a year to fund its contraceptives requirement to plug the vacuum the USAID would leave behind.

Cash - Strapped Local Governments

For sure, some local government officials, especially those in the poorest regions, know they need to provide their constituents a good range of family planning methods. But many of them apparently do not have enough resources. Dr. Junice Melgar, head of the nongovernmental organization (NGO) Linangan ng Kababaihan or Likhaan, says that in one forum, a provincial governor complained about the DOH’s lack of support in this arena. The DOH officials present, however, could only repeat Malacañang’s line of giving natural family planning a chance.

This, say observers, has been a tremendous setback for the poorest provinces mostly in the Autonomous Region in Muslim Mindanao, where the highest “unmet needs” in family planning have been recorded.

Mary Catherine Sumapal, who mans La Frutera’s health clinic, recalls that when Datu Paglas was a killing field, girls would usually be married off by the time they were 13. They would then proceed to have children almost every year. “It was common then to see ‘do-re-mi’ children,” she says.

But now Sumapal says that with the Muslim religious leaders’ edict and La Frutera’s family planning program, which was launched early this year, there is at least a bigger chance for their workers to have planned pregnancies. In fact, the program’s first year supply of contraceptives worth P200,000 is now in the pipeline.

Rose Sira, La Frutera’s personnel department head, says the family planning program will help ensure that each farm worker’s child has health coverage. The company’s health service covers a maximum number of four children per worker. Sira adds, “The workers know that if they just keep on having wives or children, and they get sick, they spend a lot of time away from work, and they lose income.”

In a sense, La Frutera itself is already the most effective family planning tool in the province. As more heads of the family and young people begin to have financial independence, many are reluctant to be weighed in by raising a big family; young people delay marriage in favor of an education and a career.

Nevertheless, Ustadz Abdulwahid Sumaoang still counsels farm workers on family planning, especially the men, who have grown accustomed to a culture of having more than two or three wives, with their number of children often unplanned. He often tells them, “If you are God-fearing, you will plan your family.”

A Muslim professor, Sumaoang has been La Frutera’s values consultant since 2003. He says that he often had to mediate in couples’ fights, mostly because the men did not secure their wives’ permission before getting a second or third wife, as stated in the Holy Qur’an. Some also strayed from the Islamic ideals of choosing “widows and orphans” as second or third wife. “They have forgotten that it is a responsibility, an effort to provide sustenance to a disadvantaged woman,” he says.

Sumaoang says that Muslims also place emphasis on natural family planning. But he says that since this method is not 100-percent foolproof, they have made artificial contraceptives available should couples have the need for it.

La Frutera clinic’s records show that two percent of its clients have chosen natural family planning. The rest rely on artificial methods.

This may well reflect the general attitude toward family planning nationwide. In a Pulse Asia survey conducted just before the May 14 polls, 92 percent of the respondents said it is important to control and plan one’s family. Nearly nine in 10 also said the government should allocate funds for family planning measures other than natural methods.

Ateneo Drops Population Management Course

But advocates of natural family planning have become stronger in recent years, having clinched seats in various levels in government since Gloria Macapagal Arroyo became president. Recently, their influence has been felt even in schools like the Ateneo de Manila University, which is run by the Jesuits, who are considered to be mavericks among the Catholic orders.

This year, the Ateneo would have offered an MBA in Health, with emphasis on strategic population research management. But pro-life and several similarly aligned groups protested, saying that “as a Catholic university, the Ateneo should not be receiving funding support from an organization that openly espouses abortion, population control, and reproductive health.” Ateneo has dropped the course.

Dr. Napoleon Juanillo, program director of Ateneo’s Leadership and Managerial Excellence in Health Systems, says that being a “transplant” from Cornell University, he was surprised at the level of discourse on the issue of population in the country. “It’s pushing us back to the medieval period,” he says. “It is an affront to science, on the rights of women.”

He says the course, which was to receive a $250,000 funding from the David and Lucile Packard Foundation, would have elevated the discourse on population management to a “more intelligent, scientific level.” Yet while he expresses disappointment over the scrapping of the course, Juanillo says he takes his hat off to the Catholic Church and pro-life groups like the Alliance for the Family Foundation Inc. (ALFI) for having “a good war tactic.”

ALFI wrote letters to Ateneo officials and demanded that the course be pulled out. Says Juanillo: “They merely did what they had to do, since it is part of their advocacy.”

He admits that the university was unprepared for the negative reaction to the course. In the end, he says, the university was left all alone carrying the flag. He says NGOs should have backed the school, adding, “This is a wake-up call to the RH (reproductive health) groups. They should fight and join the sphere. The NGOs did not do their job.”

That may be because they were busy trying to convince local and national officials to fund family planning measures other than the natural methods. As some NGO workers tell it, they would rather not have a repeat of what happened to Manila under Mayor Joselito ‘Lito’ Atienza, who ended a nine-year run in City Hall just recently and is now the environment secretary.

Atienza banned contraceptives in Manila from 2000 to May 2007. Women interviewed earlier this year by Likhaan, the Reproductive Health, Rights and Ethics Center for Studies and Training (ReproCen), and Center for Reproductive Rights told tales of financial, physical, and emotional difficulties when contraceptives totally disappeared from Manila’s health centers.

Some of the 67 women interviewed for the NGOs’ study said they wanted to have two to three children, but ended up with more than double their ideal number of offspring when contraceptives and ligation at government-funded facilities were banned. All of them belonged to the poorest bracket of society, where a P35 packet of pills is an unbearable monthly burden.

Women, Doctors Tell Tales of Woe

One 32-year-old mother of seven said she had wanted just three children. She wanted to be ligated after her fifth pregnancy. But the public hospital she went to would not perform the procedure, citing Atienza’s Executive Order 003, which was already in effect. In language, that EO pushed for natural family planning, but in practice, it worked against any artificial method.

Then there was a 36-year-old mother of eight who had dreamed of having only two children. She said that she was unable to get her regular supply of pills. She wanted to undergo tubal ligation after her fourth child, but the public hospital near her home no longer offered the service. By then, she said, her family’s daily meals were already consisting of just three sachets of coffee and a few pieces of pandesal for breakfast, rice and soy sauce for lunch, and bread for dinner.

Officials of the Dr. Jose Fabella Memorial Hospital also observed many high-risk cases among women patients, because of “anemia, too-frequent deliveries, very short spacing, and sometimes no spacing at all,” said the NGOs’ study.

An official at another government hospital told the NGO interviewers that the ban resulted in many unwanted pregnancies, prompting a greater “tendency to have an abortion.” One hospital director, in fact, said that abortion complications, including deaths, were “the second largest cause of admissions in his hospital, and a leading cause (of admission) in most hospitals.”

Other women interviewed post-Atienza told of marital spats, physical and verbal abuse, and being abandoned by their partner because of their refusal to have sex to avoid getting pregnant.

Government health workers agree with those from NGOs that Atienza’s EO 003 should be revoked. But they say that with the national government policy on family planning similar to Atienza’s, a legal victory is unlikely.

Big Population an Economic Plus?

Indeed, Jose Sandejas, President Arroyo’s consultant on family matters, downplays the report by Likhaan and company. “There are studies by people who have an agenda to push,” he says, “so you really have to look at who funded it.”

He adds that there are groups in Manila’s slums promoting natural family planning “and they will be the ones to tell you most men are responsible, even in the slums.” He argues that the urban population growth will go down even without contraception. Urbanization, he says, will leave couples naturally wanting smaller families because of the higher cost of living, as compared to living in the provinces.

Sandejas, however, would rather focus on the positive effects of keeping the population growth robust even though 2006 figures show this may be causing a downtrend in major education indicators like elementary enrolment and survival rate in schools.

“Even if you are not able to educate them as well you would like,” he says, “in the end their capability to quickly learn skills in the health services, in construction, as seamen, is going to save the Philippines.” Sandejas says that even the current generation, “where we have low levels of education, our overseas Filipino workers are saving us at this time.”

It’s a line that could well upset people like medical anthropologist Michael L. Tan, who writes a popular column for the Philippine Daily Inquirer. In a 2003 column on Arroyo’s policies, he observed the president, being an economist, should know better than “arguing that a large population is good for the economy because it means more consumers, more business, even more workers to export.”

“There is just no way government or the private sector can cope with the demands for jobs, housing, health, education and other social services, not with the present rate of population growth,” Tan added. “As for exporting Filipinos as caregivers to the world, I find it terribly immoral that we can think of producing children mainly because we see them as possible exports to bring in dollars later, even as we export their parents today.”

Interestingly, Arroyo’s stance is nowhere near that of Ed Panlilio, a Catholic priest who is the new governor of the president’s home province, Pampanga. According to Panlilio, he will pursue the family planning program already in place at the capitol, and that includes providing artificial contraceptives to those who ask for it.

“As governor and a public official,” he says, “the reality is I cannot impose my Catholic stand on the issue. Otherwise, I will be violating the human rights of my constituents.”

Panlilio says he will ask health workers to offer the whole range of family planning options to couples so they can practice a method based on the dictates of their conscience. He admits this may make him a target of attacks by Catholic hardliners. But he says he is confident Church leaders will understand the position he has taken.

“Nobody should dictate the choices couples should take,” says Panlilio, “not even the Pope, not even the president.”