Unintended Pregnancy and Unsafe Abortion in the Philippines: Context and Consequences

July 2013

The Philippines, with a steadily increasing population that is approaching 100 million, faces significant challenges in the area of reproductive health.¹ About 25 million of its citizens are women of reproductive age, and they experience high levels of unintended pregnancy, have relatively low levels of contraceptive use, and frequently experience unsafe abortion and consequently high levels of mortality and morbidity.^2–4 This report summarizes existing evidence on the context and consequences of unintended pregnancy and unsafe abortion in the Philippines—particularly among vulnerable populations such as poor, rural and young women—and highlights key areas in which policymakers and reproductive health advocates can focus efforts to improve the health and well-being of Filipino women and their families.

Access to services is opposed by influential groups

Women’s access to reproductive health services faces challenges or outright opposition from various—often powerful—segments of Filipino society. While contraception is legal in the Philippines, until mounting pressure to reduce maternal mortality and morbidity and to combat poverty in the country arose in recent years, the government had shown only weak support for access to modern contraceptives.⁵ Since 1971, much of the free contraceptive supply had been funded by the U.S. Agency for International Development (USAID) and other international donors, but in 2008 USAID discontinued its support to encourage the Philippine government to become self-reliant.⁶ Local bans on contraceptives—such as the mayor of Manila’s executive order in 2000 to remove contraceptives from public clinics, and the 2001 ban by the Department of Health on the emergency contraceptive Postinor—created yet more barriers to access, and particularly affected poor women who rely on public services.⁷

In the Philippines, the Catholic Church hierarchy wields strong influence on society and on government officials. The church not only condemns abortion, but forbids the use of modern contraceptives.⁶ Despite this opposition, recent legislative developments have been supportive of reproductive health.⁵ In contrast to former president Gloria Macapagal Arroyo, who opposed public provision of modern contraceptives in favor of promoting natural methods approved by the Vatican, the current president, Benigno S. Aquino III, endorsed the highly debated Responsible Parenthood and Reproductive Health Act of 2012 (commonly known as the Reproductive Health Law),⁸ which provides modern contraceptive services, counseling and sex education, particularly for rural and poor Filipinos.⁹ This policy was (and still is) strongly opposed by the church hierarchy; however, it is generally supported by the Philippine public. In December 2012, lawmakers passed the bill and President Aquino signed it into law. As of early 2013, implementation of the law was delayed by the Philippines Supreme Court. Nonetheless, passage of the bill represents a historic milestone.

In contrast to the liberalizing trend in contraceptive policy, the Philippines’ abortion law is among the strictest in the world. Abortion remains illegal in the Philippines under all circumstances and is highly stigmatized. While a liberal interpretation of the law could exempt abortion provision from criminal liability when done to save the woman’s life, there are no such explicit provisions.^5,10–12 There are also no explicit exceptions to allow abortion in cases of rape, incest or fetal impairment. The Penal Code considers abortion to be a criminal offense punishable by up to six years in prison for doctors and midwives who perform abortions and by 2‒6 years in prison for women who undergo the procedure, regardless of the reason. A separate set of laws under the Midwifery Act, Medical Act and Pharmaceutical Act permit the revocation or suspension of the licenses of any practitioner who performs abortions or provides abortifacients.

Unmet need is widespread and unintended pregnancy is common

In 2008, there were 1.9 million unintended pregnancies in the Philippines, resulting in two main outcomes—unplanned births and unsafe abortions.¹³ In the Philippines, 37% of all births are either not wanted at the time of pregnancy (mistimed) or entirely unwanted (Table 1),³ and 54% of all pregnancies are unintended.¹³ On average, Filipino women give birth to more children than they want (3.3 vs. 2.4 children—Figure 1), highlighting how difficult it is for a woman to meet her fertility desires. This is particularly striking among the poorest Filipino women, who have nearly two children more than they intend to have (5.2 vs. 3.3 children).

Table 1

Among married women using any method of contraception in 2011, one in four used a traditional, less effective method such as periodic abstinence.¹⁴ Though married women showed a modest increase in modern method use between 1998 and 2011 (from 28% to 37%), this latter rate was still substantially lower than the comparable subregional average in Southeastern Asia (55%) and rates in other populous countries in the subregion, such as Indonesia (57%), Vietnam (68%) and Thailand (79%).¹⁵

Much of the gap between women’s total and wanted fertility rates in the Philippines can be attributed to low contraceptive use and high levels of unmet need for contraception: In 2008, more than 90% of unintended pregnancies occurred among women using traditional, ineffective methods or no method at all.¹³ In 2011, only 49% of married women of reproductive age were using any contraceptive method, and this represented a negligible increase since 1998 (Table 2).¹⁴ Poor women are less likely to use a contraceptive method than nonpoor women (43% vs. 51%), and in regions where poverty is common, contraceptive use is substantially lower than the national average—for example, 38% in the Zamboanga Peninsula and 24% in the Autonomous Region in Muslim Mindanao.¹⁴

Table 2

The proportion of married women with an unmet need for contraception did not decline between 1998 and 2011: At the time of both surveys, one in five married women did not want a child soon or wanted to stop childbearing altogether, but were not using any contraceptive method. In 2011, poor women had much higher levels of unmet need than their nonpoor counterparts (26% vs. 17%).¹⁴ Unmarried women who were sexually active had even more dramatic levels of unmet need for contraception: In 2008, nearly 50% of these women wanted to prevent pregnancy but were not using a family planning method, and nearly 70% were not using a modern method.³

There are many reasons why, and circumstances in which, Filipino women do not practice contraception. According to the 2008 Demographic and Health Survey,³ after excluding women who were unable to bear children and those who wanted children soon, the two most commonly cited reasons were fear of side effects or broader health problems (36%) and difficulty obtaining a method (27%). The lack of governmental support for contraceptives, widespread local bans on contraception and the USAID phase-out of contraceptive supplies are major reasons for women’s inability to obtain modern methods and accurate information about their safety and efficacy.^3,7 Despite the strong influence of the Catholic Church hierarchy on policies regarding family planning, few women cited religious or personal opposition as reasons for nonuse (2–4%). Poor women are particularly vulnerable to barriers to access, as the public-sector provision of modern contraceptives has shifted to private, and often more expensive, sources: In 2003, two-thirds of women using a modern method obtained it at a public facility, but by 2008 the proportion had dropped to less than half.³ Furthermore, more recent data show that 56% of poor women who use hormonal pills (the most commonly used method) obtained them from the public sector in 2006, while 32% did so in 2011.¹⁶

Adolescents and young women and are particularly vulnerable

Sexual activity among young people is becoming more common in the Philippines. The proportion of women aged 15–24 who were sexually experienced increased from 25% in 1998 to 32% in 2008.^3,17 Despite the taboo against premarital sex, many women report such behavior: In 2008, the median age of marriage among young women was nearly a year later than the median age at first sexual experience (22.1 vs. 21.3 years).³ Filipino women are also giving birth earlier: Among first-time mothers, the proportion who were teenagers increased from 20% in 2000 to 27% in 2010.¹⁸ Adolescent females are particularly at risk of unintended pregnancy because they lack access to comprehensive sex education and contraceptive supplies.⁵

Abortion is common in the Philippines

Of the hundreds of thousands of Filipino women who have unintended pregnancies each year, many face a difficult choice: either give birth to a child they are not prepared or able to care for, or obtain a clandestine, and often unsafe, abortion. Because abortion is highly stigmatized and punishable by law, it is extremely challenging to directly estimate the number of abortions in the Philippines, as both women and providers are likely to not report the procedure. The most recent study on national abortion incidence in the Philippines used indirect estimation techniques and hospital records to estimate a rate of 27 abortions per 1,000 women of reproductive age in 2000, with lower and upper estimates of 22 and 31 abortions per 1,000 women.¹⁹ Notably, this rate was considerably higher than a more recent estimate of the unsafe abortion rate in Southeastern Asia as a whole (22 abortions per 1,000 women), indicating that the Philippines may have more unsafe abortions than some neighboring countries.20 Projections based on the 2000 national abortion rate, and taking into account population increases, estimated that 560,000 abortions occurred in 2008 and 610,000 abortions in 2012.^2,5,19

Figure 1

Who has abortions in the Philippines, and why?

According to a national 2004 survey of women of reproductive age, individuals who have abortions are similar to Filipino women overall: They are typically Catholic, are married, are mothers and have at least a high school education.⁴ The most common reason women identified for having an abortion—cited by nearly three in four—was the inability to afford the cost of raising a child or an additional child. More than half of those who had had an abortion said they underwent the procedure because they felt they already had enough children or that their pregnancy came too soon after their last birth. Nearly one-third of women felt that their pregnancy would endanger their health, and another third believed that their partner or another family member did not want or support the pregnancy. Perhaps most disturbingly, 13% of women who had had an abortion cited pregnancy as a result of forced sex as their reason for getting an abortion.

Not surprisingly, larger proportions of poor women than of their nonpoor counterparts cited economic reasons for having an abortion, and roughly two-thirds of women who had had an abortion were poor.⁴ Women younger than 25, who accounted for 46% of abortion attempts in the 2004 survey, also cited reasons related to their age—they wanted to avoid interrupting their schooling, had problems with their partner or considered themselves too young to have a baby. Among all the women interviewed, economic reasons and being unmarried or too young were cited as the most important reasons for why women obtain abortions, illustrating that many Filipino women who have not had an abortion understand why other women choose to have one.²¹

Most women who had had an abortion had discussed the matter with at least one person, but fewer than half had discussed it with their partner, suggesting that in many cases women feel that their partner will not be supportive of their situation or decision.⁴ Nearly one-third of women who get an abortion do not tell anyone, highlighting how stigmatized abortion is in the Philippines.

The clandestine nature of getting an abortion often leads to unsafe procedures

The process of obtaining an abortion in the Philippines is often not straightforward, and may involve many methods and attempts, some of which may have serious health consequences. While the skill and training of providers and the safety and effectiveness of methods vary widely, nearly all abortions are clandestine and therefore carry associated risks. Some women seeking pregnancy termination may be able to obtain medically recommended procedures such as manual vacuum aspiration (MVA) or dilation and curettage (D&C), but the providers may be untrained or the settings unsanitary.²² Conversely, a woman may go through a series of ineffectual methods and steps, only to find herself still pregnant and at a more advanced point in gestation.

According to the 2004 national abortion study, most women who obtain an abortion do so in the first trimester, but a substantial proportion—nearly one in four—do not terminate their pregnancies until later, when risks are greater.^4,23 A higher percentage of poor women than of nonpoor women have abortions after the first trimester, which could be a result of failed or ineffective attempts to terminate the pregnancy or inability to secure the money to pay for the procedure. Surgical methods that are considered relatively safe and effective (when performed by a trained provider) are often expensive, and poor women may resort to dangerous, painful or ineffective means (Figure 2). Particularly dangerous methods include the insertion of a catheter or other object into the uterus, which often causes infection and perforations, and heavy abdominal pressure or "massage" to expel a fetus, which a traditional practitioner (hilot) may administer.^4,10,23 An estimated 22% of poor women used massage or a catheter in an abortion attempt, while no nonpoor women employed such methods. Moreover, poor women were far less likely than the nonpoor to use safer methods such as D&C or MVA (13% vs. 55%).⁴

Figure 2

Furthermore, poor women are much less likely than nonpoor women to obtain an abortion from a doctor (17% vs. 55%), or seek an abortion in a health facility (21% vs. 60%); instead, they are more likely to self-induce or to employ the help of a friend, acquaintance or partner (44% vs. 30%).⁴ In many cases, women are able to self-induce by taking misoprostol (also known by its brand name Cytotec) obtained through street or Internet vendors; however, the drug is expensive and the correct dosage may not be dispensed, which lowers the effectiveness of the method.^4,24 A small study that interviewed young people about their experiences and perceptions regarding abortion found that many issues were involved in both the selection of a method and the perceived level of efficacy.²⁴ Some participants felt that a method’s effectiveness was due to the position of the fetus, the "will" of the fetus or God’s will.

The health consequences of unsafe abortion are significant

In 2008, an estimated 1,000 maternal deaths in the Philippines were attributable to abortion complications.¹³ According to the Philippines Department of Health, the country’s maternal mortality ratio increased from 161 to 221 deaths per 100,000 live births between 2006 and 2011.²⁵ This ratio is well above the government’s Millennium Development Goal 5 target of 52 maternal deaths per 100,000 live births for 2015.²⁶ The Department of Health acknowledges that high maternal mortality is preventable through the provision of effective family planning methods to combat unmet need, particularly among poor women, and that access to antenatal care and to care for pregnancy- and abortion-related complications would also help to reduce maternal mortality.

Tens of thousands of Filipino women are hospitalized each year as a result of complications from unsafe abortion, at a rate of 4.5 individuals per 1,000 women, and countless others have complications but do not receive treatment.^4,19 In Manila, the hospitalization rate was nearly double the national average, likely because of better access to care than in rural areas of the country. Projections based on data from 2000, assuming that the rate stayed the same and taking into account increases in population, indicate that 90,000 Filipino women were hospitalized for abortion complications in 2008, and over 100,000 women in 2012.^13,15,19 Furthermore, nearly one-quarter of the 2,039 hospitals included in the abortion incidence study recorded abortion (induced and spontaneous) as among the top 10 causes for admission in 2000.¹⁹ More recently, abortion-related surgeries (surgical completion of incomplete abortion and D&C) were among the 15 most common surgical claims submitted to the national health care system, PhilHealth, in 2011.²⁷

Women may experience a range of complications from unsafe abortion. More than 80% of Filipino women in the 2004 study who terminated their pregnancies experienced a complication, and 46% of those women (more than one-third of all women) experienced a severe complication.⁴ Generally, the most common complications of unsafe abortion are incomplete abortion or retained products of conception, excessive blood loss and infection.^22,23 Less common but more serious complications include septic shock, peritonitis, cervical or vaginal lacerations, and intestinal perforations. In the Philippines, certain methods and providers carry more risk of serious complications: Seventy percent of women who used a massage or insertion of a catheter experienced a severe complication, compared with 13% of those who received a D&C or MVA.⁴ As discussed earlier, larger proportions of poor and rural women use unqualified providers or riskier measures than do nonpoor and urban women, and they therefore disproportionately experience more severe complications. Finally, if postabortion care is delayed, inadequate or not administered at all, mild complications can become more serious or acute, and eventually affect long-term health and well-being. Studies have shown that long-term problems may include anemia, chronic pain, pelvic inflammatory disease and infertility.^20,22,23

Providing postabortion care poses serious challenges

Because so many Filipino women experience postabortion complications, the need for early and adequate postabortion care is particularly urgent. However, many women who develop health problems after an unsafe abortion may be reluctant to seek help; about one in three women with complications do not receive postabortion care.⁴ Cost can be a significant barrier, particularly for more serious complications in which women may have to receive multiple procedures and medications or stay overnight in a health facility.⁵ Some women leave the hospital prior to completing treatment because they fear they will be unable to pay the final bill, leaving them to manage their complications through other means. At the time of the 2004 national study, it was estimated that government hospitals typically charged ₱1,000–4,000 (US$24–94) for postabortion care, and private hospitals charged substantially more, up to ₱15,000 (US$375).⁴ In a country in which one in seven people live on less than US$2 a day, postabortion care may be entirely out of reach for many women.²⁸

In the Philippines, the stigma surrounding abortion is another factor that makes it difficult for a woman to seek postabortion care. Some women report feeling shamed and intimidated by health care workers, and in some cases women are not provided with pain relievers and anesthesia, or treatment is delayed or denied altogether.^4,5 Others report being threatened that they would be turned in to the police. Doctors themselves report having a bias against postabortion care patients, with some believing that these women have committed punishable crimes. Other health care providers may have difficulty properly managing complications when women conceal the cause of their medical emergency.

The Prevention and Management of Abortion Complications program was established by EngenderHealth in 2000, under the approval of the Philippines Department of Health, to strengthen the capacity of the health care system to manage abortion complications by training providers in techniques, counseling and sensitization.^4,29 The pilot program ended in 2002, however, and it was never fully integrated into the health care system.³⁰ The Department of Health subsequently replaced it with the Prevention of Abortion and Management of Pregnancy Complications program, thus effectively deemphasizing care specific to abortion complications. Currently, postabortion care is subsumed under Basic Emergency Obstetric and Newborn Care guidelines, yet it is not known whether training in counseling and sensitization has been incorporated. A study that interviewed gynecologists who provide postabortion care in Manila found that many preferred using sharp curettage instead of the recommended MVA for terminating early pregnancies, even though it is associated with higher risks and greater pain.³¹ The study also found that some doctors were using improper doses of misoprostol, and a small proportion were not using analgesia for surgical uterine evacuation.

Illegal and unsafe abortions carry social and economic consequences

Physical complications are not the only consequence of unsafe abortion. The social and economic costs of clandestine abortion and postabortion care are substantial, to both individual women and the health system as a whole. Because abortion is illegal, many providers charge high fees to compensate for the clandestine nature of the procedure,^4,5 and hence obtaining a relatively safe abortion in a clinic is out of reach for the average Filipino woman. Many women with an unintended pregnancy therefore resort to cheaper and often less safe methods, which may result in complications that ultimately incur significant costs to the woman and to the health care system. Recent costing studies of postabortion care in countries with highly restrictive abortion laws have found that the costs to the health systems, including drugs, supplies and staff time, are substantial.^32–34

In addition to the direct costs of care for abortion-related complications, another cost is the time that women spend in recovering from injuries and ill health. During recovery, women are prevented from fulfilling other responsibilities, such as making a living, attending school and caring for their families.^4,35 The cost of this lost time, when added to the health care costs of treating complications, means that unsafe abortion takes a substantial toll on society as a whole, as well as on individuals and families.

Legal advances and future investment in reproductive health care

The Reproductive Health Law mandates several provisions, including supplying a full range of contraceptive methods, particularly to the poor and marginalized; providing "humane and nonjudgmental post abortion care"; ensuring that health facilities have adequate and qualified personnel to provide emergency obstetric and newborn care; and offering reproductive health education to adolescents.³⁶ (However, the law offers modern contraceptive methods to minors only if they have parental consent or have had a child or miscarriage.) The law also prohibits private providers, local government officials and employers from banning, restricting or coercing the use of reproductive health services. Overall, these legislative advances have the potential to greatly improve women’s health by reducing maternal mortality and morbidity.

Another recent advance in reproductive rights is the landmark 2009 Magna Carta of Women, which promises to protect Filipino women from measures or practices that have "greater adverse effects" on women than men.³⁷ This provision could be used to identify and address barriers to the full access of reproductive health services, such as contraception and postabortion care. Furthermore, in 2012, the Philippines Department of Health pledged ₱500 million toward family planning supplies nationwide.²⁵

Regarding the critical impact of reproductive health care, a 2009 study of the benefits of meeting contraceptive needs concluded that if all Filipino women at risk of unintended pregnancy used a modern method, unplanned births would decline by 800,000 per year and there would be 500,000 fewer abortions.¹³ Achieving this goal is not possible without increased financial commitment; however, the reduced need for medical care for those unintended pregnancies and abortions that could be averted would result in a net economic savings and immeasurable social benefits. This study highlights how investing in family planning and contraceptive supplies and services would promote the health and welfare of Filipino women, their children and society.

Recommendations for addressing unsafe abortion and its consequences

The passage of the Reproductive Health Law is a milestone that will help to reduce maternal mortality and improve the overall health and lives of Filipino women and their families. With full implementation of the law, nearly all Filipino women—including young, unmarried, poor and rural women—should have access to reproductive health information and services that help them to plan and care for their families.

To fully realize the potential of the law and to further promote women’s health, Filipino national, regional and local policymakers, as well as government agencies, should:

• Educate the public about modern contraceptives and the risks of unintended pregnancy and unsafe abortion.

• Ensure adequate funding for the full range of contraceptive methods, as well as counseling, so that women can find and use the methods that are most suitable to their needs.

• Eliminate barriers to contraception among vulnerable populations—such as poor women, rural women and adolescents—by making clinics more accessible and youth-friendly and by providing family planning at low or no cost.

• Integrate contraceptive services with other reproductive health services, and provide contraceptive counseling and services for women in postpartum and postabortion care settings.

• Destigmatize postabortion care among providers, to ensure fair and humane treatment, and among the population as a whole, to encourage women to seek timely postabortion care.

• Train more medical providers, including midlevel personnel, in the use of safer and less invasive methods of postabortion care (such as MVA), and ensure availability of these methods in relevant health facilities.

• Ensure that all women have access to emergency obstetric and neonatal care.

• Study the impact of the current abortion ban, and explore allowing abortion at least in exceptional cases, such as to save a woman’s life or preserve her health, in cases of rape or incest, and where there is gross fetal deformity incompatible with life.

In the Philippines, most unintended pregnancies resulting in abortion are preventable, as is nearly all abortion-related mortality and morbidity. Better information on sexual and reproductive health, as well as access to effective contraception, can lower the incidence of unintended pregnancy, thereby reducing the number of Filipino women who resort to unsafe abortion and experience the related health consequences. Investing in women’s health yields enormous benefits not only to women’s status and productivity, but also to their families and society as a whole.

CREDITS

This In Brief was written by Rubina Hussain and Lawrence B. Finer, Guttmacher Institute. It was edited by John Thomas. The authors are grateful for comments provided by Junice Melgar and Mina Tenorio of Likhaan, Quezon City, Philippines, and for contributions made by the following Guttmacher colleagues: Akinrinola Bankole, Jessica Malter and Gustavo Suarez.

 

REFERENCES

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