Reproductive Health in the Philippines: An Ecological Analysis

Faced by the challenges of a growing population and rapid urbanization, the Philippines has inconsistently acted on issues of population control and reproductive health. Some previous policies on reproductive health and population control where “conservative” and reflective of the Catholic Church’s position on family planning. Under the Arroyo administration, government policy on family planning focused solely in mainstreaming natural family planning (NFP) as the only acceptable method of birth control and even leaving local government units (LGUs) with the responsibility of allocating budget for these family planning methods.

More recently, however, the Aquino administration strongly advocated for reproductive health both as a demographic and health intervention. As such, in December 2012, Republic Act No. 10354 commonly known as the Reproductive Health (RH) Law was approved by then President Benigno Aquino III – a battle partly won. The long-standing debate on reproductive health in the Philippines centered on the morality of instituting reproductive rights for all Filipinos, most especially women, putting aside the essence of the RH law which is the “right to reproductive health”.

The RH law seeks to increase the availability of and improve accessibility to reproductive health services such as family planning, prevention of abortion and management of post-abortion complications, prevention and management of reproductive tract infections and sexually transmittable infections, prevention and management of infertility and sexual dysfunction, among others.

A defining element of the law – RH education – sits at its core. Recognizing the need to change perceptions and behavior towards reproductive health, the law mandates that RH education be taught to adolescents by adequately trained teachers in an age-appropriate manner. Moreover, education and counselling on sexuality and reproductive health will also be offered to adults.

Shifting age old mentality and changing acquired behavior is a curse for some public policies. While this is true, the government still recognizes that education and counseling as vital tools in changing perceptions and behavior therefore adequately incorporating them into the core elements of the RH law. Human perception and behavior towards reproductive health, however, are highly influenced by social, political, and cultural contexts. Creating an environment that supports positive behavioral change requires critical analysis of these contexts.

In this paper, I discuss the ecology of reproductive health in the Philippines utilizing the relevant types of human ecology in relation to human life.

 

Behavioral and Cognitive Ecology

Behavioral ecology analyzes the ecological basis of human behavior and uses behavior to make predictions about ecological patterns. Cognitive ecology, on one hand, brings together cognitive science and behavioral ecology. Thus, in this section of the paper, we discuss the behavior of Filipino women towards reproductive health. We will examine behavior of women as a result of interactions within their environment. Behavior varies with age, and is seemingly associated with level of education and socioeconomic status. As such, behavior of women towards reproductive health is seen as an outcome of the dynamic interplay of several elements in their environment.

Women and their reproductive health

The number of children a woman bears depends on many factors. Postponing first births and increasing the interval between births reduce fertility levels and produce positive health outcomes. In the contrary, short intervals between births can lead to negative health outcomes both for the mothers and their newborns.

Age

According to the 2017 National Demographic and Health Survey, eighteen percent of women age 25-49 years engaged in sexual intercourse before they were 18 years old. By the age of 25, 73% of women have had sexual intercourse. The total fertility rate (TFR) is 2.7 children per woman, a huge decline from the TFR in 1993 which was 4.1 children per woman.

Teenage pregnancy is associated with an increased risk of acquiring complications during pregnancy and childbirth, including neonatal mortality. The median age at first birth among women age 25-49 was reported to be 23.5 years. The percentage of women age 15-19 who have begun childbearing increased from 7% in 1993 to 9% in 2017.

Contraceptive prevalence

Date from the Family Health Surveys (FHS) showed that the contraceptive prevalence rate among currently married women of reproductive age (15-49 years old) exhibited an increasing trend but has not significantly (statistically) changed in the last decade. According to the 2011 FHS, the prevalence rate for modern methods was 2.9% or 13 times the estimate for the year 1968.

For all age groups of currently married women, the prevalence rate of modern methods was higher than traditional methods. Birth control pill was the leading contraceptive method used by 19.8% of currently married women as reported in the 2011 FHS, higher than in 2006 where only 16.6% of women reported using the pill for contraception. Female sterilization and withdrawal were the next two most commonly used methods used by 8.6% and 8.2% of women, respectively. Only 1.2% of women reported using male condom as method of contraception.

Education, socioeconomic status and contraception

Level of education

The use of modern family planning methods was correlated with the level of education and socioeconomic status. The 2011 FHS found that women with higher educational attainment are more likely to be using any form of contraception than less educated women. Regardless of educational attainment, however, women preferred modern over traditional methods of contraception. Ligation was the most popular method among women with postgraduate education. For other women without postgraduate degrees, oral contraceptives were the most common method followed by ligation

Data from the 2017 NDHS also showed that the TFR declines women’s educational level increases. Among women with college education, TFR was 2.0 children per woman while women with no education have a TFR of 4.6 children per woman.

Socioeconomic standing

The same survey found that the overall contraceptive prevalence rate was higher among currently married women belonging to non-poor households than those belonging to poor households at 51.3% and 43.1%, respectively. Regardless of socioeconomic status, modern methods were more widely used than traditional methods by currently married women in 2011. Overall, oral contraceptives were the most popular method of contraception for both the poor (18.7%) and non-poor (20.3%).

The TFR and desire to have more children also declines with increasing household wealth. Women in the poorest households generally want more children than those in wealthier households. In the poorest 20% of household, TFR was 4.3 children per woman. Among those living in wealthiest households, the TFR was calculated to be 1.7 children per woman.

Birth interval (or spacing) and teenage pregnancy have also been also been associated with household wealth. Women in the lowest quintile have the shortest median birth interval (31.2 months) while those in the highest quintile have longer median birth interval of 52.6 months. The percentage of women age 15-19 years and 15-24 years who have begun childbearing decline with increasing wealth.

Women’s fertility preferences

Information on women’s fertility preferences help direct family planning program planners by assessing women’s desire for children, the extent of mistimed and unwanted pregnancies, and the demand for contraception to space or limit childbirths.

In 2017, 15% of women wanted to have another child within the next two years and another 15% wanted to wait at least two years before having another child. However, 60% reported that they do not want another child. The NDHS also reported that 74% of births were planned at the time of conception while 11% were unwanted pregnancies. About seven in ten women reported that they are in consensus with their husbands on the number of children they would like to have.

Social and Molecular Ecology

Social ecology studies the relationship between people and their environment, particularly the interdependence of people and societal institutions. It bridges ecological and social issues. In this section, we discuss the interaction of women and the greater society in relation to reproductive health.

Nominally Catholic

With the exception of the Catholic Church, all other major religions supported the RH law. Although majority of Filipinos (~80%) are (at least nominally) Roman Catholics, surveys showed that nearly eight out of ten Filipinos favored the passage of the RH Bill, supported the provision of RH education and of free RH goods/services to all, especially to the poor.

While majority of Filipinos identify themselves as Catholic, their attitudes and perception indicate rejection of Catholic Church teaching on contraception. In June 2011, SWS reported that 73% of Filipinos wanted information on legal methods of family planning while 82% said the FP was a personal choice. Thus, it can be inferred that the RH fiasco and narrative was controlled mainly by Catholic bishops and some of their loyal followers whilst neglecting the call of majority of the members of the Church to enact a law for reproductive health rights.

RH in PH health system

With the Reproductive Health Law, couples are guaranteed universal access to methods of contraception, fertility control, reproductive health education, and maternal care. Thus, couples can freely utilize these contraceptive goods and services to limit the number of children or space childbirth.

As these goods and services are more readily available to the public through the public health system, one could expect higher rates of family planning utilization among Filipinos. Data from the NDHS showed that 83% of women who are not using contraceptives did not discuss family planning either with a fieldworker or at a health facility. More than half or 56% of women using modern contraceptive methods obtain their method from the public sector.  Among women currently using modern methods of contraception, 73% were informed about the potential side effects of the method they were using, while 65% were informed about what to do if they experienced these side effects.

Despite efforts of the government and private sector to make access to and availability of reproductive health goods and services better for most women, some married women (17%) and sexually active unmarried women (49%) reported unmet need for family planning. The demand for family planning among currently married women, however, remains high at 71%.

Politics

We cannot deny how politics influenced reproductive health care in the Philippines. In this section, we examine how politics played a crucial role in shaping perception and cultivating behavior of Filipino women towards reproductive health.

It was during the Marcos regime when the country first recognized the role of family planning in population control. In 1970, the government advocated small family size and provided information and services to reduce the country’s fertility rate through the National Population Program. At the time, the average Filipino family had 6.8 children and the country’s population was 37.8 million.

Post-martial law, the change in government also signaled a change in government stance on population control. Rather than advocating for small family size, the Aquino administration advocated for the right of couples to determine the number of their children. This campaign was supplemented by integrating family planning into the country’s health programs highlighting its role in improving maternal and child health.

It was during the Ramos administration when then DOH Secretary Juan Flavier strongly advocated for family planning and reproductive health to limit family size through the provision of artificial birth control methods. The Ramos administration encouraged the use of male condoms to prevent unplanned pregnancies and the spread of HIV. However, the effort of the Ramos administration was short-lived as it was surpassed by the Catholic Church’s war against modern contraception.

Estrada, on one hand, continued the efforts of his predecessors and introduced other contraceptive methods to reduce fertility rate. Much like the Aquino administration, the Arroyo administration inexplicitly sided with the Catholic Church’s stance on reproductive health and family planning. Thus, the government shifted its focus on mainstreaming natural family planning methods.

Benigno Aquino III’s administration turned the tide when it was finally able to enact a much-awaited law on reproductive health. However, several legal road blocks prevented the full implementation of the RH law. With the FDA certification of contraceptive goods as non-abortifacients, the DOH now freely distributes contraceptives through its regional offices and partner NGOs.

Conclusion

Crucial to the overall perception and subsequent behavior towards reproductive health is the politics surrounding it. Many Filipinos, especially those in the lowest economic quintiles, heavily rely on goods and services provided by the government through its devolved health care system. Thus, improving maternal and child health as well as reducing fertility rate require that the government ensure that reproductive health goods and services are available and accessible at an affordable cost.

Reproductive health, particularly in the Philippines, is a complex health and legislative issue. And in this paper, we have explored the various ecological elements that can influence and potentially predict the behavior of Filipino women towards reproductive health. Reproductive health is a personal choice and the law respects this ‘freedom of choice’ by leaving the discretion to women (and their partners) on how they deal with their own reproductive health while providing options to support their RH needs.

Finally, education and socioeconomic status were seen to have direct influence on how women decide and utilize RH goods and services. Not until we close the gap among the poor and non-poor, educated and not educated, can we truly realize the goal of the RH law which is to improve the reproductive health of women (and men), and maternal and child outcomes.

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