THE REPRODUCTIVE HEALTH ACT Part 3 Socioeconomics By Senator Miriam Defensor Santiago

It is easy to discuss reproductive health in abstract terms such as theology, constitutional law, or international law. But it is not so facile to exchange

arguments over the hard facts concerning mother and child among the very poor. Statistics on Maternal Health1 Due to childbirth- and pregnancy-related complications: 11 MOTHERS DIE EVERYDAY! 3,000 to 5,000 mothers die every year 162 mothers out of 100,000 live births die 11% of all deaths among women of reproductive age in the Philippines are maternal deaths How many women will be affected by the RH bill? 23 million (From 15 to 49 years old) How many women are at risk of pregnancy? 15 million

See 2008 National Demographic and Health Survey by National Statistics Office.

Guttmacher Institute made a 2008 study of pregnant Filipinas, with the following results: How many pregnancies that year? 3.371 million How many were unintended pregnancies? 1.82 million What happened to the unintended pregnancies? 570,000 induced abortions 1 million mistimed or unwanted births 90,000 hospitalizations for complication of abortions 3,700 maternal deaths in one year, of which 90% deaths occurred among women using no or natural family planning methods Where do women deliver their babies? 56% at home, specially in rural areas 44% in health facility At childbirth, is skilled birth attendance available? As of 2008: 36% No; only the hilot 62% Yes; with a birth professional Does skilled attendance at delivery and emergency abortive case reduce maternal deaths? Yes, with 75% reduction

In addition to reducing maternal and child deaths during delivery, family planning would prevent not only unwanted and high-risk pregnancies, but also abortion. Under the Penal Code, abortion is a crime, and it will remain a crime under the RH bill. In fact, one important reason to pass the RH bill is that it will reduce abortions. The Act will provide full information to any mother on the entire menu of family planning options, making it unnecessary for the mother to resort to abortion. Hence, pregnancy will result in a wanted child, not an

unwanted child that the mother might be forced to abort. In the Philippines, how many unplanned pregnancies end in abortion? 1 out of 3 How many induced abortions are estimated to have taken place in the Philippines?2 400,000 in 1994 473,400 in 2004 Who are the women who resort to induced abortions in the Philippines? 9 out of 10 are married women 87% are Catholics Did the mother receive antenatal care? As of 2008: 4% - No

Guttmacher Institute and UP Population Institute, Unintended Pregnancy and Induced Abortion in the Philippines, 2006.

5% - From hilot 91% - Yes Who are vulnerable to risky pregnancies? Young adolescent women Women over 35 years old Women who already gave birth to three children Women whose pregnancies have short intervals Of pregnant Filipinas, how many are aware of danger signs of

complications, and where to go in case of complications? 50% These statistics lead to the question of how the government should prevent maternal death. The obvious answer is that government should provide access to skilled care during pregnancy, during childbirth, and during at least the first months after delivery. Poor women are more at risk of dying from pregnancy and pregnancy-related complications. Does voluntary family planning reduce deaths? Yes: 20 to 35% of maternal deaths 20% of child deaths Lower fertility rate reduces poverty incidence:3 NCR: Fertility - 2.3%
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Based on 2008 National Demographic and Health Survey by NSO.

Poverty - 7.6% Bicol: Fertility - 5.1% Poverty - 49% Actual children are more than wanted children:4 Wanted fertility rate Actual fertility rate 2.4 children 3.3 children

Each woman has excess of 1 child Unmet need for family planning - 22% Poor women have three times more children than rich women: Highest class: Desired fertility - 1.6% Actual fertility Lowest class: Desired fertility - 3.3% Actual fertility - 5.2% - 1.9%

Childbearing among teenagers: Uneducated - 25% College 3%

2008 Family Planning Survey, NSO

Similarly, a Canadian NGO5 released a fact sheet based on several studies. It showed that school-based sexual health education results in more parent-child communication. What is the incidence of failure to protect against pregnancy for early PMS? 40% unprotected for first PMS (Pre-Marital Sex) 70% of most recent PMS Is there a double standard between the two genders with respect to PMS? 40% think it is acceptable for young men 22% think it is acceptable for young women The Abortion Scare Contraceptives are not abortifacient. This issue was laid to rest as early as 2006, during deliberations on House Bill No. 4643, which sought to declare contraceptives as abortive. A position paper on reproduction issued by

international organizations,6 and released by the World Health Organization, categorically stated: None of these methods have been shown to cause the abortion of an implanted fetus. Therefore they cannot be labeled as

The Society of Obstetricians and Gynecologists of Canada published Myths, Misconceptions, and Misinformation About Sexual Health Education and Promotion in Canada, 2005. 6 UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction issued in Nov. 2006 by the World Health Organization in Geneva, Switzerland.

abortifacients. contraception.7

The position paper covered virtually all the methods of

As part of the abortion debate, the question has been raised: When does life begin? Doctors and scientists do not know, and it would be presumptuous for legislators to settle this question by the expedient of parliamentary debate. We cannot settle a scientific issue by spouting anecdotal evidence to support a laymans view. Contemporary ignorance of the answer has been admitted by no less than a former professor of biochemistry, who became former dean of the UP college of medicine. In a book published this year, 2011, the authors apparently reached the conclusion that the process of becoming human is gradual, and that there is no specific point at which a non-human entity suddenly becomes human.8 Youth Education on RH The RH bill provides for RH services and information for the youth. This provision is supported by the results of a 2002 UP Population Institute survey, 9 which showed the following: Many young people engage in risky sexual behavior. Their knowledge of reproductive health problems are inadequate. They rarely seek medical help for reproductive health problems, and They have liberal views on sex and related matters.
Combined hormonal methods, including pills and Evra patch; progestin-only methods including Depo Provera, implants, and mini pills; emergency contraception pills; and intrauterine devices. 8 Scott Gilbert, Ann Tyler, and Emily Zachin, Bioethics and the New Embryology: Springboards for Debates, 2011. 9 Young Adolescent Fertility Survey 2002 by UP Population Institute.
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The survey showed that many young people engage in pre-marital sex (PMS), as follows: Among young people 15 to 24 years old, how many have had PMS experience? 23% What is the prevalence of PMS among the sexes? 31.1% among boys 15.4% among girls What is the incidence of PMS among male youth? 20% admitted that they paid for sex 12% admitted that they accepted payment for sex Even young men who risk getting infected with HIV also suffer from inadequate knowledge. As a common practice, Filipino youth do not discuss sex at home with their parents. Therefore, it is not realistic to argue that sex

discussion should be limited to the parents and the home. Sexuality education does not encourage promiscuity among the youth. On the contrary, if young people know more about sexual health, they are even more likely to postpone sexual initiation. An American NGO10 looked at several studies made in countries where sexuality education is being taught, and reached the conclusion that sexuality education reinforces the sense of responsibility of young

The National Campaign to Prevent Teen Pregnancy published No Easy Answers in Washington D.C., 1997.

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people in terms of their sexual behavior. When they are given proper education on reproductive health, young people no longer feel a need to explore other sources of information on sex. Mistimed or unwanted pregnancies result in health risks which are higher for adolescent mothers. They are more likely to have complications during labor.11 Unwanted pregnancies compel society to pay a social cost. Parents who are able to plan their families are usually able to raise and educate them. But poor families who cannot plan their families have to rely on government for education, health, and other goods and services. Philippine Demographics The branch of knowledge that deals with human population, e.g., the statistical analysis of births and deaths, is known as demography. Here are the demographics:12 Philippine Population: 2010 2020 2040 91.8 M 105.5 M 126 M

Population Growth Rate (PGR) 2. 04% No. 3 in Southeast Asia Added Filipinos each year 2 M
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2006 Family Planning Survey. Based on the 2007 Philippine Census by the National Statistics Office (NSO).

 What is the biggest age group? 15 to 49 years old 51.11% Half of population below 21 years old Philippine population is young Implication of Demographics The consequences of all these statistics were analyzed in the seminal 2008 paper entitled Population, Poverty, Politics, and the RH Bill. It was written by some 27 UP economics professors, virtually every single one eminent in this field. The paper is so authoritative that I have to quote the first paragraph: The population issue has long been dead and buried in developed and most developing countries, including historically Catholic countries. That it continues to be debated heatedly in our country testifies to the lack of progress in policy and action. The Catholic Church hierarchy has maintained its traditional stance against modern family planning (FP) methods, particularly modern (also referred to as artificial) contraceptives. On the other hand, the State acknowledges the difficulties posed for development by rapid population growth, especially among the poorest Filipinos. According to the authors whom I shall call the Economics 27 a clear and consistent national population policy is long overdue. The RH bill would be a good instrument of such a policy. Hence, the RH bill would become an integral
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part of the strategy for development and poverty reduction. The country needs a population policy, together with a government-funded family planning program. A rapidly growing population has a negative impact on economic development. Rapid population growth is largely caused by the least urbanized, least educated, and poorest segments of our population. The bigger the family, the poorer. The bigger the family, the less educated the children. The poor know this, and prefer smaller families, but they are unable to keep the family small. The 2006 Family Planning Survey showed that among the poorest women, 44% of pregnancies are unwanted. According to the

Economics 27: Contraceptive use remains extremely low among poor couples, because they lack information about, and access, to them. The lack of access to contraception results in high maternal mortality. At our present rate, the Philippines will be unable to meet the Millenium Development Goal target of 52 maternal deaths per 100,000 live births by 2015. The more children and the more they are closely spaced, the higher the risk of illness and premature deaths for mother and child alike. Everyday, 11 to 12 women die from pregnancy and causes associated with childbirth. 13 The evil of maternal death is compounded by the evil of induced and illegal abortions amounting to half a million annually.14 2011 NEDA Study
13 14

2003 NDHS. Juarez et al 2005.

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Perhaps the most telling lesson taught by the Economics 27 is their conclusion that: Ensuring access to the free range of modern (artificial) family planning methods with appropriate information raises the success rate of achieving the desired family size. Limiting family planning options to national family planning (NFP) methods only fails to address the social costs of mistimed and unwanted pregnancies. One of the Economics 27 is the incumbent Secretary of Socioeconomic Planning, Cayetano Paderanga, Jr. of the NEDA. On our request, he has

summarized the key findings of studies related to the impact of population on reproductive health and family planning, as follows. Continued high population growth rate is principally done to the continued high total fertility rate over the last 20 years. The large number of children, specially among the poorest families, is more a result of the inability of couples to reach their desired (i.e., smaller) family sizes due to poor access to contraceptives. Getting out of poverty becomes difficult with larger family size. Poverty is strongly affected by population growth. Lower birth rates and slower population growth rate over the last three decades contributed to faster economic progress in developing countries. Countries with higher investments in health including reproductive health, family planning, and womens education register slower population growth and faster economic growth. Family size makes it difficult for families to emerge from poverty. This is the so-called burden of dependency. As family size increases, expenditures for
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education and health for family members decrease systematically. In the past, our country failed to achieve lower fertility and rapid economic growth. This failure is reflected in poor outcomes in human development concerns, as follows:15 High maternal mortality High infant and child mortality Poor educational performance High unemployment and underemployment At the household level, large family size correlates with the following:16 Higher poverty incidence Lower savings and asset accumulation Reduced per capita household expenditures for education and health. A 2010 study by the Guttmacher Institute and UN Population Fund (UNFPA) shows that maternal deaths could be slashed by 70 percent, if the world doubled investment in family planning and pregnancy-related cases. According to this latest report, investing in family planning and maternal health would have profound additional benefits, as follows: Increases in condom use for pregnancy prevention would simultaneously curb transmission of HIV and other STIs. Preventing unwanted pregnancies would increase womens educational and employment opportunities, enhancing their social and economic status.
15 16

World Bank 2010. Orbeta 2002; Orbeta 2003; Racelis 2008.

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 Family savings and investment would rise, spurring economic growth and reducing poverty. Demographic Winter Scare In its paper on Philippine population and development, the UP Population Institute defines the term demographic winter as the condition when a population no longer increases after a prolonged period of below - replacement fertility. A total fertility rate or TFR of 2 is the working definition of replacement fertility. A TFR below 2 sustained for a number of generations (with one

generation lasting for 25 years) would produce the so-called aging society, where the majority of the population are 60 or more years old. Critics of the RH bill agree that a large population in the working ages will provide a boon to development, the so-called demographic bonus, because of the large labor supply. This is fallacious, because the issue is not how big the labor supply is, but how skilled the labor supply is. To paraphrase the UP Population Institute: The Philippines may have a large pool of working-age population. But the quality of that labor pool is not optimal for economic development. They are poorly educated and not well

prepared for the jobs required in the market. Further, there may be a large pool of labor. But they may be too many to be absorbed by the market, even if they have the proper education.

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Financial Cost of RH Act Experts estimate that it will cost government some P3 billion a year to implement the RH law. This is considered modest. In the context of promoting development in less developed countries, the higher cost-benefit ratio is obtained from family planning programs than from infrastructures investment. Similar hardware requirements for development are more lumpy, time-consuming, and demand longer gestation periods. The RH cost of P3 billion a year is only one-seventh, or 14.3 percent, of the P21 billion cost of the Conditional Cash Transfer program. The two programs should be compared. On the one hand, the RH program is self-targeting, meaning that typically, it is the poor who self-select to obtain RH services which they cannot afford on their own. administer. On the other hand and by contrast, the CCT program distributes cash which is fungible, meaning that it can be precisely replaced by another. By comparison, a reproductive health service is non-fungible. Because the CCT program The RH program is simpler and less costly to

distributes cash, it prevents the real danger that the cash could be diverted to unintended recipients, such as principals and schoolteachers. The CCT program is more costly in terms of direct budgetary allocation, as well as the administrative requirements.

The 2011 SWS Survey

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The Social Weather Stations conducted a survey for the second quarter of 2011 in June 2011. The respondents were 1,200 adults in Metro Manila, the balance of Luzon, Visayas, and Mindanao, with a sampling error margin of plus or minus 3 percent. This most recent survey shows unequivocal public support for the RH Act: 73 percent want information on legal methods available from the government, while 82 percent say family planning method is a personal choice/ Here are the test statements and the scores: If a couple wants to plan its family, it should be able to get information from government on all legal methods. Agree Disagree Undecided - 73% - 13% - 13%

The choice of a family planning method is a personal choice of couples, and no one should interfere with it. Agree Disagree Undecided - 82% - 8% - 9%

The government should fund all means of family planning, may it be natural or artificial means. Agree Disagree - 68% - 16%

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Undecided

- 15%

The use of pills can also be considered as abortion. Agree Disagree Undecided - 29% - 52% - 18%

The use of condoms can also be considered as abortion. Agree Disagree Undecided - 30% - 51% - 18%

The use of IUD can also be considered as abortion. Agree Disagree Undecided - 29% - 51% - 19%

If family planning would be included in their curriculum, the youth would be sexually promiscuous. Agree Disagree Undecided - 31% - 46% - 22%

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For me, the plan of those who oppose the RH Bill not to pay their taxes is a reasonable protest. Agree Disagree Undecided - 32% - 39% - 26%

Yesterday, 16 August 2011, at the Ledac meeting, President Aquino announced that he included the RH Act in the . Thus, by his certification, the President of the Philippines has spoken. And more importantly, the greater

majority of the Filipinos have spoken. In the light of these developments, the democratic option is to pass the RH Act. -o0o-

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