The Problem of Abortion: The Philippine Case

by FLORENCE MACAGBA TADIAR, M.D., M.P.H.

Executive Director
Women’s Health Care Foundation
with the assistance of
MARIEL OMICTIN-DIAZ,
Programme Officer
Institute for Social Studies and Action
* DR FLORENCE M TADIAR is the Executive Director of the Women's Health Care Foundation in
Manila. She has been involved in women's health for more than 35 years now, not only as a private
practitioner in FP/Maternal and Child Health but as an advocate as well for women’s health and
reproductive rights. She is co-founder of several organization/agencies such as WomanHealth Philippines;
the Philippine NGO Council for Health and Welfare; Remedios AIDS Foundation; KALAKASAN or
Women against Violence; and the Alliance for Women's Health. She serves as consultant in many women's
health and rights projects of NGOs and government agencies.
Dr Tadiar graduated in medicine from the University of the Philippines followed by her Masters
both in Public Health and Hospital Administration. She underwent Special Studies in Maternal and Child
Health at the Harvard School of Public Health in 1970-1971 and is presently completing her doctoral
studies at the UP College of Public Administration. She is also Associate Professor at the U.P. College of
Public Health.

INTRODUCTION

It is estimated that 2.4 million legally married Filipino women no longer want an
additional child (PFPP, DOH Overview, 1990}. This was based on a health survey which
revealed that 63% of urban poor married women of reproductive age did not want an
additional child, and nearly two-fifths did not plan their pregnancies. Of those pregnant
during the survey, 41% admitted that their pregnancy was unwanted. (Phil. Star, 17 Feb
1989) This number falls within the estimated 155,000 to 750,000 induced abortions
estimated per year by De la Rosa (1987).
Those women who did not want another pregnancy and those at high risk of
complications including death are potential seekers of induced abortion. Valenzuela
(1983) found that 70% of women who were admitted for induced abortion in 8 hospitals
studied in 5 health regions no longer wanted an additional child. This was also true of
more than half of those who had spontaneous abortion (55.2%), and even those who had
normal deliveries (51.5%). It was also found that women who had induced abortion
tended to have repeated abortions. In 1990, the number of Filipino women who were
likely to seek abortion was estimated to be 3.6 million.
In 1992, it was estimated that 14.6 million women were of reproductive age. Of
those married {8.2 million), about 4.6 million did not want additional children, while 2.5
million wanted to practise family planning but were not. Around 5.5 million were high
risk women for pregnancy but half of these women were not practicing family planning
either. The latest survey showed that only 24.2% of all women of reproductive age are
using any form of fertility regulation, while a lower rate (15.1%) is practizing a modern
and effective method. (DHS, Prelim., 1993) Furthermore, among those who had used a
family planning method, 50% of them would drop out per year.
 Two thirds (66%) of mothers who died during childbirth were not using any
contraception. And maternal death rate has not significantly changed since 1980 (1 per
1000 live births), while fetal loss during pregnancy has been increasing since 1983 (11%)
to 1988 (15%). Good reporting, abortion, and poor health care are three factors which
have contributed to this rise in fetal loss. (Raymundo, 1992)
It is also significant to note that 6% to 16.5% of pregnancies are found among
teenage girls. The overall incidence of premarital sex has been estimated to be 12%
among the 15-24 years of age. Data suggests a higher incidence of 22%, and in fact this
seems to be increasing. As of 1989, there were roughly 6 million in this age group. If 12-
22% have premarital sex, then 720,000 to 1.3 million adolescents are in need of
protection from unwanted pregnancy. (Claudio, as cited in Robles, The Sunday
Chronicle, 10 Oct 1993)
However, only 9.6% of the 15-19 age group, and 18.9% of the 20-24 years old, or
a total of less than a third (28.5%) have been found to be using any modern contraceptive
method. (DHS, Prelim, 1993) It is a fact that young unmarried women who become
pregnant are at particular risk of illegal abortion since these pregnancies are generally
unwanted. But to protect the family name, abortion is not mentioned. Even pregnancy, is
not admitted if a woman is not married. Often, only 4% admit having had an abortion
(WHO, 1992).
Because abortion is not legal in the Philippines, except to save the mother's live,
these women have to seek abortion practitioners who are untrained and unskilled, whose
techniques are hazardous, and who perform the procedures in unsanitary facilities and
conditions. Many suffer and die due to these procedures. And their numbers are
increasing.
This paper will describe the abortion situation in the Philippines, identify major
issues and concerns related to this problem, and recommend possible approaches and
strategies which can be taken to minimize the effects of the problem, particularly as they
affect the health and life of the Filipino women.

THE SITUATION

INCIDENCE OF ABORTION

Because induced abortion is illegal in the Philippines, it is impossible to provide accurate

data on the number of procedures performed. Some health and family planning personnel
believe that the practice is increasing and estimate that at least 100,000 induced abortions
per year are performed in Metro Manila alone (IFRP, 1980).
A few community studies have shown varied incidence of abortion. This is
because not too many women would admit having experienced one or even knowing
about someone who did. Community-based interviews showed a wide range of as low as
4 in every 1,000 pregnancies to 33% of pregnancies. (De la Rosa 1987)
A survey conducted in Bohol showed that 14% of 1228 respondents (mostly
women) ages 15-55 years knew of a woman who deliberately tried to have an induced
abortion for unwanted pregnancy. But no one admitted having one. In fact, the traditional
healers and personnel of the government Rural Health units acknowledged a demand
from single and married women for abortions. (Reynes, 1976)
 On the other hand, from Galen's survey of abortion providers in 1979, the
estimate was 33.5 per 100 pregnancies. Another survey made in Laguna showed a figure
of 8.5% which rose to 10.4% in 1967. In Cavite, Flavier and Chen found in a study of 5
barrios from 1967-1969, that 13% of married women had at least one abortion during the
previous 5 years. Lawas and Duque more recently (1989) found a yearly incidence of
abortion in Maragondon, Cavite of 4 to 10.98% of pregnant women. Miralao's review of
community studies also showed 13-17% of women attempting to terminate their
pregnancy at least once.
Among 101 hospitality girls in the National Capital Region, 35% admitted having
had an abortion - 21% said theirs were spontaneous, while 14% admitted these were
induced, while 4% had stillbirths. The more sex partners they had, the higher the rate of
abortion. 67% of the abortions were of those who claimed they had more than 3 partners.
(Lawas and Dalmacion, 1989)
Several studies were made on hospitalized patients. Jalbuena et al did a study of
709 cases of septic abortion admitted to the Philippine General Hospital (PGH) from
1967-1977. The total abortion ratio was 22.5/100 live births. One third of these were
septic (6.9/100 live births). While there was an irregular trend in the incidence of all
abortions, there was a gradual increase of the septic patients. All septic ones were
assumed induced. More than half (52%) of these abortions were induced, while only 18%
were spontaneous. But only the seriously ill (52%) admitted they had an unsafe abortion.
The rate could be up to 82% since 30% of these abortions had undetermined cause.
At about the same period in Metro Manila, one out of four pregnancies ended in
abortion at 3 public hospitals studied (Cook and Senanayyake, as cited in Marañon,
1978). And in a clinic offering vacuum aspiration in one far-flung area of the country,
an average of thirty (30) abortion cases a month—were reported during the first half of a
year. (Marañon, 1978)
The study by Valenzuela (1983) showed that 1.7% of total obstetric cases or
20.8% of total abortions or 27.2%/100 pregnancies admitted to hospitals was induced.
These women tended to have repeat abortions. A higher ratio was found in Mindanao
where health services are less adequate. These induced abortions comprised 1.7% of the
total obstetrical admissions. An average of 33.3/month were admitted, and this figure was
much higher (39-44/month) during the latter part of the study (1976-78).

STORIES TO ILLUSTRATE

Belen, Erlinda, and Rose have stories to tell about their induced abortion experiences. A
vivid image of the suffering women have to go through, without access to safe, modern
methods of termination of an unwanted/unforeseen/unintended pregnancy can be seen in
their stories. Their experiences could provide a better understanding of the abortion
situation in the Philippines.

Belen
Belen is 23 years of age, an elementary school graduate, married with 6
children. She resides in a small community in Cebu where she works as a
volunteer health worker. She earns a living by vending food while her husband
works at the pier. They have a combined income of PI,500 monthly. She is
Roman Catholic but does not attend mass regularly due to lack of time. In
November, 1988, Belen underwent an abortion.
Vomitting, feeling of constant tiredness,, and amenorrhea led Belen to
suspect she was pregnant. She confided her problem to Virgie, a neighbour, who
advised her not to worry since her period might have just been delayed. But her
menstruation did not come after several days of anxious waiting, so she talked
with another friend who brought her to a doctor for pregnancy test. Belen was
already 2 months pregnant.
Belen started thinking of having an abortion. She had not used any family
planning method. She had been told by the midwife who attended to her last
delivery, that she might not be able to survive another childbirth. This was her
10th pregnancy at 23 years of age, and she already had 6 living children. Belen
had to bottle-feed her 9 month old baby so she could go out to work. Her
husband had women, alcohol, and drugs as vices.
Belen was afraid, worried and confused all at the same time. She was
afraid that her midwife's prediction may come true (that something bad might
happen), worried that if ever she would have 7 children to feed and nurture, or
that this would end up like her three other pregnancies which did not end in live
births. If she terminates her pregnancy, something might go wrong as well
because of God's anger. She was confused as to what to do.
Several days after her pregnancy was confirmed, she finally made a
decision. She had to terminate this pregnancy. She fold her husband about her
decision. He reacted by simply saying that it was all up to her since it was her
body. So she set out to look for money to be able to carry out her decision. By
the time she was brought to a woman doctor by her friend, Belen was almost 3
months pregnant.
Belen thought that the doctor was friendly, casual and sympathetic. She
was neither suspicious nor probing. But suddenly, Belen got frightened and
changed her mind. She was scheduled to return the next day but she did not.
But she still was determined to end her pregnancy. Her close friends said
she took 9 tablets of a drug and some herbs. Nothing happened. So, she claims
she induced her "miscarriage" by excessive physical exertion. In her own words:
"On the last week of November, since Christmas was fast approaching, I
decided to have a general cleaning. I scrubbed the floors, lifted the sola set... I
was then 3 months pregnant. That night, I had a pinkish watery discharge. I really
felt bad then. I felt very weak. This lasted for 3 days. My discharge increased and
each time, it was darker in colour. The pain became unbearable on the third day,
so I decided to go to the hospital. My friend accompanied me.
At the hospital, I was already very pale and my fingernails were already
greenish in colour. I nearly died. I told the Lord, "If you get me now, it's up to you.
I still have many children." I felt very tired.
I was not given medication immediately because I had to'have an
ultrasound. This revealed that the baby was already dead inside and my organs
were already infected. I stayed in the hospital for more than a week. I was very
lonely and depressed. The only person with me then was my sister-in-law. I could
not do anything. I have a husband with many vices.
 She had mixed feelings about the abortion which she insists was a
miscarriage. "I felt a thorn was taken away ... I'm supposed to be happy. On the
other hand, I also feel bad because the baby is gone. Well, anyway, I did not
abort it. I even took care of it, and yet "nuhulog pa rin" (it fell out). I did not really
have the child aborted."
Belen feels that her decision to end her pregnancy was greatly influenced
by her conscience. She believes that the mind cannot rest if the wrong decision
is made, and that it is the woman's decision that should be followed. Religion
(fear of punishment from God) and friends (their being her advisers) also affected
her decision. She had considered what her husband had to say, since he is still
her partner, but not the opinions of her parents and relatives (no one lives close).
She claimed that even her own personal values had to be relegated. As to the
law on abortion, she was not aware of it.
Note:
Belen was one of the 35 abortees interviewed for a utility on Attitudes Towards Abortion
conducted by the Institute for Social Studies and Action (1989). The interviewer found it
difficult to probe Belen. There were inconsistencies in her answers. The interviewer felt
that Belen was rather apprehensive, ashamed, and afraid to trust anyone. Although
Belen was only twenty-three, the interviewer thought she was 35 to 40 years old.

Erlinda
Erlinda is a 36 year old widow from Cavite. At 18 years of age, she co-
habited with a man for 13 years with whom she had five children. The children
were all delivered spontaneously without any medical complications every 2
years. The youngest child was just born when the "husband" died. The oldest
was 12 years old.
After 5 years of being a single mother of five rapidly growing children, she
started living with a jobless man, also Roman Catholic, 8 years her junior. This
was in May 1989. In June, she was confined for about a month at Quezon
Institute (Ql) for "lung abscess". This must have been due to Pulmonary
Tuberculosis since Ql is the main hospital for those with Koch's Infection.
Within five months of co-habiting with this second man, Erlinda became
pregnant. On December 28, when Erlinda was IVi months pregnant, she decided
to terminate her pregnancy. She had stated that her reason for this decision was
that her children showed resentment over her adding another person to the
family. They objected to having a stepfather, perhaps, because he did not
contribute anything to the family income but was in fact supported by whatever
meager income they could bring in. Erlinda must have been overworked as a
sole wage earner for her family of 7 and must have led to her contracting
tuberculosis.
Erlinda went to a known abortionist in Laguna, the next province. Abortion
was induced by the introduction of a rubber catheter which was removed the
following day, after which curettage was done. Erlinda then complained of
abdominal pain and was given anti-flatulent and antibiotics. The abdominal pain
persisted and a day after the curettage, she also had severe episodes of
vomitting coffee ground material.
 Erlinda was brought to 2 hospitals before definitive therapy was instituted.
Catbagan General Hospital in Cavite did not admit her "because she was
restless and in severe pi6in". The other hospital which quickly again rejected
Erlinda was PERPETUAL/ HELP (!) General Hospital in Laguna. She was sent
away "because of financial reasons". Meanwhile, Erlinda's pain became more
severe, and she was more and more seriously ill. She had to travel for another 3-
4 hours to reach iFabella Hospital in Manila where she was admitted on
December 31, 1989A
Erlinap had already suffered for 3 days, had become incoherent and
dyspneic, with a very fast pulse rate, fever of 38.9° C. The blood pressure was
still normal.
Her abdomen was quite distended, tympanitic, with poor bowel sounds,
tender all over. Pelvic exam showed a purplish cervix, only scanty bleeding from
the os. The uterus and the adjoining organs could not be evaluated due
to muscle guarding.
The admitting impression was abortion, induced, septic, with curettage
done outside Fabella, and peritonitis with a suspicion of uterine and bowel
perforation. The later diagnosis was strengthened after the abdominal x-ray
results.
Meanwhile, all necessary medical intervention and diagnostic work-up
were instituted: antibiotics, nasogastric tube, blood transfusion, laboratory
examinations, vital signs monitoring. Emergency laparotomy was performed.
Fecal material was found all over the abdominal cavity from 2 areas of intestinal
perforation. The uterus of course, also had a perforation and the left ovary was
cystic and enlarged. About 6 inches of the intestines, uterus, tubes and ovaries,
were all resected within 3 hours of surgery.
Throughout the operation, Erlinda had an unstable blood pressure. This
continued after the operation which became even more serious 6 hours later.
Inspite of measures to resuscitate, Erlinda died the morning after New Year's
Day, 15 hours after the operation, 5 days after an induced abortion by the use of
a catheter.
Note:
Erlinda's story was abstracted from her medical records at the Fabella Memorial
Hospital, the biggest maternity hospital in the Philippines.

Rose
Rose is 27 years old, an elementary school graduate. She is a single
mother with 2 children (ages 7 and 4 years) by different men. She supports them
herself, with the help of friends. While she was still very young, her father, a
soldier, left the family for another woman. She later had a stepfather who
sexually abused her. But her family ostracized her for bringing a complaint
against him. She and her brothers and sisters were farmed out and did not see
each other for years. She had to earn a living and ended Up as a bar girl in
Olongapo, previously the main 'Rest and Recreation Area' of the American Base
in the Philippines.
 A month after her oldest child was born in 1986, Rose started taking
contraceptive pills. But she developed skin problems with itchiness on her face.
After 6 months on pills, Rose went to a doctor to complain about the side effects.
The doctor had a Pap Smear taken and told her to stop the pills while he was
"studying an alternative prescription for her".
Without any protection against pregnancy in her work as a bar girl, Rose
soon became pregnant. Her child was less than a year old and she was
financially hard up. She decided to terminate her pregnancy.
At her friends' advice, she drank a concoction of Cortal, boiled Coke and 3
tablets of Alarin, together with a gin preparation - Sioktong. Banging her buttocks
on the wall, "dieting" (eating less), and taking other drugs (2 capsules of
Pentrexyl and 4 Alarin tablets) with gin, not water, were also recommended. At
the same time, she had her abdomen massaged vigorously by a traditional
health attendant (hi/of) for PI 50/session. The skin of her abdominal wall became
so sensitive and even peeled off. During all this time, Rose had to go on working
as a bar girl.
After three agonizing months of waiting, hoping and not knowing, Rose
began to bleed profusely. After a whole day and night of continuous bleeding,
she decided to go to a government hospital. Although she was warned that this
hospital was like a 'butchering' place, she had no choice because she could not
afford to go to a private institution. By then she was already very pale and weak,
and felt very dizzy.
The nurse who attended her first accused her of faking her weakness
(umaarte). She showed no concern at all for Rose's condition and when Rose
expressed anxiety over her blood loss, the nurse said, "Let me see if that is true"
and proceeded to take Rose's blood pressure. The nurse did not even bother to
look at the flow of blood. She asked Rose again if she already had the money.
She even admonished Rose: "Why are you in a hurry and are always
complaining? As soon as your money gets here, you will be attended to."
The doctor made Rose aware that he knew she had her abortion induced.
He admitted her but insisted that she should purchase her medicines before
curettage could be done. Rose requested the doctor to just give the drugs she
knew he had on stock and that she would just pay him later. But the doctor said
her bleeding could wait, and that he could only help her after she has purchased
the medicines.
Even the utility person showed the general attitude prevailing in this
hospital. He scolded her for her blood spillage all over the floor. "Can't you do
something about it?" he demanded.
Rose then thought of selling her only valuable property - her bed. She
asked her friend to do this for her. Rose was finally given medical attention 7
hours after she sought help in this hospital. The doctor advised her upon
discharge the following morning, to save P5.00 a day so she can be attended to
promptly the next time she seeks medical help. The doctor however did not teach
her to protect herself from another pregnancy, or how to take care of her health.
He expected her to come again for another unwanted pregnancy.
 After that experience, Rose used the Pill again. But soon, she developed
dizziness and headaches. She suspected that the pills given to her had expired.
There was no counselling given.
Rose again went to the government "Hygiene Clinic" to complain about
the Pill. Again, Pap Smear (!) was done and she was not given any other
contraceptive while waiting for the examination result. Rose says that the vaginal
speculum inserted was still hot, making her practically jump. She was told, "Your
only job is to lie down. We have to attend to the long line of women here. So
don't complain. That instrument is not hot at all."
Because Rose had to continue working as a bar girl without a means of
protecting herself from pregnancy, she soon became pregnant again. This was in
1988, a year after her first abortion. She also decided to terminate this
pregnancy.
She underwent the same process. In addition, she drank a decoction of
the Calachuchi tree bark every morning. And she had to undergo several
sessions of painful abdominal massage by the hilot who now doubled her fee
after the first month.
After 4 months and 10 days, Rose bled and the fetus came out. However,
the placenta was retained and so the fetus was hanging between her legs.
Rose went to the same hospital. She experienced the same delay in
medical attention because of no money. The cord was cut but curettage was not
done right away. Her bed and the electric fan she used to help her child sleep at
night had to be pawned. Meanwhile, the staff kept asking if she already had
money. Three hours later, Rose had money through the help of her friend, and so
curettage was performed. She was discharged the following day.
She again took the Pill, in spite of side effect. She was also given
Espeton, a barrier method for fertility regulation. But she became pregnant again
after about a year. At first she tried to induce another abortion, but changed her
mind and continued with the pregnancy. She is very happy that the baby was
normal and very handsome. This was in 1989.
Note:
Rose personally presented her story recently, at a forum on "Ethical Issues on
Abortion" sponsored by the Reproductive Health, Rights and Ethics Center for Studies
and Training. She had earlier expressed fear about being arrested if she appeared at the
forum, but was assured this would not happen. Rose broke into tears before she could
even begin to tell her story. It took her time to do this because she was overcome with
emotions.

PROFILE OF THE RISK TAKERS

Belen, Erlinda and Rose are examples of the majority of Filipino women who risk their
life and health in the process of terminating an unwanted, unintended, or unforeseen
pregnancy.
Some of those who landed in hospitals were studied and most of them had the
following profile:
  ages 16-46 years old, mostly 20-29;
 currently married;
 gravida 1-17 (3rd pregnancy for urban, 4th to 5th in rural areas);
 parity of 0 -17 (mean of 3,35.7% nulliparous);
 with 0-12 living children (mean of 2-3);
 within the first 12 weeks of pregnancy (later among the the poorer women);
 housewives/unemployed;
 from the lower socio-economic class;
 with little education;
 Roman Catholic (85%, reflective of population religious affiliation distribution);
 elect to patronize the services of practitioners in their own or nearby community;
and
 sought hospitalization around 8 days after the induced abortion, and was in an
advanced stage of infection, so was not likely to survive.

De la Rosa's review of hospital and community based studies of abortion (1989)

revealed that the peak age among abortees was 25-29 years. On the other hand,
Valenzuela et al's study of pregnancy terminations found that the proportion of teenagers
ages 15-19 years (16.5%) who had induced abortions was greater than that of women
who had normal deliveries (11.5%) and almost triple those with spontaneous abortions
(6.2%).
The general impression is that most of those who undergo abortion are the single
women who do this because of "shame or dishonour". In the ISSA survey of 1000
respondents from various parts of the Philippines (1989), the most common (68%)
perceived reason why women would have an induced abortion was because the woman is
not married (ie. brings shame.to the family since her partner does not want to or cannot
marry her, or that the woman is still young and studying). Only 20.5% were single in the
Jalbuena series, while Valenzuela found 23.1% never married, 52.6% currently married,
18.6% formerly married.
Valenzuela found the following reasons cited by those who had induced abortion
in different parts of the country:

19.4% » to space pregnancy;

17.7% » unwanted pregnancy (unmarried);
14.0% » too many children;
11.4% » additional burden financially;
10.0% » interferes with occupation/studies/employment;
and
27.5% » others like problems with husband (separated from,
quarreled with, irresponsible, had another family), poor
health, daughter asked (13 living children), refused to
answer (15%).

A closer look at the above reasons shows that the basic factor which runs through
most of these were economic or financial in nature, just like in the case of Erlinda, Belen
and Rose. Belen also had a problem husband, besides having too many children. Another
baby would mean added financial burden and create interference with her income
generating activities. Pressure from the other children had an additional influence on
Erlinda's decision. She did not give importance to her "lung abscess", so poor health was
not given as a reason for her induced abortion. Rose used abortion to space pregnancy
because having another baby would not only burden herself and her son financially, but
would also interfere with her occupation and the care she was giving to her son. The
ISSA study showed that most people believe economic reasons is only a secondary
reason for induced abortion. Less than half (42%) of the respondents thought women did
this because of financial difficulties. But among the 35 women abortees interviewed by
ISSA, two thirds (62.9%) opted
for the termination of their
pregnancy because of financial
reasons. Because of continued
poverty, which results in the
need for hard work among
women in order that they can
contribute to the family income,
many have more than one
induced abortion, and/or have
spontaneous ones.
One third of the women
abortees in the ISSA study
admitted that they had sought
this procedure more than once.
One woman had as many as five
abortions (and had 10 living
children), and another one, a prostituted woman, claimed she had eight abortions.
Almost a third (27%) of hospitalized women due to abortion in the Valenzuela
study had a repeat abortion.
One does not find any reports about the affluent undergoing induced abortion.
This is because they would go to private doctors who would be willing to help them, very
discreetly, usually for a big fee; or they can afford to go to other countries where abortion
is legal.
The most influential factors in the decision to undergo abortion among women
abortees interviewed in the ISSA study were her husband, her conscience, her religion,
and her parents, in that order. The least influential were the laws, friends, and other
relatives. Many of them, like Belen, did not even know that there are laws against
abortion, or if there were, they were generally pronounced ineffective. The drama of
abortion identifies the woman as the primary decision-maker and leading actress, and she
carries out her role with determination, logic, and above all, courage. Rose, Belen, and
Erlinda had these characteristics.

THE ABORTION PROVIDERS

It is not easy to describe the abortion providers or the so-called "abortionists" because of
the illegality of abortion in the Philippines. However, Gallen conducted an exploratory
study among the abortion providers in 1979 which showed the following results:
 the overwhelming majority are women (same as ISSA);
 most had been married;
 between the ages of 45 - 49 years;
 had relatively large families (mean of 4.5 children);
 educational attainment varied from no formal education (17%) to those with
graduate studies (13%);
 designated occupation included physicians, nurses, midwives, domestic helpers,
vendors, tricycle drivers, but the largest group were housewives;
 most had no formal medical training: 6% were physicians, about 19% were nurses
or midwives, around 25% were traditional birth attendants (hilots/herbolarios);
 more than half said they usually performed abortion within the first trimester and
three-fourths claimed they would not go beyond the fourth month;
 they had been practising abortion for a mean of 9.6 years and had been living in
the communities where they practised for a minimum of 5 years to a maximum of
45 to 50 years;
 abortion charges ranged from P2 for abdominal massage (most commonly used),
to as high as P2,500 for D&C, with an average of P185 for catheter insertion
(second most common);
 most of them learned the procedures from assisting, observing, or learning from
other abortionists who were most often their relatives, mainly mothers or
grandmothers;
 almost 80% knew of other abortion practitioners, mostly also within their areas;
 their clients came mostly from nearby places; and
 only 19% had experienced harassments from the police, health officials, husbands
or boyfriends of their clients.

Jalbuena and Valenzuela found that the most commonly mentioned primary
occupation or training/profession of the person who provided abortion service was either
by a registered midwife (40% by Jalbuena, 45.6% by Valenzuela) or hilot (49% by ISSA,
37% by Jalbuena, 15.9% by Valenzuela). In fact, 78% of births are also attended by these
same persons - 48% by midwives and 30% by hilots (Teoxon, 1991). The main reason
cited for this was "they were nearest to the house", in both rural and urban areas.
In the ISSA study, 40% went to a health professional, but no specific category
was mentioned. Medical doctors were cited by 10% of the Jalbuena series. Another study
by Lawas and Duque in a small municipality in Cavite revealed that more than a third of
abortions were done by midwives, while 27% were by physicians. Among the hospitality
girls in Metro Manila studied also by Lawas, midwives (36%) topped the list of their
abortion providers, 27% were doctors, 13% were hilots.
Apparently, women sought the services of whoever was known to be of help in
their distress, and accessible in the area where they lived. These included health
professionals although abortion is not legal. While the providers are not generally known,
women who are determined to end their pregnancy have a way of reaching them, usually
through a "friend of a friend of a friend". For a myriad of reasons such as hopes that their
menstruation was just delayed, late recognition or denial of pregnancy, trying out
traditional but usually ineffective methods, difficulties in finding out where to get help
and raising the money for the procedure itself, and often making that decision without a
show of concern and support from their husband/partner, women like Belen and Rose,
usually have their abortion in advanced stages of pregnancy, after a long period of
anxiety and worry. They end up having their abortion induced by untrained and unskilled
providers in unsanitary conditions, and because of this, they die like Erlinda, or suffer the
rest of their life in various forms of sequelae.
Many of the women also perform the abortion on themselves (15.3% by
Valenzuela, 7% by Jalbuena, 11.4% by ISSA).

ABORTION METHODS AND PROCEDURES

Although modern safe abortion techniques (eg. vacuum aspiration, dilatation and
curettage) are available in the Philippines, access to such procedures is generally not
known by persons outside the medical and health fields. Herbs and concoctions to induce
menstruation (pangparegla) are sold right in front of a big Roman Catholic church in
Quiapo, Manila, and in markets and sidewalk stalls in many parts of the country. Women
whose menstruation gets delayed or suspect pregnancy, usually first resort to using these,
or like Rose and Belen, take substances and do a number of activities which are supposed
to induce "miscarriage".
Women may also go to a doctor or perhaps, a midwife or nurse, for an injection or
tablets which they believe would induce menstruation. These are usually hormonal
preparations used to "test for pregnancy" and would not cause bleeding if there was
pregnancy. Since some patients actually menstruate after an injection or taking of some
drugs, because the amenorrhea was due to reasons other than pregnancy, women think
that these are abortifacients. Doctors know better, but because they cannot be of any help
or women request for these, doctors would go ahead and inject or prescribe these
preparations.
Since most abortion providers are midwives and hilots, the most common
methods used are rubber catheter insertion, abdominal massage, and drugs and herbal
preparations. It is of course logical that among those with septic abortion, in the Jalbuena
study, the most common procedure used was the insertion of a foreign body (80.6%
catheters, others included curettes, IUD, gauze pads). The Valenzuela study also
mentioned catheters as the top culprit which caused hospitalization.
On the other hand, massage was the most common method used among those
interviewed in the various communities studied by Reynes in Bohol and Galen among the
abortion providers. This was also resorted to by many of the women studied by Jalbuena
(10%) and Valenzuela. Many, like Belen and Rose, use a combination together or one
after the other (9% in Valenzuela study). Bitter drinks, poultice, quinine, laundry blue
and other chemicals have also been mentioned. It is not uncommon to hear that twigs,
coconut midrib, roots, clothes hangers, douching solutions such as soap suds, household
disinfectants and other decoctions are used as well by patients on themselves. Some make
use of oxytoxics and emmenogogues, or an overdose of various kinds of drugs. (De la
Rosa, 1987)
 Because most women are unable to obtain medically safe, modern abortion, they
have to resort to procedures that offer unpredictable outcomes and involve definite risks
(IFRP, 1981). As a result, many women die or have serious medical problems after
attempting to induce abortion on themselves or seeking assistance from untrained
practitioners who perform abortions in unsanitary conditions. All these methods are
dangerous. We have seen what happened to Rose, Belen and Erlinda.

THE IMPACT OF UNSAFE ABORTION

On Maternal Morbidity and Mortality

In the Philippines, around 12% of women who undergo induced abortion are hospitalized
(De la Rose, 1987). There is in fact an increase in the number of women who are
admitted to hospitals. Induced abortion was among the top 7 causes of discharges in
government medical centres and regional hospitals in 1987; and the next year, it jumped
to number 2 (DOH Hospital Development Plan, 1988-1992). Almost 10% of all patients
in regional hospitals and 14% in the big medical centres in urban areas, were admitted for
abortions. Hospitals at various levels from the smallest municipal 25-bed hospital in Sulu
(Muslims are predominant here) to the provincial hospitals (150-200 beds) to bigger
centres (450 beds) in Manila studied by Masters in Health Administration (MHA)
students in the University of Philippines have invariably recorded abortion among the top
ten causes of hospitalization (Tadiar, 1990). At Fabella Memorial, about 8% of all
obstetrics patients were admitted for abortion at a rate of 10-15 per day in 1989. Trends
show that this is increasing every year. At the Davao Medical Centre (150 beds) in
Mindanao, abortion has been either the first or second leading cause of discharge of all
patients from 1988 to 1992.

How many die due to botched abortion?

A review of maternal deaths in 78 hospitals accredited by the Philippine Obstetrics and

Gynaecology Society (POGS) attributed one fourth (24%) of the deaths to induced
abortion (Sahagun, 1987). If deaths due to unsafe abortion which occurred in non-
accredited hospitals and in the communities were counted, this may reach the 50% found
in other countries estimated by Winikoff (1988). After all, 6 out of 10 Filipinos die
without medical attendance (Health Statistics, 1989). So it is highly probable that a lot of
women who die from abortions and other pregnancy-related causes are not counted
because the person who registered their death was not aware of the real reason and
circumstances of the death.
The 1988 Health Statistics show that only 8.4% of maternal deaths were due to
"Pregnancy with abortive outcome". I suspect that out of the 6.9% who had
"Hemorrhages related to pregnancy", and even some of the 25.3% who died because of
postpartum hemorrhage, some of the women actually had undergone unsafe abortion.
Researchers speculate that the actual death rates may be twice of what has been reported.
A look at the maternal mortality by cause in 1989 showed that deaths due to
pregnancy with abortive outcome for ages 15 to 49 years ranged from 9% to 13.5%, with
the highest percentages among the 25 to 34 years. While only 3.6% were 10-14 years old,
maternal mortality in this age group was the highest (637.2 per 1000 live births), while
from ages 15 to 49 years, mortality rate was only from 0.57 to 5.26 per 1000 live births.
Inaccurate recording and reporting of maternal deaths was also pointed out by
Jalbuena in her 1964-1965 study of these cases at the PGH which is located in the City of
Manila. The City Health Officer presented a much lower ratio than the 210 deaths per
1000 live births reported by PGH. The investigators also expressed anger and frustration
at the death of women who died from induced abortion (16% of maternal deaths in this
study). These were most wasteful, she says, since their deaths could have been prevented
by contraception. De la Rosa concluded in his paper that 73% of those who underwent
induced abortion were aware of the risks of this procedure and yet proceeded to have it
clearly illustrates the desperation of these women - just like Erlinda, Belen and Rose.
De la Rosa's review of studies on induced abortion cases in the Philippines
showed a range of outcomes of unsafe procedures: from minor complaints to death,
depending on the circumstances under which the abortion was performed. These
circumstances include the general health condition of the woman, method used, skill of
the provider, duration or stage of pregnancy, and timeliness and quality of treatment for
complications.
Immediate complications may include: perforation of the uterus, injury to
intestines and other visceral organs, profuse hemorrhage, lacerations of the cervix, shock,
and coagulation disturbances.
On the other hand, delayed complications include: bleeding due to retention of
fragments of the placenta, infections ranging from mild endometritis to severe pelvic
inflammatory disease to generalized peritonitis and septicemia; thrombophlebitis and
resultant pulmonary embolism. Long-term complications include impaired fertility.
The most common complications are sepsis and hemorrhage, which happened to
our 3 examples. Uterine perforation is also quite frequent, like what happened to Erlinda.
The causes of death are usually severe anemia, septicemia, thrombocytopenic puerpena,
and complicating pneumonia (Valenzuela, 1983).

How do the women handle complications following the procedure?

You have seen how Belen, Rose and Erlinda suffered but tried to cope with their
situations. The ISSA study also showed that when pains and complications were
considered tolerable by the woman, or when her desire for secrecy was so overriding, she
tried to deal with these on her own, prescribing self-medication for the fever or the pain.
When she was able to make her way to the abortion practitioner, or send word to her, the
woman was prescribed medication or asked to return for examination and further
treatment, if needed. In a few cases, when she feared there was something drastically
wrong, she took her courage in hand and went to a doctor, for check-up and treatment.
This even when she knows she would be found to have committed a "sin" or a "crime".

On Personal and Public Health Resources

Mention has already been made on the money spent by the woman to have an induced
abortion. This ranged from P2 (in 1979) to P150-300 (in 1989) for each abdominal
massage session. For dilatation and curettage (D&C), it cost her about P2500 in 1979.
Now, D&C can easily reach up to P10,000 or even to P20,000, just like a normal delivery
at private hospitals. Before that, these women, like Belen and Rose, also spent money for
the drugs and herbs they used to induce abortion themselves. And after a procedure, when
complications became obvious, these women also self-medicated before seeking outside
help.
In the ISSA study of women abortees, the cost for complications consisted of that
paid for medicines when they self-medicate. Abortion providers charged for only the
antibiotic prescribed. However, for those who needed hospital confinement, varied
medications including intravenous fluids, doctor's fees, and the cost of a D&C were
expensive - more than what the woman and her family could afford. These ranged from
Pl,000 to P4,000. This would be equal to income earned for about a month or longer, as
was seen in the case of Belen.
The costs to the woman in terms of money, time lost from productivity and
income generation, as well as physical, mental, and emotional suffering is just appalling
and quite unquantifiable. However, despite knowing the costs and the dangers involved,
women would risk their health and life to back-alley abortion services out of desperation.
Aside from the unnecessary loss of maternal life, is the unnecessary waste of
resources spent to correct the complications brought about by these septic and illegally-
induced abortions. Dr Ricardo Gonzales, former Chief of Fabella Memorial Hospital,
says that the hospital spends more for the treatment of a septic abortion than a caesarean
operation. We have seen the type of resources applied to manage the complications of the
botched abortion on Erlinda at his hospital. However, all these came to naught because
Erlinda died after 5 days of full implementation of medical management and expenses to
save her life.
Dr. de la Rosa (1987) explains further the waste of resources from these
preventable public health problems: "The burden is not only on the medical institutions
but on society as a whole. Scarce and expensive resources - such as blood, intravenous
fluids, antibiotics, anesthesia, not to mention the hospital bed and operating rooms, time
of personnel, and laboratory procedures - are drained. These resources could have been
(made) available for basic services to high risk mothers. Under the combined impact of
high birth rates and at-risk mothers, hospital admissions to induced abortions add strain
on the medical institutions especially in their effort to provide quality care. When the
volume of abortion-related cases is heavy, fewer hospital beds and staff time result in the
discharge of women before they are fully recuperated, undoubtedly contributing to
maternal and neonatal morbidity and mortality."

Considering that,

 10 to 16% of hospital beds are occupied by abortion cases (Sahagun, 1987);

 that more complications set in among women with induced abortion than among
those with spontaneous ones (Valenzuela, 1982);
 that the length of hospital stay of induced abortion cases is higher (3.2 days) on
the average, while it is only 2.6 days for spontaneous abortions and 2.2 days for
normal deliveries (Valenzuela, 1987); and
 that abortion is a leading cause of hospitalization in virtually all hospitals, not
only public institutions but even big and small privately owned facilities,
one can only surmise that deliberate termination of unwanted pregnancies -which is here
to stay and even tend to increase - is definitely costing Filipinos a great amount of our
scarce resources.
It is also a fact that the government budget for health and other social services has
been decreasing for a number of years. On top of this, the recently implemented Local
Government Code which provides for autonomy of local officials in the planning and
implementation of basic services may cause uneven distribution of badly needed
resources. Policy makers at the local government level who do not understand the needs
of health services for women may jeopardize even further those who are in dire need of
these resources. It is said that reliance on abortion for fertility regulation signals a failure
of health systems to provide appropriate care to these women (WHO, 1992). This is so
true in the Philippines.

ISSUES AND CONCERNS

LACK OF SYSTEMATIC AND HUMANE RESPONSE TO UNSAFE ABORTION AND ITS

PREVENTION

The experiences of Erlinda, Belen and Rose illustrate the need for appropriate response
by the health system to the need of preventing unwanted or unintentional pregnancy, and
of caring for those who suffer because of unsafe abortion.
In the case of the two private hospitals which rejected Erlinda - were they not
supposed to relieve her pain and suffering, prevent her death or even maintain her
compromised status? It seems that no blood, blood products, or any intravenous fluid was
administered in these hospitals. It is ironic that a hospital named "Perpetual Help" (!) sent
her away "because of financial reasons", and that this institution has a medical school.
The other one did not even admit her when they saw that she was in serious condition.
These hospitals allowed Erlinda to travel more than 5 hours with what they should have
known as perforation not only of her uterus, but also of her intestinal tract! With a history
of severe abdominal pains and vomiting of coffee-ground like material, I am sure they
suspected that she had an induced abortion, and that is why she was refused admission.
As to the behaviour of the doctors, nurses and other staff in the hospital and the
clinic who attended to Rose, this is quite common in the Philippines and should be
condemned and corrected. Since these are health "professionals" employed at public
institutions, supported by the people's taxes and other public moneys, and the only ones
accessible financially to at least 70% of Filipino, a change in this situation makes it even
more urgent!
Questions should be raised on the care given to Rose who sought the help of the
health clinic so she would not become pregnant. Why is it that only the Pill was made
available to Rose, who cannot afford to be at risk of unprotected sex because of the
nature of her work which involves sex not only with one but several men everyday? Law
as had shown that abortions increase with the number of sex partners. Why was Pap
Smear the mode of diagnosis for side effects? Why did it take so long for the results to be
available? Why was Rose not given another contraceptive method while waiting for this
result? What kind of reproductive health care is being provided among our prostituted
women, those who are victims of poverty, of exploitation, of violence, of all kinds of
human indignities and violation of human rights?
In the case of Belen, although the doctor seemed to have accepted her responsibility 'to
diagnose, treat, cure, comfort' and to improve the quality of her client's life, she probably
failed to do proper counseling. This may have contributed to the feeling of guilt which
Belen expressed a year after she had her "miscarriage". One wonders if the procedure was
well explained without frightening the patient, if the cost was prohibitive for her, if
various terms of payment were explored, and if consequences of unsafe abortion
practices were explained. Another responsibility of a doctor is to educate and this may
not have been done as well.
One dilemma of doctors is how to equally protect the mother and the unborn, a
provision in the Philippine Constitution, and yet help a mother when she is decided on
terminating a pregnancy, where otherwise she might die, as in Erlinda's case. That a
woman takes the risk of drinking all the abortifacients given to her by non-medical
persons, of suffering from the insertion of a catheter, or from excessive and painful
abdominal massage -how can a doctor allow this to happen to anyone? Is the doctor not
causing "injury and wrong-doing' which she promised under the Hippocratic Oath not to
do (principle of non-maleficence)?
Other dilemmas related to pregnancy termination faced by health professionals
providing reproductive health care include termination of pregnancy for maternal
indications, of a woman with live anencephalic fetus, among victims of sexual abuse, the
use of morning-after-Pill, contraceptive advice and services for sex workers, management
of "septic threatened abortion', for cancer of the cervix in pregnant women, and
deferment of mother's treatment for the interest of the fetus. These were listed in a survey
conducted by Dr Augusto Manalo at the UP-PGH Medical Center (1993). He concludes
that many of these dilemmas, particularly in the question of whether to allow victims of
rape and other forms of sexual abuse to terminate a resulting pregnancy, are "not
answered in actual practice because abortion is not allowed in our country. It is the
feeling among many that our laws can be very unkind. A woman has been wronged and
will be wronged further by being made to carry a pregnancy she does not want, face the
danger of labour and delivery, and rear through most of her life an individual she never
dreamed about." (Manalo, 1993)
Which brings us to the legal and justice aspect of abortion.

THE NEED FOR THE STATE TO ENSURE THE EXERCISE OF WOMEN'S RIGHTS

The Philippines is a signatory to many international conventions and treatises where the
right of individuals to determine their family size, and equality of women and men are
recognized. This includes the Universal Declaration of Human Rights and the Convention
on the Elimination of Discrimination Against Women. In fact, the 1987 Philippine
Constitution provides (Art. XV, Sec. 3) that the State should defend the right of spouses
to determine the size of their family, according to their religious conviction and the
demands of responsible parenthood.
However, the stand of the State and the Roman Catholic Church regarding the
issue of abortion is the same. They hold on to a strictly conservative attitude towards
abortion. The Catholic Church in particular, being the most vigorous and articulate
opponent of abortion, teaches that the fetus is a human being from conception. Therefore,
any interference with its development would be tantamount to murder. In fact, the
Catholic Church even holds a very dogmatic view regarding the issue of family planning.
It approves only of the "natural' methods and considers "artificial' methods as "immoral'
and "anti-life'.
While the trend in many countries is decriminalization of abortion, due to the
influence of the Roman Catholic hierarchy, there probably is a trend towards the opposite
direction in the Philippines. This is the conclusion made by Tadiar in his Commentary on
the Law and Abortion in the Philippines (Tadiar, 1989). He says that the provision of
equal protection of the mother and the unborn from conception found in the 1987
Philippine Constitution, and the deletion of the provision on population policy which was
specified in the previous Constitution, "further restrict access to safe abortion". These
were intended to prevent any judicial decision similar to the US Supreme Court decision
in Roe vs. Wade. Furthermore, this was meant to preclude Congress from passing any
law granting rights to terminate pregnancy.
The pro-natalists succeeded in inserting the provision on equal protection in the
State Policies where "sanctity of family life" and the "family as a basic autonomous
social institution" were recognized. Tadiar believes that "while this provision guarantees
independence of family in making decisions concerning its own welfare, the right-to-life
provision (allowing abortion only to save the life of the mother) takes away the family's
autonomy in deciding whether termination of a pregnancy would serve its best interest".
He also points out that there are limits to the rights of the unborn. There can never be
equal protection, he says. You have to give more rights either to the mother or to the
fetus, given the dependent relation the fetus has on the mother, who has a legal
personality, unlike the fetus which is still part of her body until it is born.
Abortion is made a crime by the Penal Code of 1930. Penalties ranging from 2 to
20 years, where "concealment of dishonour" is a mitigating circumstance, while lack of
consent, use of violent method, use of scientific knowledge or skill by physicians and
midwives performing abortion are considered aggravating. Tadiar points out that nurses
and traditional birth attendants (TBAs) are not mentioned, but doctors or pharmacists
may risk revocation of their licence to practise their professions. The practice of safe
abortion is punishable by maximum penalty!
The prediction of Tadiar that restrictions, not liberalization of abortion laws,
would be a trend, is already becoming realized - if these were not aggressively
counteracted and these efforts are not sustained. For example, Senate Bill No. 218
(formerly 1109) is "An Act Increasing the Penalty of Imprisonment for Abortion
Practised by Physicians, Midwives, including Nurses and the Accessory Penalty therefore
to Perpetual Loss of License to Practice Profession and For Other Purposes" (sponsored
by Sen. Maceda) now provides for the inclusion of professionals omitted in the Penal
Code. It encourages abortees to squeal on the abortion practitioners by exempting them
from liability, if they were to divulge who these providers are.
Tadiar had also warned that dormant laws, like those which prohibit importation
of "abortifacients" (use of postal service to disseminate information and articles for
abortion) may even be revived and implemented with stricter prosecution. Sen. Tatad has
already filed 2 bills on this: Senate Bill No. 846, "An Act Prohibiting the Use,
Production, Sale, Distribution, or Dispensation of Abortive Devises, Defining the Same,
Providing Penalties therefor, and Amending for the Purpose the Revised Penal Code of
the Philippines and For Other Purposes", and Senate Bill No. 847, "An Act Regulating
the Use, Production, Sale, Distribution or Dispensation of Abortive Drugs, Defining the
Same, Providing Penalties Therefor and For Other Purposes".
In addition, a resolution (House Resolution 768) has been filed to look into
allegations that certain organizations and personalities "have been promoting directly or
indirectly abortion practices, devices, and literature". It is ironic that this would be
sponsored by the appointed Peasant Sectoral Representative (a man), who admitted that
abortion is widely and continuously practised among various sectors of Philippine society
"where the simplicity and poverty of farmers are being taken advantage of to promote
such criminal and highly immoral practice."
Given the fact that safe abortion is 25 times less likely to result in death than
carrying a pregnancy to term; that the death rate from safe abortion is 0.5 per 100,000
procedures, compared to that of childbirth which is 10 per 100,000 full-term pregnancies,
one may wonder on the morality of it all. (Moore, 1990)
With the restrictions on the right of a woman to regulate her fertility through her
own decision making process, particularly the poor who lack or have no access to proper
health information and services, there seems to be some inequities in social justice.
Actually, abortion cases have rarely been prosecuted during the past 80 years,
according to Tadiar. The difficulty of securing admissible evidence and/or official
tolerance of the conditions leading to abortion have contributed to this situation. 13Lit
some forces seem determined, and have adequate resources to deprive women of their
right to their complete physical, mental, and social well-being and even to their life.
Because of this, the threat of prosecution is quite heavy on women as well as on abortion
service providers.

WOMEN STILL RESORT TO UNSAFE ABORTION INSPITE OF ITS DANGERS

The ISSA study revealed that the woman abortee is an occasional church-goer and none
too close to her faith. She showed ignorance of any law against abortion, and was
convinced of their impotence and ineffectivity, if there were. Traditions have little to do
with her personal life. Except in a few instances, she does not appear to have a close
relationship with her husband. Her marriage seems not to be particularly happy. This may
explain why abortion has no effect on the marital relations of the couple. However, if
there was a good relationship to begin with, the painful experience served to draw the
couple closer together.
Thus, while variables of husband, religion, conscience, and parents were factors
considered briefly in her decision, these paled against the cost of having another child. It
was this latter consideration which led the woman to make her decision and to proceed
with courage, to carry it out by looking for a provider, contacting her, and making all the
arrangements. This was seen in the stories of the three women.
This consideration sustained her amidst the pain of the abortion itself and the
great fear for her physical safety. And in the end, there was the resolution — never again.
But then many of the women had more than one abortion. Because of the failure or
refusal to adopt a more effective contraceptive method, and above all, the continued
presence of poverty, hardship, and irresponsible sex partners, makes this resolve a
difficult one to attain (ISSA, 1989).
 According to a Roman Catholic priest, who is also a medical doctor, stated in a
recent public forum that only about 15% of Filipino Catholics know of the official church
position on Family Planning, and of that number, only half will obey these dogmas. He
further stated that only about 7.5% of the 62 million Filipinos (or the 14.6 million women
of reproductive age) are actually resisting Family Planning in the Philippines (Choices,
1993). But even if religion seems to be a factor, in the final analysis, a woman makes her
decision in a private world where her utmost need for abortion outweighs her religious
convictions.
"In one local study in Mindanao, when women were asked whether they were in
favour of abortion, an overwhelming majority of the respondents answered no (ie. for it is
against the law of God), but if these women were faced with unwanted pregnancies due
to health or economic reasons, there would be a considerable number that would be
forced to make the painful choice of abortion. (Sanchez, 1992)
Not enough multiparous women are protecting themselves from unwanted
pregnancy, although many no longer want additional children. So, the possibility of
another unwanted pregnancy is not remote. Sexually active teenagers are also vulnerable
to unintended pregnancy. Furthermore, despite a reported increase in the proportion of
women using effective contraceptive methods after an induced abortion, still many of
them are unprotected and ignorant of what to do to effectively manage their fertility. And
many of them also resort to repeated abortion as a means of fertility regulation.

RECOMMENDATIONS

What concrete and women-responsive actions can be done to minimize the occurence and
the effects or consequences of unsafe abortion?
Some approaches and strategies which can be recommended are as follows:

IMPROVEMENT OF HEALTH SERVICES

Health information and care must be accessible, available, appropriate, and client-
oriented to women, regardless of age, marital status, socio-economic class, religious and
other beliefs, and other possible characteristics. These services must be provided by
trained, competent, and humane health professionals and workers. Choices must be
available and affordable for various situations and life-styles throughout the life cycle of
a woman. Women and men should be guided to make their own informed decisions, and
should be supported in the implementation of that decision at different stages of their
lives. And the sexual partner must also be involved and must take his responsibility
seriously. Family Planning Clinics or Programmes have to be transformed to be more
responsive to the various health needs of women in their communities.
Information, education and communication (IEC) activitives on reproductive
health should include teenagers as well as women at high risk of getting pregnant (sex
workers, entertainers, etc.), as well as those at high risk of having pregnancy and delivery
complications. Negotiation, assertiveness and communication skills training would be
quite helpful to these women. Small group discussions, as well as one-to-one, face-to-
face encounters, have distinct advantages over mass media programmes and lectures.
Bringing these activities to where the women live and work at the times convenient to
them, will also bring better results. The men must not be forgotten in these programmes.
Male health workers who are gender sensitive and responsive, have been helpful in
motivating and counselling male clients too.
One condition which often causes dilemma among women and health
professionals is the transmission of Rubella or German Measles to pregnant women. The
effects of this virus can be quite horrible on the fetus. And it can be passed on without
anyone's knowledge. Immunization of girls before they reach the reproductive ages
would be one measure to prevent the need for abortion (Lader, 1966).
When an unwanted/unintended/unforeseen pregnancy occurs, even with the use of
modern methods of fertility management, efforts must be exerted to inform each woman
on the dangers of back-alley abortions. And for those who become so desperate that they
go through these hazardous abortions, proper care must be available as close and as
immediate as possible to these women. Emergency care must be instituted at the primary
level, with proper equipment, drugs, and supplies. The use of non-medical personnel,
including the hilots and the midwives can be encouraged, with proper training. This type
of training can be offered by FPAs like FPOP. But something important in this training of
health providers is the acquisition of the proper attitude towards these women. Role
playing, discussion of cases, showing of movies, and other types of experiential methods
of training, should dominate these courses. Didactic teaching is not effective for changing
attitudes. Training in counselling must also be properly done and evaluated regularly.
Participation of women clients, as well as the men, can also contribute to better training.
An effective and appropriate referral system, should be established, utilized and
monitored, with an eye for continuous improvement. As recommended by the World
Health Organization, the staff of each health facility in the referral system should be well
trained, should be knowledgeable about their specific roles, and should be aggressive in
preventing more suffering and death among these women. Motivation for fertility
regulation and ensuring choices of methods which are safe and effective, should also be a
part of their responsibilities. (WHO, 1992)
Guide manuals for this type of care and for teaching should be formulated. The
FPOP can initiate this, perhaps in lone or a few of their Chapters. Pre-testing and
finalization can be done with the help of the Central Office. Sharing of experience in this
can later be done with FPAs from other countries.
Another very specific measure which can be instituted at clinics and hospitals is
the use of manually operated vacuum aspirators for evacuation of incomplete abortions.
This has been proven to be safe and effective. It will also reduce the cost of management
of women with this condition, in terms of the time and resources spent by the hospital
(can be done at the Outpatient Department), as well as the cost to the woman in terms of
time, money, and the pain from the procedure. Training to operate these modern
equipment is not expensive financially and time-wise.
The use of risk-approach in the management of septic abortion has been
recommended. This will include the institution of more effective antibiotics and other
drugs and procedures for all women who are suspected of having had an induced
abortion. (Unpublished Proceedings, ReproCen Case Discussions, 1993)
Integration of discussions on ethical considerations in abortion and other
reproductive health issues, should be made in the health care delivery, as well as in the
teaching of health professionals and in research activities for the improvement of care
given to women.
ADVOCACY

Where the laws are restrictive on abortion practice, Cook suggests three approaches:

1. development of medical standards on the management of women who had abortion;

2. executive clarification; and
3. judicial interpretation
(as cited in Tadiar, 1989).

A definition of a pregnant woman's health compatible with the WHO approach,

based on fruitful discussions on the issues of life versus health, physical versus mental
health, can be formulated, Cook recommends. As to executive clarification, Tadiar says
that this has already been done in the Philippines. In 1973, the then Secretary of Justice
declared that tubal ligation and vasectomy do not constitute a crime of mutilation, paving
the way for surgical sterilizations to be made available. The possibility of seeking an
instruction from the present Justice Secretary to prosecutors that no prosecution of
women or abortion providers be made without constitutionally admissible proof of
pregnancy should be explored, according to Tadiar. But he cautions that the
independence of mind and receptivity of the official should first be determined. With the
Local Government Code in place, it may be possible to identify some officials who can
execute such a policy in their territories. These officials should be invited to discussions
on reproductive and other health issues.
An important activity which women's groups in Metro Manila have already been
doing, is the conduct of discussions on abortion, and involving media, health and legal
and social science professionals, as well as other sectors, with the active participation of
women, including those who have experienced abortion possibly. More discussions and
in other places of the country can be sponsored by FPOP. A recent project of ISSA and
some consultants, was to seek consultation of NGOs and other groups, on a possible
legislative and executive agenda. Decriminalization of abortion, particularly in cases of
rape and incest, was a demand that was found in these consultations. This issue also came
out in the regional consultations held by the Alliance for Women's Health in preparation
for the Beijing 1995 International Women's Conference.
Tadiar has recommended that the government "seriously examine the policy of
the Population Commission which totally rejects abortion without qualification." It is
simply wrong, he says, to impose a public policy based on a moral view upon which no
general consensus has been reached. The Population Commission is under a new
leadership, and discussions on its vision, mission, policies and programmes have included
women's rights activitists' participation. It is hoped that besides the Department of Health,
the Population Commission would also embark on activities which would respond to the
plight of women who seek abortion and suffer from the consequences of unsafe
procedures. Prevention of the need for induced abortion should be included in their
programmes. And these women or girls should not be punished nor considerd as
criminals. Lader also declares that no religion should use the power of law to force its
belief on others (1966). Therefore, the government must protect its citizens' right to
determine the size of their family according to their own religion.
 Close monitoring of bills and resolutions filed in Congress and other policy
making bodies should be actively, vigorously, and continuously pursued by women and
health activists to prevent enactment of laws which will curtail the freedom and the
exercise of the rights of women. Training in advocacy and implementation of advocacy
and networking programmes among women's groups and others, not only in the urban
areas, but also in other areas, are important. Women must be empowered to make
decisions for themselves. And government officials should consult them and involve
them in any law, policy, or programme which affect their lives and health.
To be effective advocates for the promotion of their health and rights, women
should be prepared with/and utilize accurate and adequate data and information in
making their position papers. They should also be able to help draft bills, laws, and other
policies. This of course will involve research.

RESEARCH

Improvements in health care, information, laws, and policies can only be made when
relevant information is properly collected, analyzed and interpreted. WHO has a list of
possible research topics for the prevention and management of unsafe abortion (1992). In
addition, the following information may be gathered in the Philippines through surveys,
focus group discussions, review of records, or other methods of research which can be
done by FPOP:

 Attitudes towards abortion and women who seek care for complications;
 Staff's perception of the seriousness and need of care of post-abortees;
 Waiting time - from admission to treatment, treatment to discharge
 Presence and condition of essential supplies;
 Gestational size/age at which women present for post-abortal care;
 Length of delay from onset of bleeding or symptoms to care;
 Community perceptions of quality of care and access;
 Trends in Case Fatality Rates from Abortion;
 Regrets after sterilization post-abortion;
 The use of antibiotics in post-abortion;
 Factors most important to women who seek care for complications of abortion;
 Patterns of coping with delayed menstruation; and
 Patterns of seeking care among pregnant adolescents.

The list is by no means complete. It would actually be better for each FPOP Chapter
to think about what issues or topics they would like to make studies on, depending on
their own needs and situation. Case studies would be helpful in discussions and teaching.
Writing up of women's experiences would also be a useful project for FPOP.
Presentation of findings to concerned individuals and groups should be an important
part of any research activity. An improvement of care, of laws, policies, and programmes
for women who may be prone to or who have sought abortion services, or even for all
women of reproductive age, should be the main objective of these studies. Changes based
on the information gathered should be implemented properly and evaluation of these
changes should also be niade. Ethics in research should also not be neglected.
CONCLUDING REMARKS

Abortion has been recognized as a significant public health problem. This means that
systematic, well organized efforts have to be exerted by groups of individuals and
organizations, in order to address the problem. It is a serious problem in terms of the
health and life of women. It affects great numbers of women, particularly in developing
countries where abortion is not legal and where adequate information and services to
prevent its occurrence is not in place.
The experiences of Erlinda, Belen and Rose are typical in the Philippines. Their
stories should impress upon everyone that a lot of work needs to be done to prevent or
minimize the suffering they have undergone.
While there have been a lot of initiatives, particularly by women's groups, in this
direction, we need to join hands with others not only within our country but also across
oceans where our sisters also suffer from the consequences of unsafe abortion or where
they still meet various difficulties even with the legalization of abortion. We must share
our experiences and learn from each other.
We can help each other respond to and address our own needs. But we would be
stronger and perhaps achieve our priority goals, if there are others who would encourage
and support us in our work to gain reproductive health and to exercise our rights.

REFERENCES

I. BOOKS

Danguilan, Marilcn J. Milking Choices in Good Faith. Quezon City: Woman

Health Philippines, 1993

Moore, Kathryn (ed). Public Health Policy Implications of Abortion: The

American College of Obstetricians and Cynaecologists. Washington DC:
January 1990

II. JOURNALS/MAGAZINES/NEWSPAPERS

Cabusao, Sharon. Shadows in the Abortion Debate. Laya Feminist Quarterly,

3rd Quarterly, Vol 1 & 3

Department of Health. An Overview of the Philippine Demographic Situation

and Population Programme Developments, Philippines 1990

Dixon-Mueller, Ruth. Abortion Policy and Women's Health in Developing

Countries. International Journal of Health Services, Vol. 20, No. 2,1990

Marquez, Nelia et al. Statistics on the Filipino Women. National Statistics

Office: Manila, Oct 16,1992
 Robles, Gemma Luz. Abortion A Problem Now More Than Ever. Sunday
Chronicle, Manila, Philippines, Oct 10,1993

III. PAPERS/RESEARCHES/STUDIES

Boscarino, Joseph. The Public's Rating of Hospitals. New Jersey, Summer 1988

Dela Rosa, Martin. Induced Abortion: Is It Really a Problem? National

Conference on Safe Motherhood, 1987

Flavier, Juan M. and Charles H.C. Chen. Induced Abortion in Rural Villages of
Cavite, the Philippines: Knowledge, Attitudes and Practice. Studies in Family
Planning, Vol. II No. 2, Feb 1980

Gallen, Moira. Abortion Practices in the Philippines: An Exploratory Study

among Clients and Practitioners. Circa 1979. Philippines: The International
Committee on Applied Research in Population (ICARP), May 1980

Herrin, Alejandro, N. et al. Health Sector Review: Philippines. Health Finance

Development Project, March 1993

Institute for Social Studies and Action. A Research Study on Fertility

Management with Emphasis on Induced Abortion. Quezon City: Institute for
Social Studies and Action, 1989. (Unpublished Paper)

International Fertility Research Programme. Traditional Abortion Practices.

USA, 1981

Interregional Workshop and Participation of Women in MCH/FP. Philippines

Country Report, Egypt, 1991

Manalo, Augusto. Outline of A Paper on Ethics of Reproductive Health Care,

Teaching and Research. Manila, Philippines

Maranon, Amelia, et al. Compiled Studies on Voluntary Interruption of

Pregnancy (VIP) in the Philippines (1978-1982). Philippines: Kabankalan,
North Cotobato, Menstrual Regulation and Fertility Research Center and
Southern Mindanao Agricultural Research Center of the University of
Southern Mindanao, April 1983

Marcelo, Alexandrinn B. Attitudes and Perceptions Towards Induced Abortion:

The Women, Professionals and the Public. Paper Presented at the ISSA
Conference, 15 March 1991, NEC, UP Diliman, Quezon City
Perez, Aurora E. Filipino Adolescent Sexuality and Reproductive Behaviour:
Policy and Programme Implications. Quezon City: University of the
Philippines Population Institute, 1992

Report of the Technical Working Group. The Prevention and Management of

Unsafe Abortion. Geneva, 1993

Sanchez, Rosena D. An Analysis of Women's Health Situation in Six Selected

Communites in Mindanao, Philippines. Davao City: Women's Studies and
Resoruce Center, 1992

Tadiar, Florence, M. Factors Affecting Filipino Women's Health. Paper

presented at Jakarta, Indonesia, Oct 29-31,1991

Tadiar, Florence, M. The Filipino Women's Access and Utilization of Health

Services for Reproductive Care. University of the Philippines, May 1993