This article written by Prof. Mary Racelis (IPC’s Research Scientist) was originally published on Panorama, The Manila Bulletin’s Sunday magazine, last 7 August 2016. An online version of the article is also available at <http://www.mb.com.ph/all-systems-go/>.
All systems go?
by Mary Racelis
Although the Responsible Parenthood and Reproductive Health Law (RA 10354), passed in 2012, gave hope and added services to many Filipino couples, many remain unserved. Why, one might ask, do some couples not take advantage of the apparently revitalized reproductive health opportunities? In particular, will they adopt modern methods of family planning now that it’s “all systems go?”
President Rodrigo Duterte’s SONA statement ordering the full implementation of the RH law speaks directly to advocates and, most important, the less fortunate families who will benefit most from it. It also warns government officials blocking its implementation that they will have to reckon with the President and the law if they continue their opposition.
A first supportive step would be the Supreme Court’s lifting the temporary restraining order still preventing effective implementation of the RH law. Other crucial actions call for substantially improving and providing access to health delivery systems so that underprivileged couples, who need them most, gain full access to modern family planning.
Nonetheless, cultural considerations also need to come into play for a better understanding of the socio-cultural dimensions underlying the apparent reluctance, apathy, or inaction still preventing many women and couples from making informed family planning decisions on the number of children they want, when they want them, and when they believe they can properly care for them.
Recent statistics show that as of 2013, some 55 percent of married Filipinas 15-45 years old were using a method of contraception, with 38 percent relying on a modern method. That means for the latter one or more of the following: pills, IUD, injectables, implants, condoms, sterilization, long-term breastfeeding after birth (LAM), and natural family planning. Meanwhile, 18 percent relied on traditional methods: withdrawal, rhythm, and a range of folk practices.
Unmet needs apply to 18 percent of Filipinas who wanted to delay having another child or stop having children altogether but were not taking any action on them. Of the non-users, 41 percent affirmed they would get into modern family planning, while 56 percent expressed no intention to do so. Why is that?
Before answering the question, let us first look at teenage pregnancies in the Philippines. In 2013, among girls 15-19 year olds, one out of 10 was pregnant with her first child or was already a mother. According to the 2013 National Demographic and Health Survey, 36 percent of women in the lowest wealth quintile reported having their first intimate sexual experience before age 18, compared to 10 percent for the highest quintile. Two percent, or 3,231 girls, initiated their sexual activity before turning 15.
Sheer lack of information plus prohibited access to government contraceptive programs render adolescent girls particularly vulnerable to a boyfriend who urges her to prove her love for him through sex. Many a dalaga has succumbed to the mistaken belief that her first sexual encounter would not result in a pregnancy. The need for sex education in schools is clear yet remains a contentious issue. Accordingly, many young people engage in pre-marital sex without fully comprehending what they are getting into.
Why, then, these gaps for both adults and youth?
Hurdles to modern family planning, contraception in particular, emerge for many reasons. These range, on the one hand, from inadequate or inefficient health delivery systems and couples’ limited access to supplies and information, as well as to socio-cultural realities embedded in the everyday lives and psyche of Filipinos.
INADEQUATE HEALTH DELIVERY SYSTEMS
Relevant here are people’s access to quality health services including knowledge and information. Certain characteristics of the population affect accessibility. Rural folks are less knowledgeable and informed than their urban counterparts and therefore participate less in family planning programs. Regional differences matter, too, with the highest contraceptive prevalence rates seen in Eastern Visayas, Cordillera Autonomous Region, Central Luzon, and Metro Manila; and the lowest in ARMM. Various levels of service delivery and, particularly in Mindanao, armed conflicts partially explain these findings. Also making a huge difference is education. Better educated women are more likely to engage in modern family planning than those with little or no schooling.
These are the elements that need much greater study and understanding in any investigation of family planning acceptance or rejection. Key components cover the effects of religion, the fear of side effects, male power in husband-wife interaction, and values related to the family and children.
The effects of religion. Religion in our predominantly Catholic country is widely believed to be a major cause of resistance to contraception. There is insufficient evidence, however, to show that Filipinas’ decisions are affected by the Catholic stance on family planning.
Social Weather Stations’ 2011 data show that 82 percent of Filipinos believe that “the choice of a family planning method is a personal choice of couples and no one should interfere with it.” Some 73 percent agree that “if a couple wants to plan its family, it should be able to get information from the government on all legal methods.” Meanwhile, 68 percent also agree “the government should fund all means of family planning, be it natural or artificial means.”
Clearly, the great majority of Filipinos, spanning all classes, wants access to family planning and feels they are in the best position to decide on the matter. Catholic women at all economic levels thus adopt contraceptive practices, given their ability to access the system, and because they are insistent on exercising their right to decide on how to manage their families and the number of children they want.
But the official stance of the Catholic Church, as an institution that condemns contraceptive use, does have a bearing on government family planning programs and policies. Its strong anti-contraception initiatives continue to keep the Catholic position in the forefront, reminding political figures (those who make and implement laws) and medical practitioners (who implement programs) of their duties as Catholics.
A few anti-family planning mayors have in fact curtailed the implementation of contraceptive services in their cities. In February 2015, current Sorsogon City Mayor Sally Lee signed Executive Order 3 declaring Sorsogon City as “pro-life.” In February 2000, former Manila City Mayor Lito Atienza issued Executive Order 0003, which stated that Manila would take an “affirmative stand on pro-life issues and responsible parenthood.” As a result, Manila City health services would promote only natural family planning.
A number of women living in Manila therefore lost access to contraceptive services and found themselves pregnant with another child which they had not planned. It is likely that despite abortion’s being illegal and strongly condemned by the Church, some were driven toward undergoing the procedure as their “alternative family planning” choice—with often drastic consequences for the mother’s health and even life.
Ironically, by banning contraceptive services, “pro-life” forces in effect aided and abetted women’s decisions to seek unsafe and illegal abortions as their only way to prevent another birth. In 2014, an estimated 610,000 Filipinas resorted to abortion, the vast majority of them poor and Catholic. Over 100,000 women were hospitalized and three women died every day from the complications of unsafe abortions. Understandably, the Convention on the Elimination of Discrimination Against Women (CEDAW) recommended in 2014 that the Philippines amend Articles 256 to 259 of the Revised Penal Code to “legalize abortion in cases of rape, incest, threats to the life and/or health of the mother, or serious malformation of the fetus, and decriminalize all other cases where women undergo abortion.” Its recommendations for even this modified rationale, however, found little support in official circles.
Fear of side effects. Another powerful deterrent to using contraceptives is women’s fear of side effects. Stories make the rounds that the use of certain contraceptives brings irregular or heavy bleeding, spotting, weight gain, mood changes and depression, nausea, dizziness, breast soreness, and even ovarian cancer. Although countered by family planning health workers, fear of these occasional consequences acts as a deterrent to some women as well as their husbands.
Pagkalalake and husband-wife dynamics. Gender-linked elements also come into play when men object to their wife’s interest in modern family planning. While in some cases, side effects may dominate the men’s argument, stronger but hidden reasons for their opposition often come from perceived threats to their role as household head with major decision-making authority.
Anecdotal evidence abounds in stories related to the author by urban poor women describing their husband-partners’ reactions to sex and family planning.Take for instance one poor unemployed, unmarried husband’s reaction when his wife-partner mentioned that she wanted to go for family planning after the birth of their second child. Supporting her query was their having already given up the new baby to relatives to raise (pina-ampon), with the remaining two-year-old languishing in a severely malnourished state.
The husband’s reaction: “Kung ayaw mo mag pa buntis sa akin, aalis na lang ako. Maghahanap ako ng iba! (If you don’t want to get pregnant by me, I’ll leave and look for another woman!)” Another lady recounted her husband-partner’s response to family planning: “Kaya ayaw mo mag-kaanak, siguro may ibang lalake ka. Baka gusto mo mag buhay dalaga! (If you don’t want to give birth to my children, you must be interested in another man. Maybe you want to behave as though you’re single again!)”
On the other hand, this is one woman’s reply to her drunken husband demanding sex: “O sige, bubuntisin mo ako, ikaw mag-alaga ng anak. Maghahanap na lang ako ng trabaho. (All right, if you get me pregnant, you be the one to take care of the children. I’ll be the one to look for a job).”
And she did.
Clearly, while family planning programs and Church pronouncements have generally focused their attention on women, the problems of responsible parenthood all too often originate with the uncooperative attitudes of uninformed men insecure about their traditional manhood rights. Men may interpret a woman’s desire to use contraception as a threat to their manhood, or pagkalalake. Men also fear that their partner’s access to contraception will encourage her to have affairs with other men. A source of pride is having a large number of children as evidence of their virility. Little wonder that women faced with these countervailing male reactions decide openly or secretly to opt for contraception, the pill being most preferred and, increasingly for older women, sterilization.
Views about family and children. Finally, the value of children and families enters into decisions about resorting to modern family planning. Children are seen as gifts from God. Traditionally, a big family is regarded as bringing great happiness. But attitudes are changing, especially among poor women faced with the wrenching daily task of having enough food for their hungry children and locating money for school lunches. More and more women choose modern family planning as they become better-informed, gain access to appropriate services, and take stronger decision-making roles in the family and community. Women’s empowerment matters.
In conclusion, reproductive health programs and Philippine society at large need to take both health system access and socio-cultural factors into account when encouraging more women and couples to commit themselves to a better life for their children and families through modern family planning. Improving basic health and family planning systems along with a better understanding of socio-cultural blocks and how people overcome them will go far toward fleshing out President Duterte’s call to put RA 10354 “into full force and effect.”
This means advocates and those most affected—poor women and couples—must continue raising and expanding demands for access to well-developed modern family planning programs. As a well-known adage says, “It’s the squeaky wheel that gets the oil!”
Dr. Mary Racelis is research scientist at the Institute of Philippine Culture and professor of Social Anthropology at the Department of Sociology and Anthropology, Ateneo de Manila University. She also teaches at the University of the Philippines-Diliman Department of Anthropology.