Maternal Health in the Philippines and the Responsible Parenthood and Reproductive Health Act

I have a traumatic birth story. I had just given birth and was barely getting to enjoy my first few moments with my newborn daughter when complications arose, and I suddenly started hemorrhaging. I lost consciousness and sporadically regained it. At one point I begged the medical team to not let me die before I lost consciousness again. I was lucky. I was given a transfusion, the obstetrician managed to stop the hemorrhage, and I recovered slowly. I left the hospital with my baby. My bill was $0.

I am grateful for how fortunate I am, but as it sometimes happens when you think of how fortunate you are, your mind turns to those who may not be. I think of my fellow Filipinas in the Philippines who struggle due to poverty, exclusion, and/or lack of access to health care. How some have to give birth in less than ideal situations with extremely limited resources.

Post-partum hemorrhage is listed as the third top cause of maternal deaths in the Philippines. The heartbreaking thing about maternal mortality is that it is preventable with safe, accessible maternal care.

Because of this, it has been suggested that maternal mortality is an indicator of the disparity between the rich and the poor. Poor women have double the lifetime risk of maternal death, have a higher likelihood to deliver at home without the assistance of a skilled birth attendant, have higher teen and unplanned pregnancies and higher fertility rates in comparison to wealthy women (Philippine Statistics Authority, 2014, as cited in the article “Maternal and Child Health Promotion for the Ifugao in the Philippines by Ngaya-an, Paqui ao, De Torres, 2017). Poor women also have a higher chance of having their family planning needs unmet. Contraceptives prevent unwanted pregnancies and maternal and child deaths (Singh, Darroch, Ashford, and Vlassoff, 2009, as cited in Ngaya-an et al., 2017). The impact of this is far reaching. By preventing maternal mortality, family health improves.

In 2012, The Responsible Parenthood and Reproductive Health Act (RH Law) was signed into law by President Aquino. The law promised universal access to contraception, fertility control, sexual education and maternal care. However, its implementation was delayed due to challenges filed by those who opposed the law, led by the Catholic Church. In 2014, the Supreme Court ruled the law was “not unconstitutional” and therefore the law was upheld (Ngaya-an et al, 2017).

In December 2017, I first connected with Samantha Gagnon, a doula and founder of The Maya’s Nest Birth Services, when she posted in a Facebook mom’s group we both belong to. She posted that she had had the privilege of teaching a class and visiting a birthing centre run by an organization called Glory Reborn in her hometown of Cebu that same month, and how the experience had moved her. It was timely because it was at the same time that I was reflecting on and processing my birth story. Samantha spoke of how there was little to no prenatal education in Cebu. Most of the education was focused on breastfeeding, not so much on the birthing process. Samantha travels yearly to help provide these classes. The couples who attended her most recent privately-taught classes were generally educated, wealthier, hetero; despite this, there were still knowledge gaps. “I spoke about everything from induction, pain management, vagina[l] exams, newborn procedures, delayed cord clamping, CS (C-section) options - basically the most common things that come up, and often-used interventions that we have a choice over but may not realize it. And explaining the evidence behind things.”

Samantha said she found that many of the practices that medical professionals are trying to move away from in North America are still being done in the Philippines. One example she gave were episiotomies. An episiotomy is a surgical cut done at the vaginal opening during child birth to help with a difficult delivery and to prevent the rupture of tissues. Previously, episiotomies were done routinely because the logic was a “clean” cut would heal better than a tear. However, research has shown this is not the case and that a natural tear heals in the same amount of time as an episiotomy if not faster and have fewer complications. In an article by Trinh, Roberts, and Ampt (2015), they suggest that the reason this practice may persist is because of lack of training, difference in culture and tradition, fear of injury to the perineum (the area between your vaginal opening and the anus), or differences in physiology between Asian and Caucasian women. To the latter, Samantha states “…medically and physiologically speaking, there’s no reason a Filipina vagina can’t stretch the same way western vaginas can.”

Samantha further explained that “Filipinos are amazing respectful people, and especially so with professions like doctors. I think a part of the problem is not wanting to be rude, and it seems that asking questions can be construed that way.” I can understand this hesitancy to question figures of authority. I work as a frontline social worker in a hospital and work with Filipino patients on a regular basis and I have also seen this implicit trust and hesitancy to ask questions. Coupled with gaps in knowledge and not knowing what to ask for or what questions to ask can have great impact.

I also spoke with Amina Evangelista, the Director, and Justine Fonte, a board member of Roots of Health located in Palawan. They offer prenatal education and health services, referrals to appropriate health providers for high-risk pregnancies, postpartum follow up and well-baby checkups, as well as funds, if needed, for women with high-risk pregnancies to deliver in a hospital. In addition to these services, Roots of Health provides sexual education to youth in Palawan, which has one of the highest teen pregnancy and HIV rates in the country.

In a similar vein, Amina and Justine discussed the knowledge gaps and in particular, the stigma, attached to contraceptives. In the documentary Motherland, when the mothers were offered contraceptive methods such as IUDs or implants, they hesitated - and most, ultimately refused. In a study done by Cruz, Marquez, and Kabamalan on women’s choice of contraception in the Philippines, the most common reasons why women chose traditional contraceptive methods (i.e. rhythm method and/or withdrawal) were fear of contraceptive side effects, lack of knowledge on different methods, and inconvenience of use. Remember how the Reproductive Health Law promised universal access to contraception and sex education? Justine stated that urban areas have been implementing this due to better access to resources, but the provinces are being neglected. One of the factors that Justine attributes this to is the hold the Church continues to have on Filipino society. In a news story by Al Jazeera about the continuing rise of teen pregnancy in the Philippines (which features Amina), Amina discusses how the local government in Palawan does not allocate much funds towards teen pregnancy prevention programs and contraception. Cue the Vice Governor of Palawan, Dennis Socrates, who explains that the focus should be on a “more intensive information and education campaign to tell young people that sex is good but it has be within the context of a loving and indissoluble marriage and it must be open to life, to parenting which is the natural consequence of that marital act” to which the reporter replies “so abstinence until marriage.”

There is stigma still attached to purchasing contraception, in particular, Justine suggests, if you are young and unmarried. I presumed this stigma was more attached to women of lower income trying to access birth control due to the lack of education around it. However, Amina further clarified, “it's a bit of a mixed bag with higher income women. Some are more open and liberal, and don't have any issues with being honest about sexual activity and the need for contraception. But many wealthier women are more concerned with appearances and/or with the Church, so are outwardly more negative about contraception.” I was further surprised when Amina stated that wealthier women were some of the biggest opponents of the RH bill. “Poorer women were too busy making ends meet and getting by day-by-day to get involved in policy debates.” After watching the Al Jazeera report, I had assumed that the classes for youth provided by Roots of Health may be met with challenges, but Justine discussed how the feedback has been positive in regards to providing reproductive health education and their reach now extends into the Visayas, with Roots of Health continually being invited into colleges and high schools.

As a frontline social worker in Canada, I was curious as to what work on the ground looked like in the Philippines particularly around labour and delivery. Amina stated that women have the option of three hospitals in Palawan: a public hospital and two private ones. If the pregnancy is not considered high-risk, women can choose to deliver in many lying-in clinics, which are small clinics staffed by midwives. Women can also deliver in some government barangay health centers if they are accredited for deliveries, but there is a small fee attached to this. “Most women prefer lying-in clinics. However, many of the women we serve must give birth in a hospital because their pregnancies are deemed high-risk, so the majority of births we facilitated last year were in the government (public) hospital,” Amina stated.

“A lot of the women we work with who are Indigenous People (IP) have reservations about delivering in hospitals. They are generally more conservative and the men don't like the fact that their wives could be semi-naked and viewed by male nurses or other men around in hospitals. A lot of lower income women also don't like hospitals because they aren't always treated very respectfully. We hear a lot of stories of hospital staff being rude to poor patients and humiliating them for having many children.”

I asked about the cost of giving birth and how the women they work with raise the funds needed to deliver in a hospital. "Truthfully, they don't usually manage to raise the funds so then when they give birth if they have high bills, they borrow money, or go to local politicians or the local charity sweepstakes office to ask for help in paying their bills. If they have Philhealth coverage they should have zero balance billing if they're at the public hospital. But if they have to have a Cesarean or any other procedure, their bills become much higher.”

According to Amina, Philhealth costs P2,400 (about $44 USD) per year and has a maternity package that pays for the cost of having a normal delivery in a hospital. Amina said that they found most women can't afford to pay for health insurance themselves, so Roots of Health will buy it for women with high-risk pregnancies. In the case of very poor families, the government provides this coverage. However, encouraging people to get health insurance is difficult. “It's quite hard to sell the idea of insurance to very low-income people. They often ask us, If we don't get sick, will they give us the money back? And when we say no, they opt against prioritizing it themselves.” Amina went on to say that despite their generous maternity and dengue package, Philhealth only provides coverage if the patient has a serious illness that requires a hospital admission longer than 24 hours, and not any outpatient care. Understandably, when you’re just trying to survive, paying for something all year that you may benefit from only when you give birth is a hard sell.

When speaking about the health of Filipinas, it would be remiss to not discuss the impact of colonization on the status of women. Prior to the arrival of the Spanish, women were of equal status and were able to hold positions of power. With the arrival of the Spanish and the Catholic Church, this all changed. Women were relegated to the domestic sphere and the expectations of how a woman should act and the role of women in society still persists to this day. It wasn’t too long ago that Carlos Celdran, artist and reproductive health advocate, held up a placard at a Mass in Manila that simply stated Father Damaso, the antagonist of Jose Rizal’s Noli Me Tangere, in protest of the Church’s stance on RH law. Father Damaso’s character has come to symbolize the abuse of power by the Catholic Church and its clerics.

It’s why, as Samantha said, Filipinos are respectful people who hesitate to question authority even at the risk of their own health. It’s why stigma is still attached to contraceptives. In 2016, the health department’s $21 million contraceptive budget was cut, though Rodrigo Duterte, the current president, has promised to make free birth control and reproductive health services accessible. In 2016, the health department’s $21 million contraceptive budget was cut. Abortion remains illegal in the Philippines and it is quite telling when a provision has to be included in the RH law that states women needing post-abortion care shall receive care that is compassionate, non-judgmental and humane. All this has led to putting more women at higher risk for maternal mortality, in particular the most marginalized of women. I find it hard sometimes to reconcile how an institution can simultaneously give hope to these women and families, yet perpetuate the oppression of them. I believe if you’re going to be pro-life, then that should go hand in hand with being pro-affordable, accessible contraception and sex education.

I asked all three women what can we, as Filipinas living in the diaspora, do to help these women in the Philippines? Upon reflection, I realized that it’s a broad, large question. Each woman provided a different response.

Samantha responded that at the very least, women should encourage their family members or pregnant women living in the Philippines to ask questions, “by simply learning how to ask questions, it can make a huge difference.”

In reference to Roots of Health, Amina states “the biggest help to us would be financial support…the biggest help are cash donations and also donations of supplies like contraceptives or prenatal vitamins.” I really admire the work Roots of Health has done in Palawan and as a frontline social worker, the work of the Community Health Workers resonates with me the most. In a study done by Ngaya-an et al of Ayods (community volunteers) providing maternal and infant care for the Ifugao, it was found that Ayods were trusted by their communities because they were entrenched within their communities and familiar with its cultural norms, and thus able to advocate for the specific needs of their community. In a similar vein, Amina states, “if we had to close up shop tomorrow, the CHAs would still be in our communities and able to assist their neighbors with information or referrals for care. As you noted, being in the same community as the women we serve, they're also able to help us inform our programming to make sure it is the most relevant and appropriate given the needs of our clients.”

When Justine was asked the same question, a highlight of her response was “to smash the patriarchy”. Justine stated that maternal health is not a Filipina issue, but a human rights issue. She also stated that shaking off the oppression women face can be slow moving. One of the challenges organizations like Roots of Health face is raising funds for something that has not yet happened. Trying to garner support for preventative services, such as sex education and programs that provide free or affordable contraception, is difficult. Justine explains, “it's hard to fund something when success of it means nothing bad happens. Prevention work is thankless.”

Inequities related to maternal health doesn’t just happen in developing countries. When I was in the middle of writing this piece, it was Black Maternal Health Week in the U.S. As I came closer to finish writing this article, a Mom posted in the Mom’s Facebook group Samantha and I belong to about Ireland and how the country is about to vote on whether to legalize abortion or not. Women in Ireland have to travel outside of Ireland to the U.K. to have an abortion. In my own country of Canada, Indigenous women struggle to access culturally appropriate health services and have a higher maternal mortality rate

When a mother dies a preventable death or suffers ill health due lack of pre and post-natal care, it can have serious implications for the family unit that can have significant impact. For example, if a mother dies, and the baby does not have access to breastmilk and needs to drink formula, this is a financial cost that some families cannot bear. It is especially concerning if there is no access to clean water. The change of dual income to a single income family can impact a child’s (or children’s) ability to get a proper education which has far reaching, possibly intergenerational impact.

So when I reflect on what I can do to help, I am at a loss. I acknowledge that I am a Filipina living in Canada, examining this issue from a North American lens. I understand that I may not know all the nuances of the issues that impact maternal health in the Philippines and carry my own bias. I was overwhelmed writing this article because it became apparent that “smashing the patriarchy” is a big endeavour to say the least. I have some funds that I can donate and perhaps in the future when my own baby is older, I can give of my time as well. I know speaking out about the Catholic Church goes against my upbringing and portraying them in a critical way might not win me friends. But, I can’t sit here silently. All I can do for now is bring attention to the issue and give an introduction and food for thought.

My husband said that when I lost consciousness, they asked him to step outside so they could work on stopping the hemorrhage. I imagine him sitting outside in the hallway, holding our newborn daughter, when it should’ve been a time of being together in joy and happiness. I ask my husband sometimes, when I’m trying to process (still, 20 months later) what happened, “were you scared?” He always says, “no. I knew you were going to be ok.” I imagine my husband’s confidence came from the fact that he knew we had access to the best health care from the moment we made the decision to have a child all the way to the moment I gave birth. We live in a society that affords us the opportunity to make decisions about our reproductive health (though the most recent news coming out of the U.S. with funding cuts to Planned Parenthood is disheartening). Until women in the Philippines can access some of the same luxuries afforded to us, they will unfortunately continue to suffer.

Rosanna Tecson

Rosanna Tecson is a wife, mother, and fledgling writer born and raised in Canada. Since her daughter was born, she has been reflective of motherhood and her Filipina identity. Through writing and storytelling, she hopes to make sense of this journey.