Tag Archive | "maternal death"

Paalam, Soledad


Based on true events, “Paalam, Soledad” follows the struggles of Sister Soledad with her faith and her principles amidst the realities of Santa Clara, a small town ruled by closed minds, false hopes and repressed sexuality. [YouTube’s block has been resolved; this video is now viewable.]

Scene Selection

Group song welcoming people to Santa Clara (3:12)

First Act: Baptism (11:28)

Priest sings about sacrifice and the original sin (22:19)

Sister Soledad sings about the morality of changing and loving our bodies (24:50)

Second Act: Marriage (31:22)

Four women confront Sister Soledad about how society unfairly blames women (40:08)

Third Act: Funeral (46:49)

A happy, naughty song about the IUD (47:52)

Priest and mayor sing about their mutually beneficial partnership (1:05:05)

Finale: people sing about their hopes for Santa Clara (1:16:11)

Credits (1:20:24)

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Anti-RH Spin to Make Your Head Spin


Fr. Melvin Castro, an official of the Catholic Bishops’ Conference of the Philippines (CBCP), argues that the RH bill is not needed since maternal deaths have declined significantly, and the government only needs to improve existing reproductive health services for women. For the past few weeks, anti-RH campaigners were also arguing that the RH bill is not needed since it duplicates existing laws, policies and programs of government.

Now let me see if I can make sense of the anti-RH side’s “not needed” arguments:

  1. the RH bill duplicates existing laws, policies and programs (LPPs)
  2. which succeeded in reducing maternal mortality
  3. therefore the government should improve existing LPPs
  4. except that the government should not pass the RH bill
  5. not because of religious objections
  6. but because… (back to #1).

Maybe the anti-RH folks enjoy creating twisted mind-benders. Or they’re just patching together anything, coherence and honesty be damned, to obscure the religious nature of their objections.

Based on official government statistics, an estimated 6.5 to 11 maternal deaths occurred per day in 2010. The anti-RH group Filipinos for Life produced a lower estimate by the simple trick of using registered births in its calculation, ignoring the warning from its source, the National Statistics Office, that the published number is lower than actual due to late or non-registration.

Using a new statistical model, the World Health Organization (WHO) did come up with a lower estimate of maternal mortality for the country in 2008: 2,100 at the middle of the range, some 5.8 maternal deaths per day. Because of the inherent difficulties in recording maternal deaths, which the WHO report extensively discusses, varying methods which come up with varying but overlapping estimates is not unusual.*

But on the crucial part of the WHO report, on what has to be done, the anti-RH groups are characteristically silent. Perhaps because at the end of the estimation exercise, the WHO advocated for enhanced commitment to RH measures, almost all of which are in the RH bill. Here’s part of what the WHO said:

The international community has been increasingly concerned about the fairly slow progress in improving maternal health. During 2010, the United Nations Secretary-General launched the Global Strategy for Women’s and Children’s Health, which seeks to catalyse action for renewed and enhanced commitments by all partners for adequate financing and policy to improve women’s and children’s health. The commitments would support the following elements to accelerate progress towards MDG 5:

  • Country-led health plans – development partners to support governments to implement country-led plans to improve access to reproductive health services.
  • A comprehensive, integrated package of essential interventions and services – women and children should have access to a package of integrated services including family planning, antenatal care, skilled care at birth, emergency obstetric and newborn care, safe abortion services (where abortion is not prohibited by law) and prevention of mother-to-child transmission of HIV services.

We have an ongoing tragedy whether 5 or 11 maternal deaths occur per day. Half of all pregnancies are unintended, which means family planning—using artificial or natural methods—can potentially prevent up to half of these deaths. To overcome the routineness of maternal deaths which anti-RH groups exploit, think of the thousands of deaths as two to four shiploads sinking every year. Half of the women do not even want to be passengers at all. And of the willing passengers, more than half can be saved with measures in the RH bill.

——————-

* WHO, using three different methods, estimated the maternal mortality ratio (maternal deaths for every 100,000 live births) for the Philippines at 120–280 in 2000, 60–700 in 2005 and 61–140 in 2008.

Image used: Enrico Rastelli, available at Wikimedia Commons

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Crossing Streets and Maternal Death Risks (part 2)


Hong Kong footbridgeOf around 3.37 M pregnancies that occurred in 2008, 17% led to induced abortions and 14% to unwanted births—more than a million pregnancies that women did not want. Some 92% of these occurred while using no method of family planning, or relying on a traditional one like the withdrawal or rhythm.

The fist half of this article likened maternal risks to similar risks when crossing busy streets. Risk reduction can be done two ways. One, make the process safer. Two, avoid it whenever possible.

Family planning (FP) is the second way. Using artificial or natural methods, it is a means to avoid unintended pregnancies. Using the road crossing analogy, effective FP methods are like overpass walkways that government builds to keep people away from harm. In turn, people need to learn and choose to use them to be of any good.

Relative Risks

An overpass is safer for most people, but is not risk-free. Nothing in life is. The overpass stairs may be slippery. Snatchers may declare the site as their emerging market. Civil engineers may have been sloppy. An earthquake, lightning or bullet from a cop’s warning shot may just strike while you’re in the middle of it. You simply compare all these with the risk of matching your footwork with running vehicles.

The same weighing of risks and benefits apply to all FP methods. For example, users of combined pills do have an increased risk of venous thromboembolism (VTE), a blood clot in veins deep inside the body that is 1–2% fatal. Anti-RH folks have often used this to scare people. What they fail to mention is that drug regulatory agencies have concluded that the increase in absolute risk is small, and that pregnancy confers higher risks of getting VTE than pill use:

Condition Risk of VTE
Not using pills, not pregnant 5–10 cases per 100 000 women-years
Using the most common pill
(low-dose ethinylestradiol + levonorgestrel)
20 cases per 100 000 women-years of use
Pregnant 60 cases per 100 000 pregnancies

 

Contraindications

Using an overpass is also not safe for everyone. Someone on wheelchairs who will try the atrociously steep ramp at the Quezon Avenue-EDSA overpass will probably careen down and break more bones. Urging someone with fear of heights or an asthmatic attack to climb up is courting trouble. Other more sensible methods should simply be made available.

For FP methods and all other medicines, the user may have a condition which makes the drug or procedure riskier than usual. If the risks outweigh the benefits, the medicine is contraindicated, meaning not recommended for use. Since people have unique genetics, medical histories and current conditions, the decision can only be done on a case to case basis.

For example, natural family planning (NFP) is effective for motivated couples. If one or both do not want to use it, the method is contraindicated. The risk of pregnancy would be too high. If the husband is violently uncooperative, the woman gets no benefit at all while risking a whole range of harm. Using the same principles, combined pills are not prescribed to women with pre-existing hypertension because of increased risk of heart attack and stroke; or to women with pre-existing breast cancer because both natural and synthetic estrogens stimulate the proliferation of breast cells.

Policy Choices

“An ounce of prevention is worth a pound of cure” is something we learn in elementary school. When anti-RH folks profess to support safety through maternal care services and in the same breath denigrate the value of family planning, I yearn for the simple lessons of our grade school teachers. The anti-RH position is akin to banning overpass walkways, insisting that people rely on the natural ebb and flow of traffic to safely cross streets, and allaying their fears by saying there will be more hospitals to save and mend broken bodies.

The RH bill’s safe motherhood proposal is simple. Women who are pregnant by choice or circumstance should get the standard care that has made maternal deaths a rarity in many parts of the world. Women who do not want more children or want to postpone the next pregnancy should get the family planning method of their choice to avoid maternal risks altogether.

Make the process safer. Avoid risks whenever possible. Both are needed, both should be done.

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Crossing Streets and Maternal Death Risks


Busy street in ManilaCrossing a busy street and testing one’s agility against vehicles has inherent risks. To minimize these risks, we create structures and social rules such as traffic lights, pedestrian lanes, speed bumps and so on. We also minimize the frequency of exposure to risks. Using overpass walkways, avoiding unnecessary trips and creating better planned neighborhoods are some of the ways we reduce the number of times people and vehicles cross paths.

The reproductive health (RH) bill’s approach to reducing maternal deaths follows the same dual strategy: minimize risks and minimize exposure to risks.

A woman’s lifetime risk of maternal death is a product of two factors: the risk of death from each pregnancy and birth, and the number of times she gets pregnant. The most successful countries in the world have managed to bring down both, and some of our ASEAN neighbors are on the way to making maternal death a rare possibility in a woman’s lifetime (see chart below).

Lifetime risk of maternal death

Source: World Health Organization, UNICEF, UNFPA and The World Bank,
“Trends in maternal mortality: 1990 to 2008”, Annex 1 & Appendix 14, 2010.

 

To reduce the risk of death from each pregnancy, the RH bill mandates:

  • sufficient number of skilled birth attendants (SBAs, referring to midwives, nurses or doctors) that can provide antenatal, birthing and postnatal services (Sec. 5 in both House and Senate versions);
  • enough facilities, equipment, supplies and health personnel to provide emergency obstetric and neonatal care (Sec. 6 in both House and Senate versions);
  • the maximum level of PhilHealth benefits for women with obstetric complications (Sec. 14 in House version and 11 in Senate); and
  • a review process to learn lessons from maternal deaths that do occur (Sec. 9 in House version and 8 in Senate).

Opponents of RH have expressed mixed reactions to this aspect of the bill. Some have accepted it as beneficial and have focused instead on their key issues of contraception, abortion and sex education. Others have branded it as unnecessary or a mere sweetener because the government has been doing maternal health programs without a law; or maternal death is not among the top-10 causes of deaths; or both. To check these claims, let us look at a key indicator of safety during pregnancy and birth: skilled birth attendance.

If women lack access to SBAs, they rely on the hilot (traditional birth attendants) to manage their childbirth and the immediate period after delivery. Unfortunately, around three quarters of all maternal deaths occur during these critical times. A hilot does not have the skills or resources to save women from the usual complications like severe bleeding, convulsions, sepsis and obstructed labor. How a hilot can totally mess up with diagnosing a complication and acting promptly to forestall death can be seen in the documentary Olivia’s Story. Only 37 years old, she died on May 2, 2009 in a poor community in Malabon (yes, hilots ply their trade even in a city in the country’s metropolis) after delivering her tenth child at home.

In 1999, a special session of the UN General Assembly agreed to work towards raising the use of SBAs to 80% by 2005, 85% by 2010 and 90% by 2015. What has the Philippines achieved? In 2008, actual use of SBAs by all women was only 62%, and the poorest women had use rates of only 26% (see chart below).

Percentage use of SBA, Philippines

Source: Macro International Inc, 2011. MEASURE DHS STATcompiler.
http://www.measuredhs.com, June 14 2011.

 

Was the UN target too ambitious? No. Some of our ASEAN neighbors have proven that middle-income countries can attain the goal. Malaysia, Thailand and Vietnam have met or exceeded the target. Indonesia is behind but has performed better than the Philippines (see chart below).

Percentage use of SBAs, selected countries
Source: WHO, Women and Health, Health Service Coverage,
Global Health Observatory Data Repository, June 16, 2001.

The average Filipina receives less skilled maternal care than some of her ASEAN neighbors. Those who are poor receive hardly any care at all.

Yes, the country does have a maternal care program which has been in place since perhaps the elder Aquino government, which merely reinforces the point that “business as usual” won’t be enough. Having something going on does not mean policymakers cannot make it better funded and more effective, equitable and enforceable. It would be both wise and charitable for the anti-RH forces to concede this issue in the RH bill debates.

Part 2: Family Planning and Reducing Exposure to Risks

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Reproductive Health Bill Revisited


If I remember it right, it’s been already a decade of almost nonstop controversy regarding the reproductive health and contraceptives issue. The earliest that I could remember was how Mayor Lito Atienza came under fire for banning Manila public clinics from distributing free contraceptives and teaching any other methods of contraception other than natural family planning, which is the only “contraception” method espoused by his religion. Human Rights Watch HIV program research, Jonathan Cohen, even went far in saying that “the Philippines is courting an AIDS epidemic with its anti-condom approach…the casualties will be millions of people who cannot protect themselves from HIV infection“. Lito Atienza and his wife may have had pro-life projects that truly helped impoverished women, especially those who suffered from post-abortion trauma, but still, their anti-contraceptiion stance is immovable.

And such stance has pervaded, unfortunately, some of the country’s lawmakers. For this reason, the fate of the Reproductive Health Bill, hangs in a balance.

And unfortunately, the anti-RH force is moving heaven and earth just so that this bill will not be passed.

But what is it in the Reproductive Health Bill that has enraged the Catholic clergy?

I have actually written about this particular subject several years ago (see “What the RCC hates in the RH act“). But, since this bill has gone some revisions, we shall try to review it again, during the course of which I’ll try to dismantle the misinformation being propagated by the so-called “pro-lifers” (who have more than successfully hijacked the term just so to gain unfair advantage over their opponents).

The elements of reproductive health care that are being espoused by the bill are as follows:

    family planning information and services;
    maternal, infant and child health and nutrition, including breastfeeding;
    proscription of abortion and management of abortion complications;
    adolescent and youth reproductive health;
    prevention and management of reproductive tract infections (RTIs), HIV and AIDS and other sexually transmittable infections elimination of violence against women;
    education and counseling on sexuality and reproductive health;
    treatment of breast and reproductive tract cancers and other gynecological conditions and disorders;
    male responsibility and participation in reproductive health;
    prevention and treatment of infertility and sexual dysfunction;
    reproductive health education for the adolescents
    mental health aspect of reproductive health care.

But for this post, I shall be limiting myself in those concepts that has lighted the fire under our beloved clergy’s butts.

1) Family planning information and services

Beloved Catholic clergy did not want taxpayers’ money to fund public health clinics giving out pamphlets and lectures regarding modern artificial contraceptives. Neither does it want it to be giving away free contraceptives. The clergy wanted ONLY natural methods of family planning to be endorsed and taught by these clinics. The clergy has successfully convinced some of its members to disagree with the bill by cleverly insinuating that their taxes go to activities deemed immoral by their church (not considering that NOT everybody in this country belong to their church). And so the statements, “I will not allow the government to use my taxes to pay for your condom” and “let them buy their own condoms”. Well, the idea is to help out the impoverished who cannot afford to buy contraceptives. For those who do not know, contraceptives are considered essential medicines (see section 18, WHO list of essential medicines March 2010 update). The WHO list of essential medicines is a list of minimum medicines needs for a basic health care system. If the clergy wanted to prevent contraceptives from being able in a basic health care unit, then they are, basically, preventing the government from addressing basic health care needs.

The clergy is also frowning upon the use of IUDs and tubal ligation as contraceptive measures. What most of them are blind to is the provision in the bill that these procedures will not be FORCED upon women, but rather, it would be made available to those who may wish to have these procedures.

    SEC. 7. Access to Family Planning
    All accredited health facilities shall provide a full range of modern family planning methods, except in specialty hospitals which may render such services on an optional basis. For poor patients, such services shall be fully covered by the Philippine Health Insurance Corporation (PhilHealth) and/or government financial assistance on a no balance billing.
    After the use of any PhilHealth benefit involving childbirth and all other pregnancy-related services, if the beneficiary wishes to space or prevent her next pregnancy, PhilHealth shall pay for the full cost of family planning. 

    SEC. 11. Procurement and Distribution of Family Planning Supplies
    The DOH shall spearhead the efficient procurement, distribution to LGUs and usage-monitoring of family planning supplies for the whole country. The DOH shall coordinate with all appropriate LGUs to plan and implement this procurement and distribution program. The supply and budget allotment shall be based on, among others, the current levels and projections of the following:
    (a) number of women of reproductive age and couples who want to space or limit their children;
    (b) contraceptive prevalence rate, by type of method used; and
    (c) cost of family planning supplies.

    SEC. 24. Right to Reproductive Health Care Information
    The government shall guarantee the right of any person to provide or receive non-fraudulent information about the availability of reproductive health care services, including family planning, and prenatal care.
    The DOH and the Philippine Information Agency (PIA) shall initiate and sustain a heightened nationwide multi-media campaign to raise the level of public awareness of the protection and promotion of reproductive health and rights including family planning and population and development.

2) Proscription of abortion and management of abortion complications

As early as now, I’m going to say there is nothing (I repeat, NOTHING) in the reproductive health bill that is espousing abortion (abortion being “expulsion from the uterus of the products of conception before the fetus is viable”, according to an online medical dictionary). The bill, rather, wants to strengthen postabortion care. Now, some will say this is indirectly encouraging women to have abortion. But I’m going to stop you right there. Every woman who has had an abortion, whether spontaneous or induced, whether the abortion hurts you as a believer or not, has a right to obtain good postabortion care.

I remember how it was in the different hospitals I have rotated before…girl coming to the hospital complaining of vaginal bleeding and by history, it was evident that she had induced abortion. Health care providers, then, would be rough and tough on her, just so she’d remember the pain and thus, “remember the lesson”. And some even threatened to be denied anesthesia during curettage, just so they’d break down and cry, the health care provider thinking she’d someday learn to keep herself from getting pregnant again, having more than 5 children or so at the tender age of 20. I remember crying at the time I assisted in the vaginal delivery of a 12-year old girl, a pregnancy that was a product of rape of her father. I remember her as a pained girl, who was so restless on the delivery table, not knowing what to do and too much in pain even to think, as the ob-gyne resident shouted down on her to keep her legs apart. “Ayoko na po! Ayoko na po!” were the words she had ceaselessly shouted until she was able to deliver her baby. I imagined it must be the same set of words that she have shouted back to her father while she was being raped.

No, I’m not saying that this girl should have outright abortion because of rape. But if reproductive health assistance are in place, she could have had proper prenatal care and a planned cesarean section would have been done, as her body frame is so small, she might be better off with a C-section rather than risking a vaginal delivery. However, she did not have prenatal care and the only consultation with a health professional that she had was when she was already in active labor. Or she could have had emergency contraception hours after the attack on her.

For you Anti-RH doctors out there, I don’t understand why you still can’t agree to pass the RH bill, with all that you’ve seen since medical school and clerkship. I bet almost everyone of you has rotated in government hospitals. You have seen the numerous poor pregnant women who have come in and out of these hospitals. You have heard their stories, of how they wanted only few children, but were stuck with 10 or more because they cannot refuse a husband asking for sex. You must have heard how most of these women would say they cannot complete their prenatal care because they’d rather spend on food and electricity than on transportation to hospital and medicines. You have seen how some of the health providers in these government hospitals have been rough and tough on these women, just so that they remember the pain and hardship enough to make them think twice before going into another pregnancy. You have seen the scope of how access to reproductive health medicines and procedures are sorely lacking in this country. How can you not agree with the passage of the bill? Because of your alma mater? Because of your religious convictions? This is not an issue of religion; this is a secular issue. Let these women have their choice!

3) Reproductive health education for the adolescents
The clergy keeps on asking, “do you want your children as young as 5 years old to learn about sex?” My answer to this is YES. Whether parents would be honest to themselves or not, one cannot deny the curiosity of a growing child. Yes, even at the young age of 5, kids do already have some questions related to gender and sex. As the kids grow older, the questions grow more mature and complicated. And it is the responsibility of parents to address these questions. But not every parent can be comfortable discussing sex with their children. Come on, be honest with yourselves. Have you ever discussed sex at any length with your mother/father? The all-too-common scenario at home is this: parent and youngster watching a movie on TV, then a kissing scene comes up. Father/mother brings up one hand to cover youngster’s eyes until the scene ended. “Don’t look, you’re too young for this!” And the youngster is either left bewildered at why he shouldn’t see those scenes or he already knows what those scenes are because he already saw movie at a friend’s house. Most Filipino parents would be just content at “screening out” the topic of sex without ever venturing into trying to give the appropriate knowledge to their kids. And unfortunately, these kids would learn about sex and reproduction through friends only. Talk about the blind leading the blind. And it is at this point that the whole barrage of misinformation and myths start and sometimes will culminate into teen pregnancy or other complications regarding relationship with another person.

And here comes the clergy telling us that only the parents should teach their kids about sex.

In the amended reproductive health bill:

    SEC. 16. Mandatory Age-Appropriate Reproductive Health and Sexuality Education
    Age-appropriate Reproductive Health and Sexuality Education shall be taught by adequately trained teachers in formal and non-formal educational system starting from Grade Five up to Fourth Year High School using life skills and other approaches… 

    …Parents shall exercise the option of not allowing their minor children to attend classes pertaining to Reproductive Health and Sexuality Education.

I’m not sure where the clergy got the idea that the kids will be forced to attend sex education classes. It is rather clear that the parents have the option to let their children attend these classes. However, in my opinion, children as young as those in the 5th grade should have these classes already. Fifth graders are usually in the age of 11-12 years old and this age is the start of puberty. With many changes in their bodies, these children should be enlightened and armed with knowledge they need to understand these changes.

There is still plenty left to be discussed regarding the reproductive health bill, now that the clergy and their loyal followers are so hell-bent on obstructing the passage of this bill into law. This has also brought out the worst in some people, even if they think they mean well and are only fighting for what they think is right. However, what we must remember that reproductive health bill shouldn’t even be an issue anymore. Every country needs a good reproductive health care available to its citizens. We have our own personal beliefs regarding it, whether it be religious or not. But reproductive health is a secular issue and citizens must decide on this with the objective that the laws to be passed should be beneficial and appropriate to EVERYONE in the country.

Please see these related articles:

Complete Reproductive Health Bill Text http://rhbill.org/about/rh-bill-text/
Authors’ Amendments to HB 4244 http://rhbill.org/about/amendments-hb4244/

My older posts regarding the issue:
What the RCC hates in the Rh act http://prudencemd.com/?p=488
Family planning will be taught in classes in qc http://prudencemd.com/?p=428
Courting health disaster with Philippines’ anti-condom policies http://prudencemd.com/?p=396
The blog rounds: The State of Reproductive health in the Philippines http://prudencemd.com/?p=492

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