abortion research paper in the philippines

Unintended pregnancy and unsafe abortion in the Philippines: context and consequences

Affiliation.

1 Guttmacher Institute
PMID: 24006559

Despite advances in reproductive health law, many Filipino women experience unintended pregnancies, and because abortion is highly stigmatized in the country, many who seek abortion undergo unsafe procedures. This report provides a summary of reproductive health indicators in the Philippines—in particular, levels of contraceptive use, unplanned pregnancy and unsafe abortion—and describes the sociopolitical context in which services are provided, the consequences of unintended pregnancy and unsafe abortion,and recommendations for improving access to reproductive health services.

Abortion, Criminal / adverse effects
Abortion, Criminal / mortality
Abortion, Criminal / statistics & numerical data*
Aftercare / economics
Aftercare / statistics & numerical data
Contraceptive Agents / therapeutic use*
Health Policy
Health Services Accessibility / statistics & numerical data*
Health Services Needs and Demand / statistics & numerical data
Philippines / epidemiology
Philippines / ethnology
Pregnancy, Unplanned / ethnology*
Pregnancy, Unwanted / ethnology*
Reproductive Health Services / economics
Reproductive Health Services / statistics & numerical data*
Women's Health Services / economics
Women's Health Services / statistics & numerical data*
Young Adult
Contraceptive Agents

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Abortion in the Philippines: A Matter of Choice or Life

Abortion should equally protect the life of the mother and the life of the unborn from conception.

Related Papers

Tsehai Wada

This article was published at the heel of the enactment of a revised code that has radically reversed the status of abortion. It throws light on the status of the law in comparison with similar laws elsewhere.

Legalization of Abortion in the Philippines

There are numerous issues that divide the population. Abortion, a long-standing issue, is one of these. Even in ancient and medieval times, people have engaged in such act. In ancient China and Egypt, different methods have been developed to induce abortion such as the use of herbs. The medieval period saw developments in techniques such as the use of forceps and anaesthesia. As expected, with the development of the methods of abortion also comes strong opposition, primarily from religious bodies.

The issue of abortion is a controversial topic in the Philippines, despite being a Catholic country.

This is because liberal ideas such as feminism, have reached our shores, I see that, at present, there are some women rights group in the Philippines that are pushing for the legalization of abortion. They point out that abortion is already rampant in the Philippines, although unbeknown to the general public. These abortions are usually done in make-shift clinics by people who often have no professional medical background.

This puts the mother in a dangerous and life-threatening situation, with 8 out of 10 of these women develop complications. With these findings, pro-choice groups believe that if abortion would be legalized, abortion will now take place in medical settings, ensuring the safety of the mother. They also emphasize that victims of rape, incest, and sexual trafficking who become pregnant because of the abuse should be given the right for abortion since they did not plan on having a baby in the first place.

On the other, it is clear that the Catholic Church, a big institution in the country, and pro-life groups abhor abortion since it is synonymous to murder, a mortal sin.

For them, life starts in conception, and aborting the fetus even in its earliest stage, ends a life. Abortion deprives the unborn of the life and experiences it should have undergone if it were delivered alive. They suggest that if the baby is unwanted, why not give it up for adoption.

I feel conflicted about this issue since I am both a Catholic and a woman. It is easy to say no to abortion because it is wrong according to my religion. As a woman, I, too, believe that I should be given the right to my own body. Nonetheless, taking these all side, regardless of me being a Catholic and a woman, I am a firm believer of the sanctity of life. Life, in all its forms, must be respected and protected. Everyone must be given an opportunity to experience life.

In an emotional sense, every pregnancy is different from each other. Some women have planned it for years while others get pregnant by “accident”. In sad cases though, pregnancy can occur from rape, incest, and sexual trafficking. Since the perpetrator is the father of the fetus, it is hard for the mother to develop love and affection towards it. For many, they believe that getting an abortion can solve this problem. Maybe I am not to judge their actions since I have not experienced the pain and suffering that these women must have undergone.

However, I can say that if there is someone that must be punished because of the abuse, it must be the perpetrators. The unborn child must not be harmed since it did not choose to be made. It never inflicted pain towards its mother. It is just a product of an unfortunate event. If the mother does not want to keep the baby, she should just give it up for adoption where the child is given a chance to live and experience life.

I think that abortion should not be legalized in the Philippines. In Article 11, Section 12 of the 1987 Philippine Constitution, the state must protect the life of the mother and the unborn. Abortion, therefore, is unconstitutional. If ever, but unlikely, a new constitution will be drafted and will legalize abortion in the country, this will pave the way for new ethical issues to arise. People then will argue that if abortion is legal, then why not legalize this or that. In the years to come, the Philippines will be a country that only values the wants and comforts of its citizenry, and not the sanctity of life.

I believe that the government should strengthen their campaign against abortion. It should put sharper teeth to the law in order to eliminate such practice in the country. It should also provide comprehensive assistance to victims of sexual abuse in order to help them overcome psychological stress to avoid opting for abortion, and guide them on how to raise their children.

More about the legalization of abortion find in .

abortion research paper in the philippines

Opportunities lost: Barriers to increasing the use of effective contraception in the Philippines

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Writing – original draft

* E-mail: [email protected]

Affiliation Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan

Roles Data curation, Formal analysis, Methodology, Writing – original draft

Affiliation Partnership for Maternal, Newborn and Child Health, Geneva, Switzerland

Roles Conceptualization, Methodology, Writing – original draft, Writing – review & editing

Affiliation Independent consultant, maternal and child health, Iowa City, United States of America

Roles Conceptualization, Methodology, Validation, Writing – review & editing

Affiliation World Health Organization Philippines Country Office, Manila, Philippines

Affiliation Responsible Parenthood and Reproductive Health National Implementation Team (RP-RH NIT), Department of Health, Manila, Philippines

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliation Division of NCD and Health through Life-Course, Reproductive, Maternal, Newborn, Child and Adolescent Health, World Health Organization Regional Office of the Western Pacific, Manila, Philippines

Mari Nagai,
Saverio Bellizzi,
John Murray,
Jacqueline Kitong,
Esperanza I. Cabral,
Howard L. Sobel

Published: July 25, 2019
https://doi.org/10.1371/journal.pone.0218187
Reader Comments

In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines.

One-hundred-one nationally representative health facilities were randomly selected from five levels of the health system. Sexually-active women 18–49 years old, wanting to delay or limit childbearing, attending primary care clinics between April 24 and August 8, 2017 were included. Data on contraceptive use, counseling and availability were collected using interviews and facility assessments. Effective contraceptive methods were defined as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use.

849 women were recruited of whom 51.1% currently used effective contraceptive methods, 20.6% were former effective method users and 28.3% had never used an effective method. Of 1664 cumulative clinic visits reported by women in the previous year, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility, with 83.7% having a missed counseling opportunity on the day of the interview. Most women (55.9%) reported health concerns about modern contraception, with 2.9% receiving counseling addressing their concerns. Only 0.6% of former users and 2.1% never-users said they would consider starting a modern contraceptive in the future. Short and long acting reversible contraceptive methods were available in 93% and 68% of facilities respectively.

Conclusions

Missed opportunities to provide family planning counseling are widespread in the Philippines. Delivery of effective contraceptive methods requires that wider legal, policy, social, cultural, and structural barriers are addressed, coupled with systems approaches for improving availability and quality of counseling at all primary health care contacts.

Citation: Nagai M, Bellizzi S, Murray J, Kitong J, Cabral EI, Sobel HL (2019) Opportunities lost: Barriers to increasing the use of effective contraception in the Philippines. PLoS ONE 14(7): e0218187. https://doi.org/10.1371/journal.pone.0218187

Editor: Elizabeth Ann Micks, University of Washington, UNITED STATES

Received: January 12, 2019; Accepted: May 28, 2019; Published: July 25, 2019

Copyright: © 2019 Nagai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: Data collection was funded by World Health Organization (WHO) Regional Office of the Western Pacific. The funder was involved with study design, data analysis, and preparation of the manuscript. SB, JK, and HS are affiliated with WHO. The specific role of these authors is articulated in the 'author contributions' section.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Unintended pregnancies remain an important public health problem worldwide. Between 2010 and 2014, there were an estimated 62 unintended pregnancies per 1000 women aged 15–44 years each year, with rates ranging from 112 in East Africa to 28 in Western Europe [ 1 ]. In Philippines, 54% of all pregnancies (1.9 million pregnancies) are reported to be unintended and around 610 000 unsafe abortions are performed each year [ 2 ]. Nine percent of women 15 to 19 years of age have begun child bearing [ 3 ].

In 2017, the modern contraceptive prevalence rate (CPR) in the Philippines was estimated to be 40% among married women of reproductive age and 17% among unmarried sexually active women [ 3 ]. The modern CPR increased only 2% between 2013 and 2017, with rates being much lower in some populations. Forty-six percent of married women used no contraceptive method in 2017 and 14% a traditional method, a decline from 16.7% in 2008; only 10% of women used long acting reversible contraceptives (LARCs) such as IUDs and implants [ 3 ]. Among sexually active unmarried women, traditional methods were used by 15% [ 3 ].

Women who are fecund, sexually active and who want no more children or to delay the next child, but are not using any method of contraception, are defined as having an “unmet need for family planning”. The unmet need for family planning among married women of reproductive age in Philippines was 17% in 2017, with the demand met by modern methods estimated to be 57%. Among unmarried sexually active women the unmet need increases to 49% and the demand met by modern methods falls to 22% [ 3 ]. As a consequence of the low contraceptive met need, 68% of unintended pregnancies occur in women not using any method and 24% in those using traditional methods [ 4 ]. Those using LARCs rarely have unintended pregnancies [ 5 ].

Several barriers to accessing family planning services have been observed in the Philippines. A 2013 survey found that maintenance of virginity until marriage was important for 83% of women aged 15–24, even though 14% of 15–19 year-olds and 49% of those aged 20–24 years experienced first sexual intercourse before marriage [ 6 ]. This social norm paradoxically discourages use of contraception by unmarried women. In addition, infrequent sex was commonly stated as a reason why women with an unintended pregnancy did not use modern methods. Among married women with an unmet need, half cite inappropriate health concerns as a reason not using modern methods including weight loss, chemical toxicity due to prolonged use, excessive bleeding, the buildup of blood if menstruation stops, loss of physical strength, debilitating headaches or stomach aches, and fears that devices that get lost inside the body [ 7 ]. Religion-based opposition to contraception was reported as a barrier by only 3%-6% of women and accessibility of methods by 2% to 7% [ 7 ].

Although the family planning program in the Philippines began in 1971 and was one of the strongest in Asia, religious concerns, rapid decentralization and various legal interventions have restricted implementation. The Responsible Parenthood and Reproductive Health Act of 2012, designed to re-vitalize family planning service provision, was not put into place until 2017 when legal and programmatic barriers had been overcome [ 8 ].

In response, the Department of Health in Philippines sought to identify strategies to improve family planning programming. Improvement of uptake of modern methods of contraception, especially LARCs, became an important public health priority. Experience from other countries in Asia has shown that facility-based contraceptive counseling is often poor [ 9 , 10 ]. Women are often dissatisfied with clinic visits, because they are unable to discuss their concerns and receive insufficient information about their options. Additionally, providers frequently have inaccurate knowledge about contraceptive methods, including out-of-date information [ 11 , 12 , 13 , 14 ]. For these reasons, this study was designed to review current counseling practices as a key barrier to uptake of contraception. Since the government health insurance provider (Philhealth) provides coverage for 66% of the population, with 56% of women currently obtaining contraception at public health facilities [ 3 ], the study was designed to focus on practices in the public sector. The objectives were to identify the extent of missed opportunities to provide family planning counselling at primary care visits, whether effective counselling was provided and its impact on women’s concerns and decision making to begin use of modern contraceptives. The goal was to identify systems factors that could be targeted to improve the quality of care and to reduce unintended pregnancies.

Study design

A nationally representative cross-sectional survey design was used. One hundred one health facilities (11 national hospitals, 13 regional hospitals, 23 provincial hospitals, 27 main health centers, and 27 barangay health centers) were selected. In first stage sampling, 23 provinces were randomly selected using probability proportionate to size based on the estimated number of sexually active women with unmet need [ 15 ]. Within the sampled provinces, the provincial hospital, 1 main health center and 1 Barangay health center of the most populated Barangay were selected. Regional and national hospitals within the province were also included. The number of facilities sampled was based on estimated participants sample size (n = 820) required to allow comparisons of the proportion women using modern methods of contraception by socio-economic factors with 80% power.

At each facility, women aged 18–49 years of age, who were not currently pregnant or within 6 weeks of delivery, wanting to delay or limit childbearing on the day of the visit were eligible to for the study, to avoid confounding by stage of pregnancy, place of delivery or the early post-pregnancy period on the likelihood and quality of counseling. Questions about missed opportunities to provide family planning counseling were asked about all clinic visits in the previous year. Individual interviews using structured questionnaires were conducted with 10 women per hospital and 6 per health center. Sampled women were divided into equal groups of those currently using and not using effective contraceptive methods. We defined effective contraceptive methods as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use (i.e., patch, oral pills, injectables, IUDs, implants and sterilization) [ 5 ]. We excluded lactational amenorrhea to focus on non-transient modern methods. Less effective contraceptive methods were defined as condoms, fertility self-monitoring (i.e, standard days method, basal body temperature) and traditional methods (i.e., withdrawal, calendar or rhythm method). Where multiple methods were used, subjects were categorized according to the most effective method used.

Data were collected from women attending the outpatient primary care clinic on the day of the survey. Primary care clinics included postnatal care, reproductive health, well child, and primary care. If more than the required number of women were in attendance, systematic sampling method was used. At five sampled health facilities, the minimum number of women were not available on the day of the survey. At these facilities, 24 (2.8%) women meeting eligibility requirements for the study and living within 1 hour of the facility were identified from clinic registers for the previous days and interviewed at their homes to obtain the minimum sample size.

A closed-ended questionnaire for women, interview guide and health facility assessment checklist were developed referring to previous research. These were finalized after two field pilot tests. To those women who preferred local dialects, the questionnaires and consent forms were translated into one of eight local dialects (Tagalog, Ilocano, Bicolano, Visayan, Ilonggo, Chavacano, Tausug, and Meranao) then validated by back-translation. Eight teams consisting of one team leader and one enumerator collected data from April 24 to August 8, 2017 using paper-based questionnaires. Enumerators near selected facilities were identified to minimize language differences across study sites. Data were collected using: 1) interviews with women on current, former and never use of effective contraceptive methods, concerns and attitudes towards contraception, and management of concerns at outpatient primary care clinics of health facilities; 2) facility assessments of the availability of family planning commodities and policies including hospital accreditation status for use of LARCs.

Study outcomes

Counseling was defined as any information or advice given about any contraceptive method during the woman's clinic visit. A missed opportunity was defined as a woman’s clinic visit at which a staff member at the health facility did not provide any counseling. When counseling was provided, quality of counseling was measured by asking the woman whether health staff asked about her concerns on family planning, helped her to find solutions to her concerns, offered her information about how different family planning methods work, or explained side-effects or problems she might have with any method. A health concern about a family planning method was defined as any perceived undesirable health effect. Accumulated facility visits were defined as the number of visits to health facilities made by interviewed women between January 1 and December 31, 2016. Accumulated missed opportunities were defined as the total number of accumulated facility visits at which health staff did not provide any family planning counseling on the day of that visit.

Data management and analysis

The team leader checked completeness and accuracy of completed paper-based questionnaires on the day of interview. Two data managers independently entered the questionnaire data into identical Excel sheets and compared using STATA version 13.1. Inconsistencies were validated with the original paper and corrected. Statistical analysis was also done using STATA.

Ethical considerations

Ethical clearance was obtained by the WHO Regional Office for the Western Pacific Ethics Review Committee on 12 January 2017, and the National Ethics Committee in the Philippine Council for Health Research and Development of the Department of Science and Technology on 1 February 2017. All women were asked for informed consent. Participants were informed of their right to refuse participation in the study, or not answer specific questions should they assent to participation and were assured of the confidentiality of the collected information. All interviews were conducted in private settings and unique identifiers were used to maintain anonymity. All paper copies are maintained in a locked file cabinet.

A total of 849 non-pregnant sexually active women, 18–49 years of age, wanting to delay or limit childbearing were included in the study. Only one woman meeting the entry criteria refused to be interviewed. Of sampled women, 51.1% (434) were currently using an effective contraceptive method, 16.5% (140) a less effective contraceptive method and 32.4% (275) no contraceptive method. Of all women, 36.7% (312) were currently using short-acting effective methods (pills, patches or injectables), 8.9% (76) LARCs (IUD or implants) and 5.5% (46) female sterilization. An additional 18.2% (155/849) of women had used short-acting effective methods in the past and 2.4% (20) had used LARCs in the past. An effective method had never been used by 28.3% (240) of women ( Fig 1 ).

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https://doi.org/10.1371/journal.pone.0218187.g001

Demographic characteristics of sampled current, former and never users were similar ( Table 1 ). Respondents were predominantly urban, aged 30 years, married or living together, with at least a high school education and 2 living children. They reported an average of 1.9 health facility visits in the past year. Philhealth insurance coverage in our sample was 71.3% with 24.7% having no health insurance. Women who had never used contraception were more likely than current users to have not graduated high school.

https://doi.org/10.1371/journal.pone.0218187.t001

Of all women, 83.7% (711/849) reported a missed opportunity for family planning counseling on the day of the interview. Missed opportunities were high regardless of contraceptive method used, residence, age group, marital status, education, number of children, or financial protection status, but highest among those younger than 21 years old, and women living together or not married ( Fig 2 ). Missed opportunities remained high across all levels of health facility and facility accreditation or certification status.

https://doi.org/10.1371/journal.pone.0218187.g002

The 849 women interviewed reported 1664 accumulated primary health care facility visits including antenatal care and postnatal care before discharge, between January 1 and December 31, 2016, not including the day of the interview. Of the 1664 accumulated health facility visits, 72.6% (1211) were missed opportunities to provide family planning counseling. Missed opportunities were found for 68.6% (587/856) of visits by current effective contraceptive method users, 73.4% (235/320) by former users and 78.9% (385/488) by never users. Overall, women not currently using any effective contraceptive method had a missed opportunity in 76.7% (620/808) of all clinic visits in 2016. Missed opportunities to provide family planning counseling were reported for 85.8% (241/281) of reproductive health clinic visits, 76.8% (182/237) of antenatal care visits, 74.7% (198/265) of postnatal care before discharge contacts, 73.7% (73/99) of postnatal care visits after discharge, 71.9% (264/367) of well-child visits, 70.7% (162/229) of sick child visits and 57.1% (68/119) of primary care visits for herself. Missed opportunities were lowest for contraceptive clinic visits, at which 32.8% (23/70) women reported that family planning counseling about any method was not provided ( Fig 3 ).

https://doi.org/10.1371/journal.pone.0218187.g003

Sixteen percent (138/849) of women received family planning counseling on the day of the interview. Of the 138 women receiving counseling, 67.4% (93) were asked if they had concerns about contraceptives, 59.4% (82) received information about how different contraceptives work and 44.9% (62) were told about possible contraceptive side-effects during the counseling. Current effective contraceptive users were more likely to receive information than former or never users. Of the 80 current users receiving family planning counseling, 75.0% (60) were asked about concerns, 66.3% (53) were given explanations about how different methods work, and 55.0% (44) were given advice about side-effects. In contrast, the same information was given less frequently to the 24 former users receiving counseling (50%, 41.6% and 37.5%, respectively) and the 34 never users receiving counseling (62.9%, 55.9% and 23.5%, respectively).

Overall, 55.9% (481/849) of women reported a total of 567 concerns about any effective contraceptive method on the day of the interview. The prevalence of concerns was 72.6% (126/175) among former users, 56.0% (242/434) among current users, and 47.5% (113/240) among never users. Only two women reported concerns that were not related to health: one woman who had never used effective contraception stated that it was illegal to use sterilization and IUDs; and another currently using injectables stated that the church did not allow the use contraception. Of all 567 concerns, 64.9% (368) were medically known side effects such as changes in bleeding patterns, irritability (mood changes), headaches and weight gain 4 , while 35.1% (199) were misperceptions. The latter included the belief that contraceptives caused uterine cancer, cysts, fetal malformations, varicose veins, and dry skin. Misperceptions accounted for 33.6% (38/113) of all concerns among current, 25.7% (44/171) former and 41.3% (117/ 283) never users. Misperceptions were particularly high about female sterilization (87.0% or 20/23 of concerns such as frequent bleeding or cause uterine cancer) and IUDs (67.6% or 50/74 of concerns were misperceptions such as movement to other organs inside the body). Misperceptions were a low proportion of concerns for implants (37.5% or 9/24 of concerns), pill (27.9% or 79/283 of concerns) and injectables (25.1% or 41/163 of concerns).

Of the 481 women with a health concern about effective contraceptive methods, 16.3% (79/481) received family planning counseling on the day of interview. Regardless of contraceptive usage status, information given to women with concerns was limited, with only 2.9% (14/481) of women reporting that their concern about a specific method(s) had been addressed by the health worker during counseling ( Fig 4 ). Only 0.6% (1/175) of former users and 2.1% (5/240) never users with concerns said they would consider starting a modern contraceptive method at the time of the interview.

https://doi.org/10.1371/journal.pone.0218187.g004

A stock of non-expired effective short-acting contraceptive methods was available at 87.5% (42/47) of government hospitals, 95.7 (45/47) of health centers, and 100% (7/7) of barangay health stations. LARCs were available in 85.1% (40/47) of government hospitals, 60% (28/47) (61%) of health centers and 1/7 (14.3%) of barangay health stations.

Of 1664 cumulative total clinic visits reported by the women wanting to delay or limit childbearing in 2016, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility or socio-economic indicators. On the day of the interview in 2017, 83.7% of women had a missed opportunity. Although 55.9% of women reported health concerns about effective contraceptives on the day of the interview, 16% with a concern received family planning counseling and only 2.9% received counseling addressing her specific concerns. Only 0.6% of former effective contraceptive method users and 2.1% never-users said they would consider starting effective contraceptive method in the future. As relatively few facilities had stock-outs, most women in our study could have received an effective contraceptive on the day of the visit, if they had received high quality of counseling, been offered a method and had decided to use it.

These findings suggest that the quantity and quality of family planning counseling provided at primary care clinic contacts in Philippines to women who wish to delay or limit childbearing is inadequate and unlikely to significantly increase the use of effective contraceptive methods. Around 20% of women attending clinics in this study had previously used an effective contraceptive method, but had discontinued use, highlighting that contraceptive services must focus not only on attracting new users but also on improving continuation rates [ 16 ]. To do this, current users should receive continued counseling at every contact, to address the emerging or ongoing concerns about methods; and past users who have stopped use targeted, where appropriate, to resume use by identifying reasons for discontinuation.

The high prevalence of missed opportunities to provide family planning counseling found in this study is consistent with other studies in both developed and developing country settings [ 17 – 19 ].

The World Health Organization recommends providing routine family planning counseling at antenatal care, postnatal care, and other contact points [ 20 – 23 ]. However, experience with integration of family planning counseling into routine primary care is mixed. Significant improvements in family planning outcomes have been seen when improved counseling or referral is integrated into both immunization clinics and general primary care clinic settings [ 24 – 26 ]. In other settings limited improvements in contraceptive use are seen with integration into other services [ 27 – 30 ]. These studies suggest that integrating family planning counseling into routine practice cannot be effective unless systems barriers at primary care clinics are addressed, including the availability of staff, patient numbers and flow, space for adequate one-on-one counseling and availability of low-risk contraceptive methods.

Client-centered counseling approaches are associated with improved method continuation. Women who report experiencing higher quality care have higher rates of contraceptive continuation and contraceptive use [ 31 – 33 ]. In reality, interactions between clients and providers are often provider-dominated, with minimal engagement with women in the process of method selection and with frequent failure of providers to deliver personalized counseling tailored to the individual women's needs and preferences [ 34 – 36 ].

Most counseling in primary care clinics in Philippines is provided by doctors, nurses and midwives. Although family planning counseling at both antenatal and postnatal care contacts is included in national policies and guidelines in Philippines [ 37 ], our findings indicate they are rarely translated into practice. Improving delivery of effective contraceptive methods requires addressing wider legal, policy, social, cultural, and structural barriers which prevent individuals from accessing and using contraception and influence the quality of counseling provided. Some recent policy initiatives in Philippines may promote improved family planning counseling. The Universal Health Coverage Act (RA11223) signed into law in Philippines in February 2019, requires that FP counseling should offered at all primary care contacts, along with a package of essential services. The Expanded Maternity Leave Act (RA11210) also signed in February 2019, increases paid maternity leave from 60 to 105 days and is designed to improve opportunities for postpartum care, including improve family planning counseling and method provision. In 2012, the Responsible Parenthood and Reproductive Health Act (RPRHA) passed, which guarantees universal and free access to modern contraceptives, in particular for poor women [ 8 ].

However, the RPRHA imposes a ban on the purchase of dedicated emergency contraceptives by national hospitals, and requires parental consent for minors to access contraceptives. These restrictions directly impose barriers to contraceptive use on poorer women and adolescent girls [ 38 ].

Although many Philippine-governmental norms and standards are in agreement with adolescents’ human rights to contraceptive information and services recommended by the WHO, a significant number are restrictive, reflecting the strong influence of conservative religious beliefs [ 39 ]. In addition, decentralization of the health system, gives local chief executives the power to ignore national health policies and programs. For example, the mayor of Manila banned contraceptive services in local health facilities in 2000 because of his own religious objections [ 40 ]. In Philippines, staff report that providers who are members of the church often face pressure not to distribute contraception and sometimes pressure from anti-reproductive health groups. Religious beliefs are not cited as important barriers among women of reproductive age, however, suggesting that if appropriate information and counseling was provided, many women would consider adopting modern methods.

There are also a number of provider perceptions that may limit counseling provision, including lack of knowledge, training, and comfort, assumptions about patient pregnancy risk, negative beliefs about contraceptive methods, a reliance on patients to initiate discussions; and limited communication with other primary care staff [ 41 , 42 , 43 ]. Our finding of 32% missed opportunities at contraception clinics suggests that provider-related perceptions and skills continue to play a role in limiting the quality of counseling in the Philippines.

Social norms are believed to be particularly important barriers in Philippines. These norms prevent women, especially adolescents and unmarried women, from accessing services and using methods effectively. The high value placed on virginity at marriage discourages women from admitting sexual activity and inappropriate health concerns [ 6 ].Women frequently do not use any contraceptive method, despite wanting to avoid pregnancy, because they do not perceive themselves to be at risk of pregnancy or they have concerns about the methods, perceptions that are reinforced by families and communities where they live [ 44 ]. In some cases, health-provider or community assumptions about needs may conflict with the women’s own assessment, especially in contexts where there has been a history of contraceptive coercion or discrimination. Providers often offer less-effective methods such as condoms to adolescents believing that LARCs are inappropriate for women who have never had a child. This is despite the fact there is no medical reason to withhold LARCs from adolescents and young women [ 45 ].

This study confirms that LARCs such as IUDs and implants are used less frequently than short acting methods in the Philippines despite being far more effective [ 5 ]. Although previous studies have shown that cost and availability are minor contributors to stoppage or non-use of family planning in general, long-acting methods require specially trained workers and upfront payments which may present barriers to use [ 46 ]. In the Philippines, the national policy allowing only accredited facilities, mostly hospitals, to administrator LARCs results in lower availability at peripheral level facilities. Alternative models, which provide on-site family planning counseling and services, have been shown to increase uptake of LARCs [ 23 ].

In summary, improving family planning counseling at all clinic contacts in the Philippines will require actions at several levels. Recognizing the role of effective contraception to improve the health and economic development of the country is the first step and should be reflected in national laws and policies. Legal barriers such as limitations on the availability of emergency contraception and requiring parental consent can be carefully re-considered and removed. National policies and guidelines should be reinforced at all levels to ensure they are consistent with WHO recommendations and to remove abstinence-centered and sex-negative content. Mechanisms to avoid local adaptations which bypass national policies and guidelines should be explored. Availability of LARCs can be increased by expanding the range of facilities where they can be provided and the number and categories of staff trained in their use. National policies, guidelines and standard operating procedures for primary care services can emphasize integrating family planning counseling at all contacts. Health worker awareness and counseling skills can be strengthened by incorporating skills into professional medical, nursing and midwifery pre-service training curricula and by providing on-the-job coaching of doctors, nurses and midwives; client-centered counseling approaches can address both relational and task-based communication focusing on common obstacles to use [ 47 ]. Development of simple screening tools may allow many counseling tasks to be done by under-employed staff at facilities, removing pressure on those providing clinical services. This approach may be particularly useful for screening current users about concerns; and for identifying and improving support for past users who have stopped use. Systems barriers to counseling need to be identified and addressed in all primary care settings. These include organization of clinic space, patient flow and time to allow counseling to take place, making adequate human resources available, task shifting to improve quality and making LARCs more widely available in primary care settings. Facility accreditation, professional licensure and performance-based financing can help to maintain the motivation of health professionals and provide incentives for prioritizing uptake of effective contraceptive methods.

This study aimed to select a nationally representative sample, based on unmet need for family planning. Since the 2014 Philippine Demographic and Health Survey calculated population-based estimates of unmet need only at the regional level, provinces within a region with higher than average unmet need may be under-represented [ 15 ]. Philhealth insurance coverage in the study population was 71.3% compared to 65.8%, in the general population; 24.7% of the sample had no health insurance compared to 9.9% in the general population [ 3 ]. Higher uninsured rates suggest that the study population may be poorer and less educated, which puts them at higher risk of not using modern methods of contraception. The sample was not weighted for different outpatient clinic attendance rates, which may differ by clinic level and could not be determined in advance. At the clinic level women were selected by order of attendance until the required number was obtained; if more than the required number was present, they were selected by systematic random sampling ordered by time of arrival. In 24 cases home visits were made to interview women who had attended on the previous day. If the characteristics of women or of counseling provided differed by time of attendance, then the sampling of women at clinics could introduce bias. In addition, the study could not control for the clinic type from which women were sampled, since various clinics often fell on certain days of the week. To mitigate these limitations of sampling, we also analyzed the data from the accumulated visits of interviewed women for previous 12 months. The universal presence of missed opportunities across all clinic types at all levels, and the consistency of findings by demographic characteristics, suggests that these factors are unlikely to produce significant biases.

Since our sample was facility-based, findings may not reflect the practices of those who have less access to public clinics or seek care less regularly. In addition, adolescents under 18 years of age were excluded, because their inclusion would have required a lengthy institutional review process which could not be completed within financial deadlines. Given the high missed opportunities among adult women, omission of these groups likely meant that our findings underestimate the extent of the problem.

We asked respondents about family planning services received on the day of the interview and at all clinic visits in 2016. A maximum period of 6 months has been suggested for the recall of non-significant events [ 48 ]. However, rates of missed opportunities did not change significantly between the day of interview and one-year accumulated visits across all demographic categories. To limit the influence of recall bias, detailed data on quality of counseling were collected only for counseling conducted on the day of interview.

Conclusions and broader implications

As in other low- and middle-income countries, the Philippines faces substantial barriers to improving reproductive health services. This study showed that the vast majority of women who wish to delay pregnancy, attending public health clinics, did not receive family planning counseling regardless of their current status of contraceptive use or clinic attended. Over half of these women had health concerns about effective contraceptive methods which were not addressed. This striking finding means that many women in contact with the health system continue to use no contraception, use traditional and other less-effective methods or stop using contraception altogether. As a consequence, many women are put at unnecessary risk of short-spaced high-risk pregnancies and cycles of high fertility, lower educational and employment potential and poverty [ 49 – 51 ]. The study shows that effective contraceptive methods are generally available and that out-of-pocket expenditure was not a major barrier. Systems approaches for improving availability and quality of contraceptive counseling at all primary health care contacts are now needed. Since similar systems problems exist across low and middle-income countries, better quantification of missed opportunities to provide contraceptive counseling and barriers to use is an urgent priority [ 52 ].

Supporting information

S1 questionnaire. questionnaire to women in english..

https://doi.org/10.1371/journal.pone.0218187.s001

S2 Questionnaire. Questionnaire to women in Bicol.

https://doi.org/10.1371/journal.pone.0218187.s002

S3 Questionnaire. Questionnaire to women in Chavacano.

https://doi.org/10.1371/journal.pone.0218187.s003

S4 Questionnaire. Questionnaire to women in Ilocano.

https://doi.org/10.1371/journal.pone.0218187.s004

S5 Questionnaire. Questionnaire to women in Ilonggo.

https://doi.org/10.1371/journal.pone.0218187.s005

S6 Questionnaire. Questionnaire to women in Meranao.

https://doi.org/10.1371/journal.pone.0218187.s006

S7 Questionnaire. Questionnaire to women in Tagalog.

https://doi.org/10.1371/journal.pone.0218187.s007

S8 Questionnaire. Questionnaire to women in Tausug.

https://doi.org/10.1371/journal.pone.0218187.s008

S9 Questionnaire. Questionnaire to women in Visaya.

https://doi.org/10.1371/journal.pone.0218187.s009

S10 Questionnaire. Facility assessment checklist.

https://doi.org/10.1371/journal.pone.0218187.s010

S1 Minimal Dataset. 1:Response of 860 women in Excel.

https://doi.org/10.1371/journal.pone.0218187.s011

S2 Minimal Dataset. 2:Response of 860 women in STATA.

https://doi.org/10.1371/journal.pone.0218187.s012

S3 Minimal Dataset. 3:Values used to build graphs.

https://doi.org/10.1371/journal.pone.0218187.s013

Acknowledgments

We are grateful for the data collection conducted by Asian Institute of Development Studies, INC, Philippines. We thank all health facilities and women who visited those facilities voluntarily participated to this study.

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A placard is displayed during an anti-abortion rally in Manila.

Abortion’s illegal in the Catholic majority Philippines, so more than a million women a year turn to other options

Miriam has seen her share of high-risk operations and procedures in her years as a veteran doctor in the Philippines – but none quite as “complicated or as dangerous” as abortions, she said.

“We take on huge risks if we agree to perform an abortion,” said Miriam, who is using an alias to protect herself from prosecution in the Philippines. She has performed four abortions on women aged 23 to 48 – all in secret.

Abortion is illegal in the Philippines – a majority Catholic country and former American colony – and has been for over a century. Under the law, women found to have aborted their fetuses face prison terms of between two to six years.

Doctors and nurses caught performing abortions or providing assistance are also subject to harsh punishment by the state. “We risk losing our medical licenses and would also face charges in court,” Miriam said.

Manila, the sprawling capital of the Philippines where millions live in slums against the backdrop of modern skyscrapers

Prosecution for abortion is now a risk for millions of women across the United States after the Supreme Court’s overturning of Roe v. Wade, the 1973 ruling that made seeking a termination a constitutional right. Now, states have control over laws governing abortion – and some have banned the procedure outright.

In the Philippines, many women seek other solutions to unwanted or unviable pregnancies, regardless of risks.

Lawyer Clara Rita Padilla, a spokeswoman for the Philippine Safe Abortion Advocacy Network (PINSAN), said that while there are “progressive interpretations” of the abortion law in the Philippines, there are no clear exemptions allowing for terminating pregnancies even in severe cases like rape and incest – or to save the life of the pregnant woman.

A study conducted by PINSAN in 2020 found 1.26 million abortions were carried out in the country, “placing the lives and health of Filipina women at risk.” And that figure is expected to grow. Another study by the University of the Philippines estimated that 1.1 million abortions occur every year in the country.

Padilla said most women who had abortions came from poorer financial backgrounds, and many were below the age of 25. In the absence of legal services, women often turned to dangerous underground abortions performed by midwives, healers, and untrained doctors in makeshift clinics, she said.

“The Philippines is a product of very conservative religious beliefs. For us, abortion bans are already a reality – and it’s women from poor families and minority groups who suffer the most.”

Abortion rights activists outside the US Supreme Court on June 30, 2022

Power of the church

Abortion rights activists in the US met the Supreme Court’s decision with outrage. But for those grounded in conservative Catholic beliefs or evangelical principles, the end of Roe wasn’t just a political victory – it was a spiritual one.

This sense of jubilation was also felt in the Philippines, where the Catholic Church wields a great deal of power and influence. Local church leaders and groups who publicly condemn abortion, divorce and the use of modern contraceptives, welcomed the Supreme Court’s decision.

“The US Supreme Court’s decision to ban abortion is good news,” Crispin Varquez, a local bishop and prelate of the Catholic Church in the Philippines, said in an interview on Radio Veritas Asia, a church-run station based out of Quezon City.

Varquez said the move was “timely” as it coincided with holy celebrations for the Feast of the Sacred Heart.

“(It’s) a decision enlightened by the Holy Spirit,” he said.

Pope Francis described abortion as akin to “hiring a hitman” and said he respected the Supreme Court’s decision.

“It’s a human life – that’s science,” he told Reuters. “The moral question is whether it is right to take a human life to solve a problem.”

The shame that many Filipina women feel for seeking abortions is often reinforced by their Catholic culture.

“The Catholic Church propagates the narrative that abortion is murder,” said Marevic Parcon, another founding member of PINSAN. Like most Filipino women, Parcon was raised Catholic. She said that religion had shaped her views about abortion very early on. “Attending church, you were always taught to fear abortions,” she said.

“Nuns would show us videos of late stage abortions – it was that horrible control they had over your psyche and emotions.”

The Filipino Catholic Church and the Catholic Bishops’ Conference of the Philippines (CBCP) did not respond to CNN requests for comment.

Pope Francis has supported the US Supreme Court's decision

Suffering in secret

Still, however great the stigma, some women – like Kristy, who is also using an alias for fear of prosecution – conclude they have little choice but to seek out so-called backstreet, or illegal abortions.

The mother of four kept her abortion a secret from her husband and family because she knew “they would never allow it.”

“They would only force me to keep the baby and we are already struggling to feed our four children,” she said. “How can we afford to raise a fifth?”

She has not been on any form of birth control and her husband does not use condoms. Access to other forms of contraception like birth control pills and IUD devices was also out of the question. “I can’t imagine how much that would cost,” she said. “I wouldn’t know how to (go about) getting them or using them.”

So when she became pregnant, she sought the services of a midwife and paid her 550 pesos ($10) for a “healing massage.”

She described being held down by the midwife’s assistant while she went to work, kneading and pounding her lower abdomen that eventually triggered a miscarriage. “It was messy and so awful,” Kristy said. “The pain was so excruciating and I could only scream. I still have trouble sleeping.”

“I feel so much guilt but I know that my family is better for this,” she added.

An anti-abortion poster on the sides of a building in Manila.

Time for a change?

Opponents say it’s time for the Philippines to get rid of “inhumane provisions” in its abortion law and finally decriminalize abortion to save women’s lives.

“These regulations have only led to a silent epidemic of unsafe abortions which have cost the lives of so many Filipina women,” said senator Risa Hontiveros, the country’s new opposition leader. “We should also not be sending women to jail after such difficult and painful experiences.”

The practice of unsafe underground abortions had to stop, Hontiveros said. She also reiterated the importance of destigmatizing abortion as a national step for the country.

“Women must vigilantly protect our rights and freedoms especially amid the rise of authoritarianism and religious fundamentalism in many countries across the globe,” Hontiveros said. “I fully support the push to decriminalize abortion under Philippine laws.”

In an interview conducted earlier in January, then-presidential hopeful Ferdinand Marcos Jr. shared his views on abortion and said he would legalize it for “severe cases.”

“I think that if it can be shown that (victims) were raped and it was not consensual sex that got them pregnant then they should have the choice to abort or not. The other is incest perhaps,” said Marcos Jr. – who has since been elected President.

He also said he was “more concerned about deaths caused by unsafe abortions” than opposition from church leaders. “It is a woman’s decision because it is her body.”

Advocates and lawmakers welcomed his liberal attitude towards abortion. “Restricting abortion does not stop it, it actually makes it more dangerous and we have seen this play out across the world,” said Parcon of PINSAN.

“Marcos raised it during his election campaign and to us, this was the furthest we have reached so far, and if he says he will make it a priority, then we must call him to account.”

Senator Hontiveros said she welcomed the new President’s “openness” in supporting changes to Philippine abortion laws.

“This gives hope that we can soon decriminalize abortion and reform our laws in consideration of the realities faced by Filipina women and families alike,” she said.

“However, I (am) waiting to see if his words reflect a genuine commitment to uphold women’s rights. For the sake of Filipina women everywhere, I hope that they do.”

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But the government of the Philippines – a deeply Catholic state – imposes a blanket ban on abortion, even in cases of incest, rape or to save the mother's life. It is one of the most restrictive laws in the world.

This does not stop women, like Ana, from undergoing over half a million procedures each year. Instead they take place underground, in murky backstreets, without professional oversight or sanitised equipment. Abortion drugs like misoprostol are widely available on the black market, along with traditional medicines and makeshift services. Ana opted for a "medical" intervention, where a catheter is inserted into a woman's cervix for up to 48 hours.

One in six women who obtain illegal procedures in the Philippines suffer complications. Many of them die. While legal, even post-abortion services are limited and women often face prejudice and abuse by medical staff. But because abortion is criminalised, a culture of stigma and impunity prevails.

"I refused to be taken to the hospital," explains Josie, another abortion survivor. "I was afraid that I would get imprisoned. I bled for more than a week."

Millennium Development Goal 5 calls for a 50% reduction in maternal deaths and universal access to reproductive health by 2015. It is commonly known as the goal least likely to be fulfilled. Unsafe abortion accounts for 13% of maternal deaths – rising to 35% in certain regions. Most of these procedures are carried out in countries where abortion services are legally restricted.

According to research by the Center for Reproductive Rights, restrictive abortion laws lead to systematic abuses of women's human rights – including the rights to life, health and equality.

"These are rights that are guaranteed very clearly under international treaty law," says Melissa Upreti, the Center's Regional Director for Asia. "So when a government denies access to safe and legal abortion they are essentially violating women's rights."

The Committee on the Elimination of Discrimination against Women has called on several countries, including the Philippines and Ireland, to liberalize their abortion laws. The UN Committee Against Torture described the blanket ban on abortion, reinstated in Nicaragua in 2006, as tantamount to cruel, inhumane and degrading treatment. Amnesty International described it as "a disgrace".

In 2006, Colombian human rights lawyer Monica Roa successfully challenged the country's total ban on abortion. The campaign, supported by Women's Link Worldwide, was successful in large part because it managed to frame the abortion ban as a health and equal rights issue, rather than a religious or moral one.

They also chose not to bandy words with their most vocal opponent – the Catholic Church. "We decided not to engage with them, because we understood that it was not their decision to make," says Monica. "We wanted to talk about what the state should do. And in a secular state like Colombia, and in countries, where there is at least freedom of religion and freedom of conscience, the state has to provide women with the freedom to make the decision whether to carry a pregnancy to term."

But despite the clear implications for maternal health and growing body of human rights jurisprudence, the international development community has been reluctant to engage in the debate around abortion – even in extreme cases like the Philippines or Nicaragua.

All the major UN development agencies, including UN Women and the World Health Organization (WHO), have refused to condemn restrictive laws, despite implicitly recognising their harmful impacts on women. WHO has published vast guidance on safe abortion practices and added misoprostol to its essential medicines list in 2005.

"The UN agencies have been the worst," says Monica. "It's very problematic because many of them have a crucial role to play in implementing change in the lives of women."

Political pressures have been substantial. In 2005, the Bush administration revoked funding from the UN Population Fund over claims that the organisation financed abortions. Despite reversing the decision in 2009, the current government has refused to endorse safe abortion as a human right. Except for Britain and Sweden, most governments share this stance. The mainstream focus remains on pregnancy prevention.

But the Center for Reproductive Rights maintains that it is impossible to address one without the other. "Any attempt to promote women's reproductive health has to include integrated strategies for addressing all these issues," says Melissa. "In order to address maternal mortality you have to address unsafe abortion and the legal issue is critical. The international community has to do more."

There is often a correlation between abortion restrictions and low contraceptive use. In the Philippines, the Catholic Church is currently challenging a proposed bill to expand the availability of birth control.

Marie Stopes International emphasises the value of reaching out to local communities and moderate religious groups. "Religion can be empowering as well as restrictive," says Louise Lee-Jones, Senior Manager. "There are many people out there with strong religious ethos who take a more liberal stance."

She adds: "It's important that any effort to liberalise abortion laws comes from within a country. It's about positioning it as a health issue and working with local people to establish what they want."

The key, agrees Monica, is untangling the moral binary and breaking the taboo. "One of the reasons we were able to win in the public debate, was to push it away from the black and white," she says. "It is very important to have catholic women understand that the position from their religion is one thing, but they still have the right to make a separate decision." A global NGO – Catholics for Choice – also works with partners across South America to send the message that you can be pro-choice and Catholic.

In the end restrictive abortion laws punish the poor, young and vulnerable, says Monica. And it is their voices that need to be heard. "If women with power and money had to have unsafe abortions the law would have been changed a long time ago."

This feature was written for the Guardian International Development Journalism competition before 13 June 2011.

Professional Longlist 2011

Progress on Abortion Rights in the Philippines

For the first time, the philippine human rights commission recommends that abortion be decriminalized., share this story.

For the first time, the Philippine Commission on Human Rights (PCHR) has expressly supported the decriminalization of abortion in the Philippines, marking a historic moment for abortion advocacy in the country. The PCHR made the recommendation in November as part of its Priority Human Rights Legislative Agenda for the 19th Congress of the Philippines. The 19th Congress convened in July 2022 and will be completed in June 2025.

The PCHR is a constitutionally established national human rights institution mandated to provide recommendations to the Congress for effective promotion of human rights and adherence to international human rights treaty obligations.

“The PCHR’s call for decriminalization of abortion is truly historic and celebratory and is in line with the global trend towards liberalizing abortion,” said Jihan Jacob, Senior Legal Adviser for Asia at the Center for Reproductive Rights. “This marks the success of advocacy movements in the region, including the Center’s, that has worked for years to realize sexual and reproductive health rights (SRHR).”

“With President Ferdinand Marcos Jr. previously expressing support for certain cases of abortion and his allies gaining control of Congress, we are optimistic that positive change to the country’s abortion law is possible,” added Jacob. The President appointed the Chairperson and Commissioner of the PCHR, which made the recommendation in November.

The Philippines has one of the most restrictive abortion laws in the world, without any clear exceptions. Two United Nations treaty bodies have recently called on the country to advance sexual and reproductive health rights.

The Center’s Recent Work in the Philippines

The PCHR’s position on abortion has evolved over the past two decades, from declaring abortion “immoral” to acknowledging the impact of abortion bans on health and human rights to finally recommending decriminalization. The Center’s advocacy efforts contributed to the PCHR’s shift in its position on abortion. ( See the timeline below for details. )

Human Rights Bodies Support Abortion Rights and Access

The right to abortion and the right to bodily autonomy are fundamental human rights. Denying abortion via criminalization violates the fundamental rights to equality and non-discrimination; privacy; the highest attainable standard of health; and freedom from ill-treatment, harmful practices, and gender-based violence.

The United Nations and other human rights bodies have frequently recommended for the right to abortion and its access and recognized it as an essential health service. Last year, two United Nations treaty bodies called on the Philippines to improve sexual and reproductive rights (SRHR) in the country. Also in 2022, the World Health Organization issued its 2022 Abortion Care Guideline , affirming abortion access as essential to health and human rights and calling for the removal of legal barriers to access.

The Philippine Safe Abortion Advocacy Network (PINSAN) , co-founded by the Center, released a statement in December calling for the decriminalization of abortion and commending the PCHR for including decriminalization in its 19th Priority Legislative Agenda.

“With progressive legislation getting more support, now is the time to advance the campaign for access to safe abortion for women and girls in the Philippines without fear of arbitrary punishment,” PINSAN wrote. “Continually denying them of this right gravely violates their fundamental rights as people and citizens.”

“The Center welcomes PCHR’s progressive stance on abortion which is in adherence with international human rights law principles. While we celebrate this win, we will continue to work closely with our regional partners to transform PCHR’s recommendations into law reform to make decriminalization of abortion a reality for Filipinos,” added Jacob.

Timeline: The Philippine Commission on Human Rights’ Evolution on Abortion

Tags: Abortion in the Philippines , Philippines abortion laws , PINSAN , Philippine Safe Abortion Advocacy Network , PCHR , philippine commission on human rights , philippine congress , United Nations , Philippine Human Rights Commission

Center’s work promoting gender equality recognized in the philippines.

The Philippine Commission on Human Rights awards the Center as a valuable partner.

This report provides a comprehensive review of the state of the science on the safety and quality of abortion services in the United States. The committee was charged with answering eight specific research questions. This chapter presents the committee’s conclusions by responding individually to each question. The research findings that are the basis for these conclusions are presented in the previous chapters. The committee was also asked to offer recommendations regarding the eight questions. However, the committee decided that its conclusions regarding the safety and quality of U.S. abortion care responded comprehensively to the scope of this study. Therefore, the committee does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

1. What types of legal abortion services are available in the United States? What is the evidence regarding which services are appropriate under different clinical circumstances (e.g., based on patient medical conditions such as previous cesarean section, obesity, gestational age)?

Four legal abortion methods—medication, 1 aspiration, dilation and evacuation (D&E), and induction—are used in the United States. Length of gestation—measured as the amount of time since the first day of the last

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1 The terms “medication abortion” and “medical abortion” are used interchangeably in the literature. This report uses “medication abortion” to describe the U.S. Food and Drug Administration (FDA)-approved prescription drug regimen used up to 10 weeks’ gestation.

menstrual period—is the primary factor in deciding what abortion procedure is the most appropriate. Both medication and aspiration abortions are used up to 10 weeks’ gestation. Aspiration procedures may be used up to 14 to 16 weeks’ gestation.

Mifepristone, sold under the brand name Mifeprex, is the only medication specifically approved by the FDA for use in medication abortion. The drug’s distribution has been restricted under the requirements of the FDA Risk Evaluation and Mitigation Strategy program since 2011—it may be dispensed only to patients in clinics, hospitals, or medical offices under the supervision of a certified prescriber. To become a certified prescriber, eligible clinicians must register with the drug’s distributor, Danco Laboratories, and meet certain requirements. Retail pharmacies are prohibited from distributing the drug.

When abortion by aspiration is no longer feasible, D&E and induction methods are used. D&E is the superior method; in comparison, inductions are more painful for women, take significantly more time, and are more costly. However, D&Es are not always available to women. The procedure is illegal in Mississippi 2 and West Virginia 3 (both states allow exceptions in cases of life endangerment or severe physical health risk to the woman). Elsewhere, access to the procedure is limited because many obstetrician/gynecologists (OB/GYNs) and other physicians lack the requisite training to perform D&Es. Physicians’ access to D&E training is very limited or nonexistent in many areas of the country.

Few women are medically ineligible for abortion. There are, however, specific contraindications to using mifepristone for a medication abortion or induction. The drug should not be used for women with confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass; an intrauterine device in place; chronic adrenal failure; concurrent long-term systemic corticosteroid therapy; hemorrhagic disorders or concurrent anticoagulant therapy; allergy to mifepristone, misoprostol, or other prostaglandins; or inherited porphyrias.

Obesity is not a risk factor for women who undergo medication or aspiration abortions (including with the use of moderate intravenous sedation). Research on the association between obesity and complications during a D&E abortion is less certain—particularly for women with Class III obesity (body mass index ≥40) after 14 weeks’ gestation.

A history of a prior cesarean delivery is not a risk factor for women undergoing medication or aspiration abortions, but it may be associated

2 Mississippi Unborn Child Protection from Dismemberment Abortion Act, Mississippi HB 519, Reg. Sess. 2015–2016 (2016).

3 Unborn Child Protection from Dismemberment Abortion Act, West Virginia SB 10, Reg. Sess. 2015–2016 (2016).

with an increased risk of complications during D&E abortions, particularly for women with multiple cesarean deliveries. Because induction abortions are so rare, it is difficult to determine definitively whether a prior cesarean delivery increases the risk of complications. The available research suggests no association.

2. What is the evidence on the physical and mental health risks of these different abortion interventions?

Abortion has been investigated for its potential long-term effects on future childbearing and pregnancy outcomes, risk of breast cancer, mental health disorders, and premature death. The committee found that much of the published literature on these topics does not meet scientific standards for rigorous, unbiased research. Reliable research uses documented records of a prior abortion, analyzes comparable study and control groups, and controls for confounding variables shown to affect the outcome of interest.

Physical health effects The committee identified high-quality research on numerous outcomes of interest and concludes that having an abortion does not increase a woman’s risk of secondary infertility, pregnancy-related hypertensive disorders, abnormal placentation (after a D&E abortion), preterm birth, or breast cancer. Although rare, the risk of very preterm birth (<28 weeks’ gestation) in a woman’s first birth was found to be associated with having two or more prior aspiration abortions compared with first births among women with no abortion history; the risk appears to be associated with the number of prior abortions. Preterm birth is associated with pregnancy spacing after an abortion: it is more likely if the interval between abortion and conception is less than 6 months (this is also true of pregnancy spacing in general). The committee did not find well-designed research on abortion’s association with future ectopic pregnancy, miscarriage or stillbirth, or long-term mortality. Findings on hemorrhage during a subsequent pregnancy are inconclusive.

Mental health effects The committee identified a wide array of research on whether abortion increases women’s risk of depression, anxiety, and/or posttraumatic stress disorder and concludes that having an abortion does not increase a woman’s risk of these mental health disorders.

3. What is the evidence on the safety and quality of medical and surgical abortion care?

Safety The clinical evidence clearly shows that legal abortions in the United States—whether by medication, aspiration, D&E, or induction—are

safe and effective. Serious complications are rare. But the risk of a serious complication increases with weeks’ gestation. As the number of weeks increases, the invasiveness of the required procedure and the need for deeper levels of sedation also increase.

Quality Health care quality is a multidimensional concept. Six attributes of health care quality—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—were central to the committee’s review of the quality of abortion care. Table 5-1 details the committee’s conclusions regarding each of these quality attributes. Overall, the committee concludes that the quality of abortion care depends to a great extent on where women live. In many parts of the country, state regulations have created barriers to optimizing each dimension of quality care. The quality of care is optimal when the care is based on current evidence and when trained clinicians are available to provide abortion services.

4. What is the evidence on the minimum characteristics of clinical facilities necessary to effectively and safely provide the different types of abortion interventions?

Most abortions can be provided safely in office-based settings. No special equipment or emergency arrangements are required for medication abortions. For other abortion methods, the minimum facility characteristics depend on the level of sedation that is used. Aspiration abortions are performed safely in office and clinic settings. If moderate sedation is used, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. For D&Es that involve deep sedation or general anesthesia, the facility should be similarly equipped and also have equipment to provide general anesthesia and monitor ventilation.

Women with severe systemic disease require special measures if they desire or need deep sedation or general anesthesia. These women require further clinical assessment and should have their abortion in an accredited ambulatory surgery center or hospital.

5. What is the evidence on what clinical skills are necessary for health care providers to safely perform the various components of abortion care, including pregnancy determination, counseling, gestational age assessment, medication dispensing, procedure performance, patient monitoring, and follow-up assessment and care?

Required skills All abortion procedures require competent providers skilled in patient preparation (education, counseling, and informed consent);

TABLE 5-1 Does Abortion Care in the United States Meet the Six Attributes of Quality Health Care?

a These attributes of quality health care were first proposed by the Institute of Medicine’s Committee on Quality of Health Care in America in the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century.

b Elsewhere in this report, effectiveness refers to the successful completion of the abortion without the need for a follow-up aspiration.

clinical assessment (confirming intrauterine pregnancy, determining gestation, taking a relevant medical history, and physical examination); pain management; identification and management of expected side effects and serious complications; and contraceptive counseling and provision. To provide medication abortions, the clinician should be skilled in all these areas. To provide aspiration abortions, the clinician should also be skilled in the technical aspects of an aspiration procedure. To provide D&E abortions, the clinician needs the relevant surgical expertise and sufficient caseload to maintain the requisite surgical skills. To provide induction abortions, the clinician requires the skills needed for managing labor and delivery.

Clinicians that have the necessary competencies Both trained physicians (OB/GYNs, family medicine physicians, and other physicians) and advanced practice clinicians (APCs) (physician assistants, certified nurse-midwives, and nurse practitioners) can provide medication and aspiration abortions safely and effectively. OB/GYNs, family medicine physicians, and other physicians with appropriate training and experience can perform D&E abortions. Induction abortions can be provided by clinicians (OB/GYNs,

family medicine physicians, and certified nurse-midwives) with training in managing labor and delivery.

The extensive body of research documenting the safety of abortion care in the United States reflects the outcomes of abortions provided by thousands of individual clinicians. The use of sedation and anesthesia may require special expertise. If moderate sedation is used, it is essential to have a nurse or other qualified clinical staff—in addition to the person performing the abortion—available to monitor the patient, as is the case for any other medical procedure. Deep sedation and general anesthesia require the expertise of an anesthesiologist or certified registered nurse anesthetist to ensure patient safety.

6. What safeguards are necessary to manage medical emergencies arising from abortion interventions?

The key safeguards—for abortions and all outpatient procedures—are whether the facility has the appropriate equipment, personnel, and emergency transfer plan to address any complications that might occur. No special equipment or emergency arrangements are required for medication abortions; however, clinics should provide a 24-hour clinician-staffed telephone line and have a plan to provide emergency care to patients after hours. If moderate sedation is used during an aspiration abortion, the facility should have emergency resuscitation equipment and an emergency transfer plan, as well as equipment to monitor oxygen saturation, heart rate, and blood pressure. D&Es that involve deep sedation or general anesthesia should be provided in similarly equipped facilities that also have equipment to monitor ventilation.

The committee found no evidence indicating that clinicians that perform abortions require hospital privileges to ensure a safe outcome for the patient. Providers should, however, be able to provide or arrange for patient access or transfer to medical facilities equipped to provide blood transfusions, surgical intervention, and resuscitation, if necessary.

7. What is the evidence on the safe provision of pain management for abortion care?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended to reduce the discomfort of pain and cramping during a medication abortion. Some women still report high levels of pain, and researchers are exploring new ways to provide prophylactic pain management for medication abortion. The pharmaceutical options for pain management during aspiration, D&E, and induction abortions range from local anesthesia, to minimal sedation/anxiolysis, to moderate sedation/analgesia, to deep sedation/

analgesia, to general anesthesia. Along this continuum, the physiological effects of sedation have increasing clinical implications and, depending on the depth of sedation, may require special equipment and personnel to ensure the patient’s safety. The greatest risk of using sedative agents is respiratory depression. The vast majority of abortion patients are healthy and medically eligible for all levels of sedation in office-based settings. As noted above (see Questions 4 and 6), if sedation is used, the facility should be appropriately equipped and staffed.

8. What are the research gaps associated with the provision of safe, high-quality care from pre- to postabortion?

The committee’s overarching task was to assess the safety and quality of abortion care in the United States. As noted in the introduction to this chapter, the committee decided that its findings and conclusions fully respond to this charge. The committee concludes that legal abortions are safe and effective. Safety and quality are optimized when the abortion is performed as early in pregnancy as possible. Quality requires that care be respectful of individual patient preferences, needs, and values so that patient values guide all clinical decisions.

The committee did not identify gaps in research that raise concerns about these conclusions and does not offer recommendations for specific actions to be taken by policy makers, health care providers, and others.

The following are the committee’s observations about questions that merit further investigation.

Limitation of Mifepristone distribution As noted above, mifepristone, sold under the brand name Mifeprex, is the only medication approved by the FDA for use in medication abortion. Extensive clinical research has demonstrated its safety and effectiveness using the FDA-recommended regimen. Furthermore, few women have contraindications to medication abortion. Nevertheless, as noted earlier, the FDA REMS restricts the distribution of mifepristone. Research is needed on how the limited distribution of mifepristone under the REMS process impacts dimensions of quality, including timeliness, patient-centeredness, and equity. In addition, little is known about pharmacist and patient perspectives on pharmacy dispensing of mifepristone and the potential for direct-to-patient models through telemedicine.

Pain management There is insufficient evidence to identify the optimal approach to minimizing the pain women experience during an aspiration procedure without sedation. Paracervical blocks are effective in decreasing procedural pain, but the administration of the block itself is painful, and

even with the block, women report experiencing moderate to significant pain. More research is needed to learn how best to reduce the pain women experience during abortion procedures.

Research on prophylactic pain management for women undergoing medication abortions is also needed. Although NSAIDs reduce the pain of cramping, women still report high levels of pain.

Availability of providers APCs can provide medication and aspiration abortions safely and effectively, but the committee did not find research assessing whether APCs can also be trained to perform D&Es.

Addressing the needs of women of lower income Women who have abortions are disproportionately poor and at risk for interpersonal and other types of violence. Yet little is known about the extent to which they receive needed social and psychological supports when seeking abortion care or how best to meet those needs. More research is needed to assess the need for support services and to define best clinical practice for providing those services.

Abortion is a legal medical procedure that has been provided to millions of American women. Since the Institute of Medicine first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized clinical trials, systematic reviews, and epidemiological studies examining abortion care. This research has focused on examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances. With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed.

The Safety and Quality of Abortion Care in the United States offers a comprehensive review of the current state of the science related to the provision of safe, high-quality abortion services in the United States. This report considers 8 research questions and presents conclusions, including gaps in research.

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IMAGES

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A Position Paper on the Illegalization of Abortion in the Philippines
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A Position Paper on the Legalization of Abortion in the Philippines

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COMMENTS

The spectre of unsafe abortions in the Philippines
On 24 June 2022, the U.S. Supreme Court overturned Roe v. Wade, the landmark 1973 ruling that protected the constitutional right to abortion, threatening the physical and mental health of millions of pregnant people in the U.S. However, this crisis has long been the reality for pregnant people in the Philippines, a lower-middle income country in Southeast Asia where abortion remains restricted ...
Unintended Pregnancy and Unsafe Abortion in the Philippines: Context
July 2013. The Philippines, with a steadily increasing population that is approaching 100 million, faces significant challenges in the area of reproductive health. 1 About 25 million of its citizens are women of reproductive age, and they experience high levels of unintended pregnancy, have relatively low levels of contraceptive use, and frequently experience unsafe abortion and consequently ...
Unintended pregnancy and unsafe abortion in the Philippines: context
Abstract. Despite advances in reproductive health law, many Filipino women experience unintended pregnancies, and because abortion is highly stigmatized in the country, many who seek abortion undergo unsafe procedures. This report provides a summary of reproductive health indicators in the Philippines—in particular, levels of contraceptive ...
PDF The Incidence of Induced Abortion in the Philippines: Current Level and
CONTEXT: In the Philippines, abortion is legally restricted. Nevertheless, many women obtain abortions—often in unsafe conditions—to avoid unplanned births. In 1994, the estimated abortion rate was 25 per 1,000 women per year; no further research on abortion incidence has been conducted in the Philippines.
(PDF) The Incidence of Induced Abortion in the Philippines: Current
In 1994, the estimated abortion rate was 25 per 1,000 women per year; no further research on abortion incidence has been conducted in the Philippines. Data from 1,658 hospitals were used to ...
PDF The Benefits of Legalization of Abortion in the Philippines
The paper proposes that abortion should be legalized in the Philippines. Between decriminalization and legalization, it is argued that abortion should be legalized rather than decriminalized as the former provides more benefits than simply removing the penal nature of abortion. Abortion is defined as the termination of pregnancy or
The Incidence of Induced Abortion in the Philippines: Current
Context: In the Philippines, abortion is legally restricted. Nevertheless, many women obtain abortions-often in unsafe conditions-to avoid unplanned births. In 1994, the estimated abortion rate was 25 per 1,000 women per year; no further research on abortion incidence has been conducted in the Philippines.
Abortion choices in the philippines
Summary. Although abortion is still illegal in the Philippines it appears to be increasing. This article reviews the methods to which women wanting to terminate a pregnancy resort, in spite of the health risks attached to them; these traditional practices include the use of herbal and pharmaceutical preparations supposedly with abortifacient ...
Abortion in the Philippines: A Matter of Choice or Life
Rona M. Salita LAW 1B Abortion in the Philippines: A Matter of Choice or Life? A Research Paper on Abortion and Related Laws Abortion The generally accepted definitions of abortion are the following: Induced termination of pregnancy, involving destruction of the embryo or fetus; Any of various procedures that result in such termination; Spontaneous abortion; miscarriage; or Cessation of a ...
Position Paper On Abortion in The Philippines
The most recent study in 2000 on the incidence of abortion in. the Philippines estimated an abortion rate of 27 per 1,000 women aged 15-44 per year. This. projects to 560,000 national abortions in 2008 and 610,000 in 2012 (Hussain & Finer). Thus, banning abortion does not stop it women from needing and seeking it.
Legalization of Abortion in the Philippines
I think that abortion should not be legalized in the Philippines. In Article 11, Section 12 of the 1987 Philippine Constitution, the state must protect the life of the mother and the unborn. Abortion, therefore, is unconstitutional. If ever, but unlikely, a new constitution will be drafted and will legalize abortion in the country, this will ...
Opportunities lost: Barriers to increasing the use of effective
Background In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines. Methods One-hundred-one nationally representative health facilities ...
The Incidence of Induced Abortion in the Philippines: Current Level and
In the Philippines, abortion is legally restricted. Nevertheless, many women obtain abortions—often in unsafe conditions—to avoid unplanned births. In 1994, the estimated abortion rate was 25 per 1,000 women per year; no further research on abortion incidence has been conducted in the Philippines. METHODS
Abortion in the Philippines: A Study of Clients and Practitioners
abortion is virtually a taboo subject because of its legal, religious, and cultural implications. Thus, only a very limited number of research investigations have been conducted on any aspect of the subject up to this time. 1 The objective of this exploratory study was to in-vestigate induced abortion practices in the Philippines
PDF Facts on Abortion in the Philippines: Criminalization and a General Ban
research into the status of reproductive rights in the Philippines. The facts are as follows: m For over a century, abortion has been criminalized in the Philippines. The criminal provisions on abortion do not contain any exceptions allowing abortion, including to save the life of the pregnant woman or to protect her health. Abortion
Philippines: Abortion's illegal in the Catholic majority country, so
Abortion is illegal in the Philippines - a majority Catholic country and former American colony - and has been for over a century. Under the law, women found to have aborted their fetuses face ...
Abortion in the Philippines: A true story
The law on abortion. Such is the fate of many Filipinas today. According to a Guttmacher Institute study in 2006, one out of three women aged 15 to 44 chooses to terminate their pregnancy through abortion. Abortion is a reality for many women in the Philippines, but many consider it taboo. The Church regards it as a mortal sin.
Abortion
Abortion is a common health intervention. It is safe when carried out using a method recommended by WHO, appropriate to the pregnancy duration and by someone with the necessary skills. Six out of 10 of all unintended pregnancies end in an induced abortion. Around 45% of all abortions are unsafe, of which 97% take place in developing countries.
Abortion in the Philippines
Wed 29 Jun 2011 10.35 EDT. "I heard a nurse say 'If you die, it's all your own fault'". Ana, a 35-year old Filipino, looks down as she recalls the day she was brought to the hospital in a pool of ...
Progress on Abortion Rights in the Philippines
1999: The PCHR viewed abortion as "immoral." In its position paper on House Bill 6343 entitled "An Act Legalizing Abortion on Specific Cases" introduced by Hon. Roy Padilla Jr., the PCHR registered its opposition to the bill for being "immoral and/or contrary to the moral standards and religious conviction of the Filipino people."
5 Conclusions
With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed. The Safety and Quality of Abortion Care in the United States offers a comprehensive review of the current state of the science related to the provision of safe, high-quality abortion services in the United States ...