Life and death in the Philippines

Abstract

In a country in which contraception is controversial, abortion illegal and in which reproductive rights are limited, IVF is an unaffordable dream for most couples. But things are slowly changing in the only Christian democracy in Asia: the Philippines. In December 2012 the Senate passed the Reproductive Health bill and president Benigno Aquino III signed the measure into a law which is still not implemented due to the opposition of the ultra-orthodox Roman Catholic Church. However, the more liberal perspective of pope Francis on sexuality and human reproduction may have an positive impact on this issue. While government funding for contraceptives is still being opposed, the IVF market is estimated to grow considerable. This creates promising opportunities.

In the summer of 2013, news agency Reuters (1) predicted exciting opportunities for the fast-growing IVF market in Asia as women delay giving birth and fertility rates are plummeting due to the crisis. According to the Asia-Pacific industry lobby group Aspire (Asia Pacific Initiative on Reproduction) the IVF market will increase massively, despite the expensive cost of the treatments. More affordable IVF options, including micro-IVF (also known as mini-IVF, eco-IVF, low- or no-stim IVF, and eco-IVF) as well as natural cycle IVF are becoming popular. There is a bright future for IVF, especially in India and China but also in countries like Singapore, Japan and South Korea. According to Aspire “their governments are becoming concerned about the ‘low fertility trap’.” This means that fewer children leads to less spending on “education and accompanying services, making it even more difficult to boost birth rates”. Even less affluent countries such as Cambodia, Vietnam and also the Philippines, with higher fertility rates, want to encourage births to counter ageing populations, Aspire proclaims.

Aspire, of course, only has wealthy customers in mind. From Indonesia to Kazakhstan and from Iran to Japan affordable IVF means affordable for the well-to-do. The introduction of very cheap IVF for all layers of society in developing countries is another matter. It is a complex matter, involving not only mere access to a cheaper IVF technique, a better health care and government subsidies. In some cases, it involves a confrontation with ancient prejudices of powerful moral institutions. Like in the Philippines, an overpopulated country with the third highest fertility rate in Asia, where daily life is dominated by an ultra-orthodox Catholic Church. Its approach to IVF is a fundamental ‘no’.

Ring of fire

It is a land of extremes and contradictions. Its location on the Pacific Ring of Fire and the tropical climate make the Philippines one of the most vulnerable countries on the planet. Surrounded by the Sulu Sea, the Celebes Sea, the South Chinese Sea and the Pacific Ocean, the 7.107 Philippine islands are susceptible to earthquakes and typhoons. Not only the weather is extreme; the biocultural diversity of the country is spectacularly rich and in many ways unique as well. The Malay and Chinese influence, mixed with the indigenous cultures, have blended with 300 years of Spanish, almost 50 years of American and 5 years of Japanese rule. The result is a complicated, family oriented and idiosyncratic culture which is difficult to assess by western or other standards.

This remarkable developing country has other crowns upon its heads: it is the third largest English-speaking nation and one of the most female-friendly countries on the planet; it is the first democracy and the only Catholic country in Asia. Although admittedly the Filipino definitions of ‘democracy’ and ‘Catholicism” are somewhat unusual. The Catholic Church still dominates pretty much of the ethical and moral spectrum in a way that resembles the preconciliary Church in Europe and the Americas. While its population strikes foreigners as extremely pleasant and helpful, the country is prone to much violence. Endemic corruption, clan violence and deep political rivalries invariably lead to bloody elections. The military regularly clashes with the communist rebels of the NPA and with the Muslim Moro National Liberation Front on the resource-rich island of Mindanao. And in the midst of all this upheaval and uncertainty there are the Filipino children. They are one of the Philippines’ riches.

The unborn

And one of its wastes.

In Quezon City, someone left a plastic bag with twin fetuses, six months old, at the back of St. Paul the Apostle Church.

In the Quiapo Church in Manila, a fetus was found inside a jar hidden in a basket of fruits. It was left as an offering during Sunday Mass.

Another fetus with a severed head was discovered in a Tupperware inside the compound of the Santa Cruz Church in Quiapo – it was thought to be a bomb - and yet another one near the entrance of the Minor Basilica of the Black Nazarene.

Recently three aborted fetuses were found in a church’s women’s bathroom in Quezon City.

The unborn and churches have a strange relationship in the Philippines as churches often serve as a favourite dumping ground for unwanted fetuses.

According to reproductive-rights groups, this symbolises the rising tension between the Catholic Church and the Filipino people concerning matters of reproductive health. But according to others there is a more pragmatic reason for the disposal: fetuses are dumped in and around Catholic churches as the mothers believe that this saves the child’s soul. “Don’t forget that we are pragmatic people,” says a woman who guides me through the subtle mazes of the Filipino culture. We are near the Quiapo Church in metropolis Manila“. The vendors and stalls that are clustered around holy places like this sell anything you want. From contraceptives to drugs and ancient potions used to induce an abortion. Killing and redeeming, it happens on the same spot. We are practical people.”

Fact is that the absence of a strong family planning and reproductive program in the Philippines has had enormous consequences for its population. In the absence of national legislation to regulate and create universal access to reproductive health care services, local government units implemented their own local policies. With terrible consequences, as documents ‘The Imposing Misery: The Impact of Manila’s Contraception Ban on Women and Families, a report by the Center for Reproductive Rights’(2). It describes the devastating impact of a remarkable decision of Manila’s mayor. In the year 2.000, Mayor Jose Atienza decided to “uphold natural family planning” and discourage “the use of artificial methods of contraception like condoms, pills, intrauterine devices, surgical sterilization, and other methods.” Atienza was the former president of Pro-Life Philippines, an organization that promotes the exclusive use of natural birth control methods. His law even forbade city health centers and hospitals from giving contraception to women in need. His ban favoured the promotion of ‘natural’ family planning in order to improve morals. Only in 2012 did Manila relax the laws on contraceptives.

Abortion mentality

The Catholic Bishops’ Conference of the Philippines (CBCP) warned the public that a “contraceptive mentality” preceded an “abortion mentality” (3). Poor women are the main victims. A survey conducted in Manila, in 2006 (4), showed that although the poorest Filipinos, which make up 10 percent of the population, prefer two to three children, they usually have six or seven. Yearly around 560.000 women have an induced abortion, 68% of them are poor. Around 90.000 are hospitalized for post-abortion care and1.000 die. Safe surgical abortions can cost up to 300 euro, so many have unsafe abortions (5).

According to the Center for Reproductive Rights (New York) (6), Filipino women use a plethora of methods to induce abortion. Some use insertion of objects (such as catheters, hangers and brooms) in the vagina, plant and herbal concoctions (pamparegla), abdominal massage (hilot) and ingesting Vino de Quina and other liquors. Others beat their bellies, exercise intensively or jump from high places. Cytotec, a drug against stomach ulcers, is also commonly used. Only a third of Filipino women get the medically prescribed procedures for terminating a pregnancy. And because abortion is prohibited, clinicians deny women who seek a safe abortion. “I got married at 19 and tried to be pregnant for ten years,” says Kim Pizarro (32), a worker from Cagayan de Oro. “I did not succeed, and the reaction of my husband and his family was extremely damaging. I tried everything from ovary massage to drinking potions and taking some medicines to become fertile. I lost weight, he started working less and stopped drinking alcohol. But nothing happened. I tried to adopt one of the kids of my best friend, she has five, but she refused. The family pressure got very high. His family told my husband to take another wife because marriage without kids is pointless.” Kim got separated. “My ex has three kids now, from his mistress. And every year brought him another child. I live with my family and I stopped looking for a husband. Men want kids, I cannot make them happy. So now I have a female partner. Not openly, but it brings a certain kind of warmness in my live, and that is all I want right now.”

The fate of people like Kim is unmentioned in Filipino society. Even though one in 10 Filipinos cannot conceive, according to a study commissioned by pharmaceutical firm Merck Serono (7), infertility remains a taboo in this densely populated and land-poor island nation of nearly 106 million people. Concerning children, the focus is always on overpopulation in the Philippines. According to a recent report the Philippine population will grow by 85 percent in the next six decades (8), although huge numbers of women have gone to work overseas. More than one third of its population is younger than 14 years old. More than one third of the population lives in real or extreme poverty. But most people perceive themselves as poor. A survey found 54 percent or about 10.9 million families claiming to be poor (9). They consider a childless relationship a failure. Traditional IVF treatments are unknown to them. Studies like that of Merck Serono’s do not target them. This year the company started an infertility awareness campaign in 13 Asian countries. In the Philippines, it was organised in collaboration with the nation’s top fertility doctors and leading centers for assisted reproductive technologies (ART). The campaign Hope for Starting Families (August 25-31) wanted to make it easier for couples to “understand their situation, find their partner in fertility care and encourage them to take the first steps in starting their family” (10). At least those families who are wealthy enough to pay for it and ignore or hide from the Catholic Church.

Catholic Church

Family planning and maternal care are no luxury in the Philippines. For 14 years, the Catholic Church has made the family planning initiatives of the government a battle of epic proportions. This year, the Philippines Supreme Court has delayed a reproductive health bill that had been decades in the making. The new law guaranteed universal and free access to almost all modern contraceptives, also for the nation’s poorest people – through government health centers. It meant also reproductive health education in state schools and it recognised a woman’s right to post-abortion care as part of the right to reproductive healthcare. But it did not, however, legalize all contraceptives, emergency contraception remains illegal. It also reinforced the legal status of human embryos. The “life of the unborn” is protected, which leaves the door open to ban in-vitro fertilisation – because some of the fertilised eggs created in the process are destroyed. The law also allowed private and religion-affiliated hospitals to deny reproductive health services.

The controversial law - to give Filipino women access to sexual education, subsidised contraception, family planning and prenatal care – would be reheard by the court in June 2013. But the Reproductive Health Law was suspended indefinitely by Supreme Court in July 2013 (10). The conflict between local bishops and an increasingly secular society was apparently won by the former. The hope that thousands of maternal deaths through often fatal illegal abortions would be prevented, and families and communities would rise out of devastating poverty appeared to be in vain.

The Catholic Church may have won this point in its campaign against maternal healthcare, but it has probably already lost the war, is the general opinion. The impact of the church on society is diminishing by the impact of urbanisation, migrant workers and a popular culture unusually open about sex. Catholic influence is also being eroded by the enduring presence of two nationalist Christian denominations, the Iglesia ni Cristo, and the Aglipayans, by the success of Protestant sects and evangelical and charismatic preachers. And then there are Pope Francis’ comments urging a change of attitude on those issues contraception, abortion and homosexual marriage. Philippine Catholic leaders are standing firm against the Pope’s words, but a progressive position of the new pope will surely finds its way between the masses of the faithful.

Prince and Princess

This also opens the door for IVF. It was Angela Ho who in 1996 established the first successful IVF center in the Philippines. That year the first IVF birth was a fact. Although the Catholic Church only condones procedures that ‘assist’ conception that will happen naturally, such as intrauterine insemination and gamete intrafallopian tube transfer, IVF has gained increasing popularity. That is due to some Filipino and American celebrities having admitted to having gone through IVF. Such as gay businessman Joel Santos Cruz, president & CEO of Aficionado Germany Perfumes, who contracted a surrogate mother in Moscow. “I chose a woman who looks like Julia Roberts,” he told the media. “A 31-year-old long-legged single mother.” Santos Cruz called his twins Prince and Princess.

The maximum number of embryos allowed for implantation in the Philippines is two. There are currently five centers that do IVF in the Philippines: Center for Reproductive Medicine (Manila), Victory A.R.T. Laboratory Manila, Center for Advanced Reproductive Medicine and Infertility (Cebu), Kato Repro Biotech Center (Manila) and Repro Optima Center for Reproductive Health (Cebu). The procedure, however, is limited to married couples only. The average success rate is around 30% to 50% depending on the center. The average cost of IVF is about P135.000 (2.300 euro), plus doctor’s fee (which can range from P75.000 (1.270 euro) to P400, 000 (6.800 euro). This cost covers only one IVF cycle and does not include medication, ultrasound, and other expenses. There is no infertility health insurance, so couples have to cough up the money themselves. Good to know: the average annual income per capita in the Philippines is less than 100 euro.

“No wonder, treating infertility is very stressful,” wrote one Deborah (32) on her blog infertilityphilippines. “Aside from the emotional stress, there is also the financial burden as to whether you can afford all the treatments needed to bring you a child.” In June 2013 Deborah, a housewife from Manila, got pregnant after seven expensive years of trying. She went from IUI to IVF and from the Philippines to Taiwan. She is one of the Filipina’s who testify about their journey to happiness anonymously. Her posts are read by 37 women.