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 with no explicit exception for high-risk pregnancies, fetal impairment, rape, and incest.¹ Nonetheless, 1.1 million induced abortions occur in the country annually, a number that was estimated to increase by 14.6% in 2020.² 1000 Filipino women die each year from post-abortion complications.³

Unsafe abortion contributes significantly to preventable maternal mortality in the country yet remains the sole option for many young, low-income, and rural women,^1,3 as 75% of Filipino women seeking abortions are financially unable to raise another child. Disturbingly, over 10% of women are victims of sexual violence.³ Unsafe abortive methods include unsupervised catheter insertion, abdominal manipulation or massage, and self-induction with unapproved herbs.^3,4 Misoprostol, an internationally accepted abortifacient, also remains illegal and inaccessible due to restrictions on abortion. These frequently result in mortality from hemorrhage, sepsis, genital trauma, and bowel necrosis, with many survivors suffering long-term complications (e.g., poor wound healing, infertility, and incontinence).⁵

Though the provision of humane post-abortion care is constitutional, Filipino women face both societal stigma and maltreatment from healthcare providers, the latter ranging from verbal abuse and religious sanctimony to outright refusal of care.⁴ With over 80% of the Filipino population identifying as Roman Catholic,⁶ strong religiosity may be a contributor to societal stigma. This, compounded by fear of legal prosecution, may lead women to delay seeking post-abortion care. Filipino healthcare providers themselves risk criminal prosecution, license revocation, and ostracisation from peers for participating in abortion-related activities.⁷

Legal barriers further thwart safe post-abortion care. A 2016 Department of Health Administrative Order (DOH AO), drafted in consultation with reproductive health advocates, provided protections on confidentiality and redress mechanisms for abortion patients.⁸ However, a 2018 DOH AO, developed without consulting health advocates, removed these guidelines explicitly maintaining patient privacy.⁸

Women who continue with unintended pregnancies are exposed, willingly or unwillingly, to the effects of pregnancy itself, which range from normal physiologic (e.g., increased workload to the heart, hypercoagulable state of the blood) to life-threatening (e.g., preeclampsia, venous thromboembolism).⁹ Quality prenatal care manages these risks, but remains out of reach for low-income Filipino women, especially those dwelling in geographically isolated and disadvantaged areas (GIDAs), due to high out-of-pocket costs and concentrated healthcare resources in urban centers.¹⁰

Religious, political, and socioeconomic forces influence the Filipino woman's reproductive freedoms beyond abortion. Unintended pregnancy remains a public health challenge in the Philippines because of limited access to contraception and sexual and reproductive health (SRH) services. Over half of all pregnancies are unintended and over half of these unintended pregnancies end in abortion.¹¹ Seventeen percent of Filipino women have an unmet need for family planning, an estimate projected to rise by 67% in 2020, due to community quarantine-related service disruptions.² Such unmet needs may be partly due to the deep-seated political and cultural power of the Philippine Catholic Church, ineffective widescale implementation of sexuality and contraception education, high rates of gender-based violence, stalled implementation of the Reproductive Health (RH) Law, and the delayed registration of contraceptives due to a former restraining order issued by the national Supreme Court.^1,3,4 The RH Law, passed in 2012, promises to provide modern contraceptive services, counseling, and sex education, especially for rural and poor Filipinos.³

We advocate for the decriminalisation of abortion and ensuring access to safe abortion, which begins with halting the prosecution of patients and abortion care providers. Training obstetric and primary care providers for safe abortion care is also critical to expand access, especially in GIDAs. In the meantime, to reduce maternal morbidity and mortality from unsafe abortions, policies addressing post-abortion care should prioritise the expansion of existing treatment options by nurses and midwives according to WHO standards and should be made in consultation with SRH advocates. Legislation should be crafted to protect the privacy of women seeking these services.

The country must address the determinants underlying unintended pregnancies through efforts to promote SRH literacy and universal access to modern contraception, while effectively addressing gender-based violence. Finally, to improve outcomes for people with unintended pregnancies, it is imperative to reduce out-of-pocket costs of prenatal care and mobilise prenatal care providers towards and within resource-limited areas. Ultimately, it is time for the Philippines to rethink its long-standing cultural condemnation of induced abortion and consider how safe abortion access can not only save lives but also defend women's health, security, and dignity.

Contributors

Conceptualisation, resources, writing (original draft), writing (review & editing) - JRMP, GRSM, PJCN, MVPNA, EPDP, FDVH, CRAP.

Declaration of interests

We declare no competing interests.