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May 16, 2012

The Issue On Population Issues 2/3

The great desire of the RH bill is actually to lower maternal deaths through improving maternal health care. There is no argument here. Maternal health should be a priority of the government. In fact, with or without the bill, maternal health is already part of the Department of Health’s program ever since, the reason why I feel there is no need to have a bill or law on this since there have been many laws in the past concerning this. The problem with the Philippine government is its lack of implementation of these laws and programs.

Based on personal observation, among the reasons why government could not implement maternal health care in the past is because 1) lack of prioritization when it comes to budget appropriation for health. This is true both on the National and Local government. Many politicians don’t feel they should give more money to our health care workers and the health programs of the government. The thinking is still dole-out and for many politicians, the mere fact that they are giving out cash incentives to people who are sick or coming out of the hospital, that is already for them a support to the health program of the government; 2) Many local chief executives won’t hire or can’t afford to hire health care professionals. For example, the Local Government Code requires that all LGU’s must hire a Municipal Health Officer. This is an imperative position. But some Local Chief executives won’t hire simply because they don’t want to spend the money.
Some Local Chief Executives cannot afford to hire because they don’t have enough money coming from the National government (Internal Revenue Allotment). Worse, some of these health care professionals are being “politicized” by these mayors and vice-mayors. Thus, while we produce at least 10,000 doctors a year, many of our rural frontlines don’t have doctors because most would prefer to practice privately or in the urban areas.

It is no surprise then why the Philippines has yet to reach its target of reducing maternal deaths: not because there are too many women giving birth, but there are too few doctors and nurses and midwives being hired. And I have already explained the common reasons why only a few are being hired.

Therefore, instead of investing on human resources (which we have) and infrastructure such as birthing facilities (which we badly need), our government would instead buy condoms and pills to be given out for free with the hope of solving the problem of maternal deaths.

In some countries, they even pushed for legalizing abortion in order to save mothers from dying due to complications of pregnancy and childbirth.

In a study done in Chile, as cited by a panel of Obstetricians and Gynecologists, it noted that Chile’s maternal-death rate continued to fall even after the government banned abortion.

What the study emphasized is that increasing education levels, maternal literacy rate and maternal health services appear to be the most important factors in lowering maternal deaths.

One OB-GYN in the panel working in Nigeria mentioned that, “Health systems in developing countries are failing because the focus has been shifted to “reproductive health,”” The same OB-GYN further stated that “there is the need to strengthen family, community and cultural factors as the first-line support for poor mothers and to increase training and staffing of health facilities to combat maternal deaths.”( http://www.lifenews.com/int1651.html)

That is why some countries even pushed for laws protecting the unborn. One European country that has very rigid laws against abortion and protecting the unborn is Catholic Ireland. Based on the World Economic Forum Gender Gap Report of 2009, Ireland, despite the ban in abortion, has the lowest maternal mortality ratio (1 per 100,000 live births) (http://www.weforum.org/pdf/gendergap2009/Ireland.pdf).

But then one would mention, as mentioned by Representative Edcel Lagman in his speech in support of his RH Bill, that Ireland, while Catholic and has anti-abortion laws, has laws also that promote Contraception. Further reading of their laws on contraception reveal that while they allowed the use of artificial contraception, the evolution of their laws started with very restrictive measures such as requiring of prescriptions for the purchase of oral contraceptive pills. The practice in the 1980’s was to even indicate in the prescription whether the patient buying the OCP’s is married, since only married persons are supposed to use the contraception.

In the same Gap Gender Report, Indonesia, which has a big population and a nation which aggressively promotes contraception, has a fertility rate of 2.20 births per woman and a population growth rate of 1.15%, definitely much lower than the Philippines which in the same report was stated to have a fertility rate of 3.30 births per woman and a population growth rate of 1.87%. Indonesia has a much higher contraceptive prevalence rate among married women (58%) than the Philippines which has only 51%. But Indonesia has a much higher rate of maternal deaths (420 per 100,000 live births) than the Philippines (230 per 100,000 live births). The reason for this high incidence of maternal deaths in Indonesia may be due to its low female literacy rate.

Malaysia on the other hand, also has a low contraceptive prevalence rate among married women (55%) but it has a much lower maternal mortality ratio than Indonesia and the Philippines: only 62 per 100,000 live births! What could have lowered down the maternal deaths in Malaysia? The same report indicated that Malaysia posted a 100% or births attended by skilled health workers.

Vietnam did the same thing. While it has a high contraceptive prevalence rate of around 70%, its births attended by skilled health workers is 88% thus lowering the maternal deaths to around 150 per 100,000 live births only.

The said data would only indicate that contraceptive prevalence rate (includes artificial and even modern-natural) as a factor which drives maternal deaths up or down go is not reliably indicative of the pattern.

Theoretically, one would say that an increase in the use of contraception (both artificial and even modern-natural) would also indicate a decrease in maternal mortality ratios. In fact, the USAID, one of the leading international agencies that supplied contraception to the Philippines in the previous years, produced a study saying that it is so.

However, a review done in 2005, an analysis based on the WHO systematic review of maternal mortality and morbidity (published in BMC Public Health, 2005), which employed the methodology of using regression models, relationships between study-specific and country-specific variables with the maternal mortality estimates, showed that contraceptive prevalence rate is not independently associated with maternal mortality in the multi-variate model.

Data tabulated (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1351170/table/T2/) showed that Africa has the highest maternal mortality ratio (498) but also has the lowest in childbirths attended by skilled birth attendants, lowest female net primary school enrolment ratio and also lowest contraceptive prevalence rate. Latin America and the Caribbean has a much higher contraceptive prevalence rate than Africa but its maternal mortality ratio, although not as high as Africa’s, is much higher than the maternal deaths in Asia which has a much lower contraceptive prevalence rate. The reason perhaps is because Latin America and the Caribbean posted a much lower rate of childbirths attended by health professionals than Asia. Thus the review concluded that “the findings here are supportive of the potential positive impact of skilled attendant at birth to reduce maternal mortality. Independent of this, increased health expenditure is also an important indicator supporting that not only skilled care but also general health infrastructure has an impact on maternal mortality.”(Betran, Wojdyla, Posner and Gulmezoglu, 2005)

Thus, an effective option for the Philippines to reduce its maternal mortality ratios is the deployment of health workers in rural and far-flung areas. In fact, in one of his lectures on the Philippine health scenario, Dr. Jaime Galvez-Tan, former DOH secretary, recommended that a one midwife:one barangay strategy is effective in reducing maternal deaths. This is how other countries did and they were able to reduce maternal deaths by half in the span of 3 years. Asked if the government had the funds to do so, the former DOH secretary confidently said yes. The problem is not the lack of funds, he said, but the lack of knowledge on how to use these funds.




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