COVER STORY

This might be your last year to access birth control

The slow and steady expiry of contraceptives in the Philippines is a quiet problem — one that will spill out of the slums and into gated subdivisions, as the struggle to provide reliable access to family planning options becomes more politicized.

 

Manila (CNN Philippines Life) — Joy Cabeñan has a problem.

Her bedridden mother, for one, has bone cancer. Rosalie Cabeñan was the subject of the award-winning GMA News TV documentary “Bente Dos,” named for the number of her children.

Joy, the sixteenth of 18 surviving children, was around 13 when the documentary aired in 2012. That same year, Joy Cabeñan swore she would not get married early.

Five years later, at the tender age of 18, she has been married for three years, with two children: a three-year-old named Angelo and an infant reaching three months. Her parents have around 12 grandchildren, the same number of people left in the household since some of her siblings left. Motherhood has aged her, as it did her mother.

And despite the media mileage that being part of a 24-member nuclear family can bring, they still live here: at a two-storey cement house in Baseco, Tondo, one of the densest and poorest communities in Metro Manila.

“Ayoko na talaga masundan. Kasi sa bunso ko, muntikan na akong mamatay diyan,” said Cabeñan. She recalled that she broke blood instead of water prior to delivering both her children.

“Nung hindi pa ako nasusundan sa bunso ko, nag-usap ako sa asawa ko. Sabi ko, gusto ko magpa-family planning,” she said. “Sabi ng asawa ko, ‘Huwag kang mag-family planning, gagawin pa natin lima yan!’ [Sabi ko,] ‘Ang kapal ng mukha mo, hindi mo nga kaya buhayin yung isa mo tapos dadagdagan mo pa!’”

RH Tondo and Baseco-3.jpg Joy Cabeñan, at 18 years old, is a mother of two children and sister to 21 siblings. Photo by JL JAVIER

Her husband earns roughly ₱600 a week, which they use to buy milk, rice, and a fraction of the medicines for her mother, which cost ₱25 a tablet, needed three times a day.

But Cabeñan is safe for now. After that conversation with her husband, she sneaked out and got an injectable — a contraceptive that kept her from conceiving for three months. After Angelica was born, she went and got an implant. It’s supposed to last for three years.

For now, these are Joy Cabeñan’s problems: how to pay for her mother’s meds, how to feed the baby, how to put food on the table. She has another problem, but she doesn’t know it yet.

By the time her implant expires, there may be no more contraceptives available for her.

You have the same problem as Joy Cabeñan. The problem is a quiet, sneaky one — one that will spill out of Baseco, Tondo and onto your streets, from the slums to gated subdivisions.

As early as next year, government and non-government organizations alike may be forced to halt the distribution of family planning resources. The reason is simple: There is a looming possibility that it will no longer be on the market. Not even over the counter.

By 2018, it might be possible that no Filipino woman — not Joy Cabeñan or you, whether you are a well-to-do mom with enough-kids-for-now or a career woman who wants to put childbearing off — will be able to avail of contraceptives for women.

***

On June 2015, the Supreme Court released a temporary restraining order halting the distribution of contraceptive implants and prohibiting the Food and Drug Administration (FDA) from “granting any and all pending applications for registration and/or recertification for reproductive products and supplies, including contraceptive drugs and devices.”

Alliance for the Family and Foundation (ALFI) declared its opposition to a total of 77 contraceptives, taking its case to court, arguing that contraceptives had abortifacient qualities.

“Sabi ng asawa ko, ‘Huwag kang mag-family planning, gagawin pa natin lima yan!’ [Sabi ko,] ‘Ang kapal ng mukha mo, hindi mo nga kaya buhayin yung isa mo tapos dadagdagan mo pa!’”

The Supreme Court denied a petition to lift the TRO in 2016, directing FDA to conduct a hearing that would allow ALFI to air its grievances and present its evidence. It also ordered that the FDA and the Department of Health (DOH) come up with specific guidelines to prove these contraceptives were non-abortifacient and allow “interested parties... to intervene.”

All this is on top of the Responsible Parenthood and Reproductive Health Law — which provides that these contraceptives be made distributable — being disputed in court.

For its part, the executive department, through President Rodrigo Duterte — keeping to an earlier promise — has signed Executive Order No. 12, which hopes to accelerate the implementation of the Reproductive Health Law (at least, by providing for collaborations between civil society and the private sector), even as access through public agencies faces a conundrum in the judiciary.

Still, the EO may not be enough. “The issue will be that no one will be allowed to provide any family planning methods ... whether it’s the government or the private sector or a UN agency doesn’t matter, because it’s the product registration that would be not in place,” explained Klaus Beck, United Nations Population Fund (UNFPA) Philippine Country Representative.

Beck describes two ways the TRO affects the public. First, although it only targets one form of contraception — the implant — it targets the go-to method for women in rural communities.

“The implants have increasingly become the method of choice for many women because it's very convenient,” Beck says. “That's particularly important if you're living very far away from health facilities, you have limited access to health services and health supplies.”

“Secondly, by having this TRO in place, it has sown a lot of confusion among people about what is and what is not allowed, which has meant that many healthcare providers, government units have been confused about what is covered [and what isn’t],” Beck continues.

klaus beck.jpg Klaus Beck, United Nations Population Fund Philippine country representative. Photo by JL JAVIER

Commission on Population Executive Director Juan Perez III estimated that by next year, only four out of the 48 available contraceptives would be on the market, in an interview in Esquire Philippines. The same report estimated that by 2020, condoms would be the only contraceptive available.

But Dr. Junice Melgar, founder of the Likhaan Center for Women’s Health, estimated that it would be as early as next year. Although these date estimations vary among sources, they all agree — to quote Melgar — that “there will come a time when not one contraceptive will be allowed and all women, whether rich or poor, will not have access to contraceptives.”

It’s unclear whether an actual move for a public hearing is in the works. Just this month, Perez and former Department of Health Secretary Esperanza Cabral called on the SC to lift the TRO again.

We tried to reach Supreme Court for comment on the subject.

Their spokesperson, Atty. Theodore Te, answered: “It’s a pending case so I cannot comment on it.”

But would there at least be a time that the SC is looking at for ruling on the case?

“The resolution of the SC pretty clearly states who has the burden in terms of time frame,” Te wrote back. “and it’s not the SC. The DOH should know that if it read the resolution.”

Sir, the TRO asked DOH and FDA to come up with detailed guidelines and allow ALFI to air their objections. Were they able to provide these to the SC already?

Te replied, “Please ask them, not us.”

***

“That will delay the process. Parang tinanggalan mo 'yung FDA ng mandato ... Kaya nga sila Food and Drug Administration eh,” says Dr. Eric Tayag, spokesperson of the Department of Health (DOH). He was referring to subjecting contraceptives to a public hearing. “Ibig ba sabihin lahat ng gamot na ice-certify, parang bakuna, gagawin mo nang ganung proseso?”

He said this at the DOH office in Manila, two weeks before we contacted the Supreme Court. This was in response to an update on the TRO.

eric tayag.jpg Dr. Eric Tayag, spokesperson of the Department of Health. Photo by JL JAVIER

“This is a situation wherein there are supplies, but you cannot buy them kasi wala ngang certification from FDA. So you are actually denying women of their rights sa family planning commodities,” says Tayag.

When Health Secretary Dr. Paulyn Ubial went on CNN Philippines’ The Source in January, she estimated that there were 400,000 contraceptive implants with DOH that were expected to expire in 2018. I ask Tayag where they are.

He waved an arm and said, “Nasa bodega.”

And then, “Parang siyang baso ng tubig na nakalagay sa mesa, na unless someone drinks from it, it’s not water.”

If critics of the Reproductive Health Bill are pro-family, so is DOH — in its own way. Tayag maintains: They are only trying to save mothers. He cites: Maternal deaths in the Philippines over a decade ago show 14 women die every day during pregnancy or childbirth.

“And there’s also science that tells us that 40 percent of these deaths can be prevented with family planning,” Tayag adds.

“Can you imagine kung tatlo 'yung anak niya and suddenly she leaves them kasi namatay siya? Most likely [that child] will never get out of the poverty cycle ... ‘Yung nanay ang fulcrum ng isang pamilya. Siya [ang] mag-aalaga,” he continues. “[She is] the one individual [who] makes sure the child, [in his] growing years ... is able to survive. At pag wala yung nanay, forget it. We have a generation of orphans.”

I ask Tayag if their hands are tied by the TRO.

“Hindi ko nga alam kung sa gobyerno natin ... Dito sa [health] center, ewan. Kung hindi pa mga nanay pupunta doon, hindi namin malalaman na may pinamimigay silang pills o ano man. Wala silang ina-announce ... hindi namin nalalaman.”

“[They’re] tied, but it’s not something na wala naman kaming ginagawa. Meron pa naman kaming mga supplies, but we cannot guarantee na in the next few years [ganito],” Tayag explains.

“Kumbaga, sa ngayon lang may [field] assessment na ginawa 'yung POPCOM (Commission on Population) ... kung ano ang impact ng TRO. Naapektuhan pati 'yung available namin na supplies, may hesitancy sa local government na ibigay. So we have to send memos regularly na hindi yan apektado ng TRO, ituloy niyo lang 'yan.”

“Ang ginawa ng DOH — as in the practice [worldwide] — is not to impose on which method women should use ... It’s about choice.”

 

Tayag says that they have gathered 117,000 signatures in a petition to make family planning methods more accessible. Their target: 1 million.

“Sinasabi namin 'to kasi we just want to tell women [that] your choices are running out ... maybe you can do something about it,” says Tayag. “Because kayo maapektuhan, kayo na magsalita. We cannot be lawyers for you ... Hindi ba it’s about time?”

***

“We’re not hearing them. We only hear about each other in media, which is very sad. Parang we’re washing our dirty linens in public!” the President of Pro-Life Philippines laughs, then sighs, almost exhaustedly. “There is so much hatred.”

Rita Dayrit was just inducted as president of the foundation in February. A prim and proper woman and hospitable hostess, she has been married for 35 years and has borne five children. We are sitting in one of the rooms of her house as she explains why she believes contraceptives bear abortifacient qualities.

“What [happens] when the woman is taking the pill ... It becomes bad soil. What happens is pagka-implant niyan” — she makes a popping sound ― “ma-abort 'yun. Kasi ang asim asim na because of the pills. That is hormonal abortion.”

“And the woman would regularly have her period. Hindi naman niya nalalaman na may tao na pala,” she continues. “Totoo naman, blood pa lang 'yun … but the Constitution states life begins at fertilization.”

rita dayrit.jpg Rita Dayrit, president of Pro-Life Philippines. Photo by JL JAVIER

I say that some officials and scientists argue that the contraceptives only work before fertilization.

“Oo,” she concedes, “it’s working all the time ... It makes your sinapupunan an unhealthy environment for anything … so you’re not even doing anything pero umaasim na 'yan.”

“Would you say that one of your goals is to take contraceptives off the market?”

“That would be nice. Being a Catholic pro-lifer, that would be nice — but that is beyond our control, beyond our capacity and our territory,” she answers.

Dayrit’s statements range from those difficult to fact-check — linking contraceptives to breast and cervical cancer — to those difficult to dispute: “Take care of the other aspects of life. Not just stopping people from being born ... but also the other issues of life, like nutrition, education, healthcare. 'Yung naglilihi pa lang, they give vitamins, [they can] go to a doctor every month.”

“If they prove that contraceptives are safe, then what would [your] stand [be]?” I ask.

She says that this proof should be a “meeting of the minds.” I ask the question again and she responds, “Yes, and then let the couples decide for themselves. As a Catholic, I would not recommend [it], but as a citizen knowing that things are beyond me, okay. But please, please ... ensure the safety [of women].”

The problem is, she says, they can’t even do that. She says that they were only presented product inserts as proof of safety; they of course vouched for the products. She adds, “Wala nga silang ma-present na studies na safe. Show us that it is safe.”

Baseco.jpg A worker estimates the length of an implant she is preparing to insert. Though the contraceptive was banned from government distribution by a Supreme Court order, they remain popular among women, who can get free provisions from non-government organizations. Photo by JL JAVIER

Dayrit concluded the interview on a light note, even open to collaboration with the government. About a week after the interview, she corrected herself via text message, citing a recent conversation with one of the clergy.

“He told me that partnerships were forged in the past but then the government used it against us by saying that the Church now advocates the use of some forms of contraception apart from the natural method citing [our] partnership,” she disclosed.

Back at the interview at her house, I ask how they would get their message across to non-Catholics.

“Self-control, chastity, purity are not Catholic traits. They are traits of a person who is acting like a person, because we are a species that has reasoning,” she says. “We can wait. We are not like dogs that when we need to do it, we just do it… Delayed gratification is training in character.”

“[Using contraceptives] is against my belief that marriage should always be open to life,” says Dayrit. “If you don’t want to get pregnant, you don’t do it.”

***

While access may be a problem in the Philippines, there is no lack of options when it comes to contraceptives for women all around the world. Here’s a list of some endangered contraceptives in the Philippines that face a looming expiry:

  • Pills: A hormonal contraceptive that has to be ingested daily. Some pills only work if ingested at the same hour every day.
  • Injectables: Also a hormonal contraceptive, which lasts three months, and is injected.
  • Implants: A hormonal contraceptive that lasts three years; tiny rods that closely resemble cotton bud stems, the implant is inserted into the upper arm and are the main target of the TRO.
  • Intrauterine Device (IUD): A small, T-shaped device inserted in the uterus which works for as long as ten to twelve years, but can also be removed any time. The copper in the IUD is toxic to sperm cells. Side effects may include heavy menstrual flow or cramps in the first few months.

reproductive-health---pills.jpg Birth control pills are hormonal contraceptives that have to be ingested daily. Some pills only work if ingested at the same hour every day. Photo by JL JAVIER

All these methods can supposedly be as high as 99 percent effective, although the contributing factors vary — especially with different lifestyles and traits among women.

If you’re the busy type who forgets regular dosage, pills might not be advisable. If you’re allergic to copper, shy off the IUD. If you have a heart condition or hypertension, you might want to stay away from hormonals.

Dr. Junice Melgar explains that the main action of all these contraceptives is to “prevent ovulation [and] the release of the egg from the ovary.”

“And the other function of some is to thicken [cervical] mucus, so that the sperm cannot penetrate,” she adds. “So they don’t even reach fertilization; they all act very early.”

Pro-Life Philippines argues that some of the drugs prevent implantation, but work after fertilization. The first of the drugs it mentions in its 19-page commentary is Levonorgestrel, the same one that the World Health Organization endorses. WHO says it delays fertilization.

“Contraceptives cannot cause abortion, because they cannot work once a woman is already pregnant. Abortifacients are different sets of drugs from contraceptives,” Melgar explains. “For example the drug Misopostrol, which a lot of women use here, which is usually marketed legally for … ulcer, gastric ulcer, actually can work to contract the uterus and expel. It’s abortifacient. None of the contraceptives work [that way].”

junice melgar.jpg Dr. Junice Melgar, founder of the Likhaan Center for Women’s Health. Photo by JL JAVIER

In the same document, citing papers from the American Fertility Society among other organizations, Pro-Life PH lists the risk factors of the IUD as ranging from “spotting between periods” to “death.”

However, WHO also endorses the method, and vouches on its safety, adding that “risks of infection, expulsion or perforation are low.”

This is just a couple of areas of contention. The list goes on.

***

UNFPA Philippine Country Representative Klaus Beck vouches on the quality of these contraceptives.

“Most of these are internationally produced contraceptives that are sold worldwide in many, many other countries,” he says. “These are very ... well-researched, well-documented methods of contraception that have been also revisited not only by the Philippine Food and Drug Administration, but also by international bodies ... including the World Health Organization.”

The primary mandate of UNFPA is achieving universal access to reproductive health, “for delivering a world where every pregnancy is wanted, every childbirth is safe and every young person’s potential is fulfilled.” Apart from advocating policies and data-gathering, the agency works to “ensure a steady, reliable supply of quality contraceptives.”

“In places like Tondo, some husbands think the more the merrier despite the poverty, or bear an impression that using protection makes them less of a man.”

On the wall are the faces of children and their slogan: People count. Despite their agency bearing the word "population," Beck is the first to say their mission is not about population control. “It’s about people counting,” he says, “not about counting people.”

“It’s almost unimaginable ... because I don’t think any place in any country has ever seen such a scenario unfold,” Beck contemplates as he leans forward in his seat.

“It would be a deep, deep crisis and it would be a huge, huge health issue. You would see many, many women dying if that was to be the case, and it’s hard to imagine that scenario will be allowed to unfold without any type of action being taken,” he continues. “From an international perspective, it would be a history that we would never see unfold in any other country, that there would be no method of family planning except for maybe condoms.”

His agency has slowly eased out of work in communities to make way for more technical and administrative support to the Philippine government.

The Philippines first inked its commitment to accessible family planning at the International Conference on Population and Development in Cairo, in 1994. It reiterated this commitment in the Family Planning Summit in London, in 2012, where the Philippines agreed to invest more in family planning and reduce unmet need for it by 2020.

A ruling against contraceptives would not only break this promise, but it would also make it impossible for the private sector or international organizations to donate contraceptives.

Beck goes through the figures: 18 percent unmet need for family planning — six points higher than Asia’s average of 12. All this despite an estimated 75 percent support for the Reproductive Health Law.

Likhaan clinic in Tondo.jpg Hall of small Likhaan clinic at Zaragosa Street, Tondo, Manila. Photo by JL JAVIER

“I don’t think you would see other countries coming out and putting pressure on the Philippines to achieve their goals, because the goals are the Philippines’ own commitments,” Beck says. “I think even more importantly — it matters on a daily basis for people’s lives that are at risk.”

“[It] is already affecting access to choices, reducing choices. Every month, every year that goes on… we have more limited choices, which means there’ll be less use of modern methods of family planning,” he continues. “Which means, we know from evidence, more maternal deaths, and… more illegal abortions. We know what the evidence says.... If your goal is to reduce abortions, then family planning is a solution, not the problem.”

***

Dr. Junice Melgar just returned from the Commission on the Status of Women in the United Nations headquarters in New York. She was there as a non-government organization participant; Melgar founded the Likhaan Center for Women Health, which operates in Tondo and other clinics across the country.

She recalled that there was a blizzard outdoors. Indoors, she recalled, “The U.S. for the first time sided with Russia and Iran and all these really ... fundamentalist countries that oppose contraception, abortion, and they were actually expanding family obligations.”

The problem with the natural planning method, a number of the sources have said, is it only works for women who have a regular period. It also assumes, they explain, that women lay down the law with their bodies — but this is not necessarily true, especially in places like Tondo, where some husbands think the more the merrier despite the poverty, or bear an impression that using protection makes them less of a man.

Melgar recalls encountering a case where the husband would stick his fingers into his wife just to check if the IUD string was there.

“It’s an indication that regardless of how the world perceives us as a gender equal country, it’s really not true in some communities.” 

When asked about the push for a public hearing for contraceptives, Melgar said, “FDA never does that. Not in any country. That particular decision of the Supreme Court is kind of unique, because it would open not just the contraceptive products, but all products of FDA to a public hearing.”

“We know what the evidence says.... If your goal is to reduce abortions, then family planning is a solution, not the problem.”

She recalled that the FDA usually takes three to six months to determine the safety and efficacy or products, and now that could be delayed.

“Anyone who opposes the medicine needed to be given time ... it adds another layer of bureaucracy,” said Melgar. “[FDA] can still issue their own opinion based on their scientific appreciation of the facts, but even their decisions could be subject to a litigation in the Court of Appeals.”

 

“Initially we thought they could be convinced by scientific evidence. Apparently [not],” says Melgar. “Because they have these very strong beliefs — beliefs nga eh … Nobody could challenge anyone’s beliefs. A lot of people turn away from science, because they couldn’t understand it.”

“[The issue] has become so politicized. Science cannot explain it anymore. Politics has defined what science is in contraception, whether a contraceptive is abortifacient or not,” she adds. “I don’t think many of [our legislators] have a good appreciation of science.”

Melgar says that they had an “inkling” that the decision was in the works; they had been informed that the verdict would be a “win-win,” though she is not sure what that means.

“Women have been able to enjoy the rights for quite some time, even in the Philippines,” Melgar notes of the international shift toward conservatism. “They know how important it is, and I’m sure that they will fight for it — in the same way that they will fight for contraceptives here, before the Supreme Court, or even outside.”

So you are confident that the women here will not allow that?

“It’s too important,” she adds. “Women know what contraception means to them.”

While some women chase the reproductive clock, time chases others. In places like Tondo, women have all the time in the world to reproduce children, but not enough to raise them or provide for them — especially now that contraceptives are inching towards a possibly permanent, national expiry.

***

Joanna Cerbito has a problem, but she doesn’t know it yet. Another resident of Baseco, she is a local volunteer at Likhaan, 30 years old, with two kids: a fourth-grader named Chellow, and a six-year-old named after her husband, Raymond.

RH Tondo and Baseco-7.jpg Ever since a miscarriage after Chellow and her brother were born, Joanna Cerbito and her family decided they wouldn't risk it again. "Sabi namin, tama na yung dalawa," she recalled. "Kung maraming anak, mahirap magbigay ng mga pangangailangan nila." Photo by JL JAVIER

Cerbito has been on the IUD ever since a miscarriage for her would-have-been third child.  Thankfully, her husband is supportive of family planning. Other women in the community get their pills crushed or thrown out at best, and some women get beaten at worst.

“After 12 years, kung gusto mo ulit magpa-IUD, puwede naman,” she says, explaining how it works. “Ewan ko lang, kung ako'y hindi pa magme-menopause, gagamit pa ako ulit niyan.”

She recalls when she went to Congress a few years back to show her support for reproductive health.

“Nag-rally kami noon para ipasa 'yung RH Law kasi maraming... hindi pumapayag,” says Cerbito. “Hindi rin kami pumapayag. Paano na pagka-wala 'yung mga family planning? Eh di magsisidamihan kami dito.”

She throws back her head and laughs.

“Hindi mapipigilan yun. Lalong lalaki ang populasyon, lalong maghihirap.”

I ask her if she even feels that the law she fought for was passed.

“Hindi nga eh. Hindi ko nga alam kung sa gobyerno natin ... Dito sa [health] center, ewan,” Cerbito shrugs. “Kung hindi pa mga nanay pupunta doon, hindi namin malalaman na may pinamimigay silang pills o ano man. Wala silang ina-announce ... hindi namin nalalaman.”

The government bought a lot of implants, I tell her in Filipino. But they can’t distribute it because of a temporary restraining order from the Supreme Court. I did not mention that the availability of all family planning methods depended on this decision, because she immediately looked confused. I asked her if she had heard of the order.

Cerbito frowns and says, “Hindi ko nabalitaan yun.”

***

Editor's note: After this article was published, Rita Dayrit sent a clarification to the following statement: "It [using contraceptives] is against my belief that marriage should always be open to life .... If you don't want to get pregnant, you don't do it." Dayrit clarified that her statement is this: "I abide by the teaching of the Catholic Church that marriage should always be open to life thus if a married couple does not want to have children yet then they should abstain if a woman is fertile."