Compassionate care eludes post-abortion patients

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By ELENA MASILUNGAN. Originally published on Newsbreak.
Newsbreak’s Maggie de Pano Fellow

Government has a policy aimed at ensuring proper treatment for women suffering from post-abortion complications. But has it worked?

MANILA, Philippines – Abortion is a crime and a sin in predominantly Catholic Philippines. But because women continue to have it, the government has put in place a policy that sets aside these considerations so women suffering from complications as a result of unsafe abortion could get treatment from health facilities.

Called the Prevention and Management of Abortion Complications (PMAC) policy, it was issued by the Department of Health in 2000 “to address the health and medical care needs of many Filipino women who have had abortion, regardless of cause.”

Since then, however, the policy has been rendered “dormant”—a casualty of the country’s restrictive law on abortion, the prevailing negative attitude toward it, and the reluctance of health providers to earnestly respond to it lest they be seen as condoning it.

When the policy was announced in 2000, DOH estimated that 46 induced abortions happened every hour in the country.

The profile of women who had induced abortion shows that 90 percent of them are married or are in a consensual union. Nearly 90 percent are Roman Catholics, even if the Church emphatically condemns the practice.

Socio-economic considerations play a big role, the numbers indicate. Two out of every three women who opted for abortion are poor. More than half had at least three children by the time they decided on abortion.

Killing mothers

Data from the health department shows that, on average, one out of every 10 women admitted in hospitals accredited by the Philippine Obstetrics and Gynecological Society as obstetrics and gynecological cases had to seek treatment due to post-abortion complications.

A Guttmacher Institute study notes than in 2008, there were 560,000 induced abortions in the Philippines, with 90,000 women seeking treatment for complications, and 1,000 women dying because of them.

Unsafe abortion is among the top five reasons why many Filipino mothers continue to die in relation to pregnancy. It accounts for one of every 5 pregnancy-related deaths in the country.

The Philippines has one of the highest rates of mothers dying in relation to pregnancy in the Western Pacific region.

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The country’s maternal mortality rate ranges from 162 deaths to 250 deaths per 100,000 live births. (The lowest figure is from government data while the highest is from the World Health Organization.)

Clearly, if this issue is not addressed, it is unlikely that the country will be able to meet the Millennium Development Goal of lowering maternal mortality rates by 52 deaths per 100,000 live births by 2015.

PMAC is one of the 10 elements of the DOH’s reproductive health program, together with maternal, infant and child health and nutrition, family planning information and services, adolescent and youth health, and elimination of violence against women, among others.

Through it, the health department aims to give women suffering from post-abortion complications “quality and humane care services by competent, compassionate, objective and nonjudgmental service providers in a well-equipped institution.”

Break the cycle

PMAC takes off from post-abortion care that has been widely adopted by the international reproductive health community.

In 1991, Ipas, a global nongovernment organization that advocates putting an end to preventable deaths and disabilities from unsafe abortion, proposed that post-abortion care (PAC) be integrated into family planning services in health care systems “to break the cycle of repeat unwanted pregnancy and (to improve) the overall health status of women in the developing world.”

Originally, Ipas’ PAC model had three elements: emergency treatment services for complications of spontaneous or induced abortion; postabortion family planning counseling and services; and links between emergency abortion treatment services and comprehensive reproductive health care.

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By 2002, the model had expanded into what the Guttmacher Institute describes as a shift in focus from the “facility-based medical treatment to a public health approach that responds to women’s broader sexual and reproductive health needs.”

PAC’s components now include community and service provider partnership, counseling, treatment, family planning and contraceptive services, and reproductive and other health services.

The partnership between the community and service providers involved mobilizing community leaders and advocacy groups, health workers, traditional healers and formally trained service providers to work together to promote health education that would “combat unsafe abortion, increase access to quality postabortion care services, and improve women’s reproductive health.”

The new model also encourages health facilities to provide all the appropriate health services for women’s post-abortion care. If possible, a post-abortion patient must be able to get these services in the same facility where she is seeking treatment. If this is not possible, the facility must be able to refer her to other facilities or health providers.

Some of these services that a patient may need are on prevention, screening and treatment of sexually transmitted infections, including HIV; services addressing gender-based violence; infertility diagnosis, counseling, and treatment; and screening, counseling and treatment for reproductive-related cancers, among others.

Promising start

PMAC was off to a promising start.

With the help of the nongovernment organization EngenderHealth Philippines and other donor agencies, health providers in the pilot sites where it was first introduced were given training on post-abortion care that included counseling, infection prevention practices, and clinical management of post-abortion complications. The trainings also aimed to transform the attitudes of health providers, including health workers in the community, to be less judgmental and to be more compassionate and humane in their treatment of patients.

EngenderHealth’s end-of-project report in 2003 singled out transformed attitudes of health providers and improved services as PMAC’s early achievements

Once funding support from the donors was over, however, PMAC’s implementation gradually weakened.

“This is the problem with donor-driven programs. When donors end their involvement, we cannot seem to sustain them. They must be institutionalized in the health system, with the DOH taking the lead to counter this situation,” said Dr. Alejandro San Pedro, chief of the Department of Obstetrics and Gynecology of the Bulacan Provincial Hospital.

This provincial tertiary hospital is one of the few hospitals that continue to implement PMAC. Despite an administrative order issued by the DOH to adopt PMAC in 2000, only a number of hospitals nationwide actually did so. Some of them are not even aware that there is such a policy and are thus not able to provide other components of postabortion care apart from treating complications.

Weakest link

All doctors interviewed for this story admit that counseling is the weakest link among the constellation of services that health facilities must make available to their patients.

This includes family planning counseling since the main reason why women risk unsafe abortion is unwanted or unplanned pregnancy. DOH data say that one in every three births in the country is either unwanted or unplanned.
“Patients must be educated on the full range of family planning methods available to them so they can manage their fertility and not have any unplanned or unwanted pregnancy. Family planning counseling must be given immediately because ovulation happens at once following an abortion. Patients must also be made aware of the dangers of unsafe abortion,” explained Dr. Darlene Estuart, project director of the Brokenshires Woman Center in Davao city that has a post-abortion care program similar to PMAC.

All hospitals are directed to provide immediate treatment to patients suffering from post-abortion complications as part of their obstetric emergency care, including hospitals managed by religious congregations. Providing them with counseling service is a different story, especially when it involves family planning counseling.

Dr. Yolanda Tuazon is a consultant with the San Pedro Hospital in Davao city, which is operated by the Dominican nuns.

In San Pedro, according to Tuazon, the nuns do the rounds to counsel post-abortion patients, particularly the “moralizing kind of counseling” for spiritual guidance. They also do counseling on natural family planning methods but not on the modern methods, for understandable reasons.

“I give my patients in San Pedro family planning counseling but in a limited way, with restrictions. We all know what the Church’s stand is on modern contraceptives. I respect that,” she said.

Tuazon is a staunch advocate of reproductive health. But she also recognizes the position of the hospital where she works as a consultant. To get around this “personal dilemma,” she asks her post-abortion patients to see her in her private clinic outside the hospital so she can give them family planning counseling.

“(In my clinic,) I can educate the patient on the whole range of family planning methods available to her…. With abortion, you don’t end with treating the patient. You continue to give her counseling so that she will not resort to it again or you present to her options so she will not be in that situation when she has to go through another abortion,” Tuazon explained.

Aside from family planning counseling, counseling must also address the patients’ emotional concerns such as grief, fear, anger, guilt, and depression. Contrary to what others believe, women do not decide lightly to have an abortion. Whether spontaneous or induced, abortion is a traumatic experience and counseling is key to enable women to recover and heal from it.

Unfortunately, this type of counseling is hardly included in the services provided by hospitals to post-abortion patients.

Not enough

PMAC is proof that government recognizes that unsafe abortion happens despite the criminal restriction on it.

In developing PMAC, the DOH turned to evidence happening in local communities and hospitals to validate why a policy on post-abortion care is crucial even if there is a law penalizing abortion.

Yet, Dr. Marilen Dañguilan, a health policy consultant and former senior adviser for maternal health of UNICEF, thinks the DOH has not done enough to address post-abortion care.

“DOH has not advocated PMAC in a way that would create a sense of ownership of the policy. It has lumped post-abortion care into one supposedly comprehensive reproductive health program. Because of this, nothing happens. There is no focus on post-abortion care. How is it even monitored?” she asked.

Norma Escobido, supervising health program officer of the National Center for Disease Prevention and Control, the office that oversees the PMAC, admits that no regular monitoring is done on how health facilities implement the policy. This is mainly because health services are now devolved to local governments and are not implemented by the DOH anymore.

For PMAC to work, it is not enough that a national policy is in place.

Local governments must also support it by allocating funds to train health care providers, purchase family planning commodities and essential obstetric supplies and medicines, and improve hospital facilities.

If local government officials do not see the wisdom of prioritizing reproductive health services, chances are they view post-abortion care in the same manner.

In a way, even if PMAC is a public health policy, its success is affected by politics and religion. Reproductive health advocates argue that the present law on abortion must, at the very least, be reviewed to decriminalize it, or to remove its punitive measure. They also favor allowing abortion when the life of the mother is threatened by the pregnancy, in cases of rape and incest, or in cases of fetal impairment or congenital defects.

The Church, however, will never allow it under any circumstance and would prefer the status quo.

Sacred law?

Legislators, on the other hand, are too intimidated by the Church to introduce legislation that would amend the existing law so that it can be more reflective of the realities of women’s lives.

“The consensus is you cannot touch this law. This law has been made sacred that you cannot make a rational discussion about it that would lead to a more enlightened policy. Mothers are dying (from this restrictive law), but so what? We cannot even get ourselves to be angry about it,” noted Dañguilan.

Another doctor, Junice Melgar, executive director of the Likhaan Center for Women’s Health, shared the same sentiment. “Discussions must be promoted where you can talk about changes in the law and the value of a woman’s life. This has to be open discussions where you can explore the possibility of a law on abortion that respects the autonomy of a woman to make decisions for herself and the right to life of a mother. Making abortion illegal does not stop it.”
The DOH was in the right direction when it developed PMAC.

Even though it was difficult to gather data about unsafe abortion and monitor cases involving it because it is illegal, there was enough evidence to suggest that it was increasing and it was exacting a heavy toll on women’s health and well-being.

This was the impetus for the policy 10 years ago. Today, the policy is barely making a dent, even as evidence shows that women’s health continues to suffer, or worse, women continue to die from complications from unsafe abortion.

(The series was produced under the Maggie de Pano Fund for Investigative Reporting on Health. The Fund, which is managed by Newsbreak, is made possible through a grant from Macare Medicals, Inc.)

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