To label the RH bill controversial is both an accurate assessment and an erroneous attribution.

It is a correct observation because something which is controversial is also perceived to be divisive and problematic – so much so that during public debates, our presidentiables dread questions on whether or not they support the enactment of the RH bill or if they are for or against family planning. Such questions are cause for concern that even the most eloquent and straightforward among them fumbles for words and answers with uncharacteristic ambivalence.

It is accurate to brand the issue of reproductive health as controversial because it is highly contentious and regularly strikes a discordant note with adverse partisans. In my experience speaking in forums on the RH bill, people are either strongly supportive of the bill or rabidly against it. Most of the time, people have strongly-held opinions on the matter. There are almost no instances when people are merely lukewarm about the issue of family planning and reproductive health. They are either advocates or detractors.

But it is also an erroneous attribution to describe the bill as controversial because a controversy implies that there is something offensive and scandalous about the measure when in fact the RH bill is a rational, health and rights-based and human development oriented policy.
The RH bill is not about sex. Neither is it about religion. It is about health, rights and sustainable human development.

A thorough and careful reading of the bill will reveal that there is nothing extreme or radical about it. It is based on solid evidence that a rapidly ballooning population and high unwanted fertility are detrimental to development even as they are primary factors in restricting both educational and employment opportunities for women and are responsible for the alarmingly high infant and maternal mortality and morbidity rates in the country.

The ability to plan and space one’s children is a basic human right. Neglecting reproductive health would be tantamount to disregarding an indispensable aspect of overall health.  Waving it aside as insignificant will be equivalent to compromising the wellbeing of women and children.

Therefore, RH and family planning should not be considered controversial or debatable issues. For it is beyond debate that people have the right to decide when and how often they want to become parents. Or if they want to be parents at all.

We are in the last legs of the first decade of the 21st century and yet the Philippines still has the dubious distinction of being the sole middle income developing country in Southeast Asia without a clear, coherent and comprehensive policy on reproductive health and population development.

In the more progressive countries of Europe and Latin America, including traditionally Catholic countries, political leaders, ecclesiastics and ordinary citizens do not anymore debate on the need and efficacy of reproductive health and family planning, including contraceptive use. They leave this matter to the jurisdiction and determination of the secular State.

Two years ago, in a forum sponsored by the Philippine General Hospital, there was a comment from a Belgian woman that was truly enlightening. This woman was working with an NGO providing health services to urban poor communities and was genuinely confused as to why there were still round-table discussions on RH and family planning when everyday in her work she saw women dying from maternal causes and babies being born without the least chance of survival. She worked with women who had as many as twelve to fifteen children and who were not even in their 40s – meaning they had at least a decade more of childbearing years before them. These women were practically begging for family planning information and services. 

She asked why we were all still sitting around discussing the pros and cons of the bill when the need for RH and FP services was beyond debate. Her statement was simple: “people need this bill so that they and the children they decide to have can live dignified lives.”

I hope you do not get the impression that I’d rather not be here discussing the merits of the RH bill. I am always more than willing to talk about the bill especially with students of the health sciences. The point the Belgian woman wanted to underscore was not that we shouldn’t have intelligent and enlightening discussions on RH and family planning. What she was against was the protracted debates that veered away from the real issues and focused on false and malicious arguments against the bill and unduly delayed its passage into law.

As nurses and health care providers, you will play a crucial role in ensuring reproductive health and it is therefore imperative that you are informed and knowledgeable about the RH bill which I will re-file in the coming 15th Congress.

As nurses your role in the health care system is multi-faceted. In the promotion of overall health, you will be expected to provide care and assistance to patients and even their families; educate patients and the public in general on the prevention of ill health; participate in rehabilitation; and provide invaluable support to doctors and allied health care providers.

But it is precisely because the versatile role nurses play is so comprehensive that your influence on both patients’ lives and the health care industry is so far-reaching and extensive. This is also the reason why you should be well-versed when it comes to the promotion of genuine reproductive health.

While the RH bill assures an enabling environment where women and couples have the freedom of informed choice on the mode of family planning they want to adopt based on their needs, personal convictions and religious beliefs, RH is certainly not merely about contraceptives and family planning.

ELEMENTS OF RH - Family planning is only one element of reproductive health. Equally important are the other elements of RH which include:
(1) maternal, infant and child health and nutrition;
(2) promotion of breast feeding;
(3) prevention of abortion and management of post-abortion complications;
(4) adolescent and youth health;
(5) prevention and management of reproductive tract infections, HIV/AIDS and STDs;
(6) elimination of violence against women;
(7) counseling on sexuality and reproductive health;
(8) treatment of breast and reproductive tract cancers;
(9) male involvement and participation in RH;
(10) prevention and treatment of infertility; and
(11) RH education for the youth.

It is a pity that the debate has been confined to contraceptives because the other elements of RH, which will similarly protect and promote the right to health and reproductive self-determination, have been largely ignored.

MIDWIVES FOR SKILLED BIRTH ATTENDANCE – The bill supports safe motherhood. It proposes that every city and municipality shall employ an adequate number of midwives and other skilled attendants. This will help prevent maternal and infant mortality which are both alarmingly high in the country. Currently, only 57% of Filipino women give birth with the assistance of a trained medical professional.

EMERGENCY OBSTETRIC CARE - Each province and city shall ensure the establishment and operation of hospitals with adequate and qualified personnel that provide emergency obstetric care. If we are to make headway in our commitment to the Millennium Development Goals (MDGs) to lower infant mortality and improve maternal health, it is imperative to provide emergency obstetric care to those who need them. The miracle of life should not mean death for 11 mothers daily and the importance of facilities that can provide life saving services to pregnant women cannot be overemphasized.

HOSPITAL-BASED FAMILY PLANNING - Family planning methods requiring hospital services like ligation, vasectomy and IUD placement shall be available in all government hospitals. Maternal and infant mortality and morbidity are public health concerns that government can address if effective and long-term methods such as IUDs and permanent methods like ligation and vasectomy are readily available in government hospitals – the health facilities the poor and marginalized regularly utilize.

CONTRACEPTIVES AS ESSENTIAL MEDICINES - Reproductive health products shall be considered essential medicines and supplies and shall form part of the National Drug Formulary. The classification of contraceptives as essential medicines will help the poorest of our women, who continue to have an average of six children, avoid unplanned pregnancies and maternal death. Both the WHO and UNFPA have declared that contraceptive use can prevent 1/3 of all maternal deaths.

Our maternal mortality rate which is pegged at 162 deaths out of every 10,000 live births is both alarming and insidious. Fourteen percent of all deaths in the female population can be attributed to pregnancy and childbirth-related causes (DOH and NDHS 2003). This is unacceptable. No woman should die giving life.

It should be underscored that modern contraceptives are included in the World Health Organization Model List of Essential Medicines. Their inclusion in the National Drug Formulary will enable government to purchase contraceptives and not merely rely on unpredictable donations.

REPRODUCTIVE HEALTH EDUCATION – RH education in an age-appropriate manner shall be taught by adequately trained teachers from Grade 5 up to 4th Year High School. As proposed in the bill, core subjects include values formation; prevention and avoidance of sexual advances and molestation from acquaintances and strangers; parts and functions of the reproductive system; responsible parenthood; natural and modern family planning; proscription and hazards of abortion; reproductive health and sexual rights; abstinence before marriage; and responsible sexuality, among others.

Sexuality education seeks to assist young people in cultivating a positive view of sexuality; provide them with information and skills about taking care of their sexual health; and help them make sound decisions now and in the future. It has also been shown to make adolescents more sexually responsible and adds a level of maturity to their attitudes towards sexual relations.

Formal education on RH and sexuality is necessary because of the parental default at home where conversations on sex is traditionally taboo.

Moreover, a 2008 SWS survey shows that 76% of Filipinos approve of the teaching of family planning to the youth. Family planning encompasses reproductive health and sexuality education.

EMPLOYERS’ RESPONSIBILITIES - Employers shall respect the reproductive health rights of all their workers. Women shall not be discriminated against in the matter of hiring, regularization of employment status or selection for retrenchment. Employers shall provide free reproductive health services and commodities to workers, whether unionized or unorganized.

These are all restatements and improvements of existing provisions of the Labor Code and prevailing Collective Bargaining Agreements (CBAs).

CAPABILITY BUILDING OF COMMUNITY-BASED VOLUNTEER WORKERS - Community-based workers shall undergo additional and updated training on the delivery of reproductive health care services and shall receive not less than 10% increase in honoraria upon successful completion of training. This will improve the ability of our barangay health workers to deliver relevant RH information and services.

PROHIBITED ACTS – The following persons, and no one else, shall be held liable for prohibited acts, as follows:

1. Public and private health care providers who:    

(a) Knowingly (with malicious intent) withhold or impede the dissemination of information about the programs and services provided for in this Act or intentionally give out incorrect information;

(b) Refuse to perform voluntary ligation and vasectomy and other legal and medically-safe reproductive health care services on any person of legal age on the ground of lack of spousal consent or authorization;

(c) Refuse to provide reproductive health care services to an abused minor and/or an abused pregnant minor, whose condition is certified to by an authorized DSWD official or personnel, even without parental consent which is not necessary when the parent concerned is the perpetrator;

(d) Fail to provide, either deliberately or through gross or inexcusable negligence, reproductive health care services as mandated under this Act; and

(e) Refuse to extend reproductive health care services and information on account of the patient’s civil status, gender or sexual orientation, age, religion, personal circumstances, and nature of work: Provided, That all conscientious objections of health care service providers based on religious grounds shall be respected: Provided, further, That the conscientious objector shall immediately refer the person seeking such care and services to another health care service provider within the same facility or one who is conveniently accessible: Provided, finally, That the patient is not in an emergency or serious case as defined in RA 8344 penalizing the refusal of hospitals and medical clinics to administer appropriate initial medical treatment and support in emergency and serious cases.

2. Any public official who prohibits or restricts personally or through a subordinate the delivery of legal and medically-safe reproductive health care services, including family planning (inaction is not culpable).

3. Any employer who shall fail to comply with his obligation under Section 17 of this Act or an employer who requires a female applicant or employee, as a condition for employment or continued employment, to involuntarily undergo sterilization, tubal ligation or any other form of contraceptive method.

4. Any person who shall falsify a certificate of compliance for parties to contract marriage as required in Section 14 of this Act.

5. Any person who maliciously engages in disinformation about the intent or provisions of this Act.

Now that I have discussed the most relevant provisions of the RH bill, I would like to clarify some of the misconceptions about the measure.

If the RH bill is deemed controversial, it is because of the misinformation being purveyed by its critics, most especially the Catholic hierarchy and lay organizations.

THE BILL IS NOT ANTI-LIFE. It is pro-quality life. It will ensure that children will be blessings to their parents since their births are planned and wanted. It will empower couples with the information and opportunity to plan and space their children. This will not only strengthen the family as a unit, it will optimize care for fewer children who will have more opportunities to be educated, healthy and productive.

Life is truly precious. It should not be wasted or lost because of poverty, neglect and lack of opportunities for sustainable development. Multiplicity of family members leads to the forfeiture of a better life.

Contrary to the claims of its oppositors, it must be underscored that the bill is not against the birth of children. It does not advocate that women and couples stop having children. What it aims to do is to help women and couples achieve their fertility goals and achieve effective spacing of their children.

If they want two children, then family planning will help them have two children. If they want three, family planning, whether natural or modern, will help ensure that they have only three. If a couple wants eight children, they have all the right to have eight if they so desire. But without family planning, they would more likely have nine, or 10 or 11 children, not the eight they originally wanted. And with effective access to family planning information and services, they might just freely abandon their desire to have many children.

THE BILL DOES NOT FAVOR MODERN FAMILY PLANNING METHODS OVER NFP. Both natural and modern family planning techniques are contraceptive methods. Their common purpose is to prevent unwanted pregnancies and the bill does not impose a bias for either method. Section 3(a) of the bill unmistakably provides: “In the promotion of reproductive health, there should be no bias for either modern or natural methods of family planning.”

The unfortunate bias of the government today is actually for natural family planning methods because currently, the POPCOM is promoting only NFP even though only 27% of women acceptors employ NFP and traditional methods compared to the 73% who use modern methods.

The bill in fact democratizes family planning because it will make available to couples all possible family planning methods and not just NFP methods preferred by the Catholic Church.

Central to the bill is freedom of informed choice. Limiting the choice of family planning method to either only modern or natural will negate this fundamental freedom.

THE BILL DOES NOT LEGALIZE ABORTION AND WILL NOT LEAD TO ITS LEGALIZATION. The measure repeatedly underscores that abortion is illegal, criminal and punishable, and is not part of the menu of legally permissible and medically safe family planning methods.

Moreover, the use of contraceptives will not lead to the legalization of abortion. Catholic countries like Panama, Guatemala, Brazil, Chile, Columbia, Dominican Republic, El Salvador, Honduras, Nicaragua, Venezuela, Paraguay and Ireland all prohibit abortion as a family planning method even as they vigorously promote contraceptive use. Muslim and Buddhist countries like Indonesia and Laos have likewise liberalized the use of contraceptives but still continue to criminalize abortion.

There is also an inverse correlation between contraceptive use and abortion. The regular and correct use of contraceptives drastically reduces abortion rates since unplanned and unwanted pregnancies are avoided. According to the Alan Guttmacher Institute, effective contraceptive use can reduce rates of abortion by as much as 85%. Consequently, women do not have to resort to abortion and the State will find no need to legalize abortion.

IT DOES NOT ENDORSE ABORTIFACIENTS. Hormonal contraceptives are BFAD-approved, medically safe and legal. They do not cause a “medical abortion” or “hidden abortion” as claimed by critics of the bill.

The primary mechanism of pills and injectables is to suppress ovulation. If no egg is released, how can there be an abortion? They also prevent the sperm from reaching the egg. If fertilization is avoided, how can there be a fetus to abort? Articles in peer-reviewed medical journals testify that IUDs do not cause abortions because they avoid fertilization. A recent study revealed that not a single fertilized egg was recovered from the fallopian tubes of women using IUDs proving that they are amazingly successful in preventing fertilization.

The UNDP, UNFPA and WHO have submitted to the House of Representatives an expert opinion on the mechanisms of modern contraceptives and they state that contraceptives “cannot be labeled as abortifacients” as none of these methods have been shown to cause abortions.

The bill is truly anti-abortion. It will tremendously reduce the incidence of abortion in the country which in 2002 has been recorded to be about 470,000 even as the UN has estimated that the incidence could have escalated now to about 800,000. Data also show that it is not single women and teenagers but poor, married, Catholic women in their 20s who most often undergo abortions because they cannot afford another child.

CONTRACEPTIVES DO NOT HAVE LIFE THREATENING SIDE-EFFECTS. Medical and scientific evidence show that all the possible medical risks connected with contraceptives are infinitely lower than the risks of an actual pregnancy and everyday activities. The risk of dying within a year of riding a car is 1 in 5,900. The risk of dying within a year of using pills is 1 in 200,000. The risk of dying from a vasectomy is 1 in 1 million and the risk of dying from using an IUD is 1 in 10 million. The probability of dying from condom use is absolutely zero. But the risk of dying from a pregnancy is 1 in 10,000.

Although pregnancy is not a disease, it is fraught with risks, especially for women who have too many children or unremitting pregnancies or those who are more than 35 years old or younger than 18 years. Persistently high maternal mortality is a violation of women’s right to health and life.

SEXUALITY EDUCATION WILL NOT PROMOTE PROMISCUITY. Age-appropriate RH education promotes correct sexual values. It will not only instill consciousness of freedom of choice but responsible exercise of one’s rights. The UN and countries which have youth sexuality education document its beneficial results like understanding of proper sexual values; initiation to sexual relations is delayed; abstinence before marriage is encouraged; multiple sex partners is avoided; and spread of sexually transmitted diseases is prevented.

Parents who do not allow their children to attend RH and sexuality education classes will not be prosecuted and jailed. The provision on Prohibited Acts does not include parents who raise objections.

THE BILL DOES NOT CLAIM THAT FAMILY PLANNING IS THE PANACEA TO POVERTY. It simply recognizes the verifiable link between a huge population and poverty. Unbridled population growth stunts socio-economic development and aggravates poverty. The connection between population and development is well-documented and empirically established.

UN Human Development Reports show that countries with higher population growth invariably score lower in human development. In 2007, the Philippines, as the 12th most populous country in the world, ranked No. 90 out of 171 countries in the Human Development Index rankings made annually by the United Nations. In 2008, we were down to No. 102. In 2009, we went down further to rank 105. Over the years, the Philippines has consistently been the worst performer among Southeast Asian countries.

The Asian Development Bank in 2004 also listed a large population as one of the major causes of poverty in the country. Recent studies also show that large family size is a significant factor in keeping families poor across generations.

However, the authors of the bill do claim that the bill will help promote sustainable human development. The UN has stated that “family planning and reproductive health are essential to reducing poverty” The UNICEF also asserts that “family planning could bring more benefits to more people at less cost than any other single technology now available to the human race.”

AN RH LAW WILL NOT BE SUPERFLUOUS. It is a myopic view that since contraceptives are available in the market, there is no need to enact a law on reproductive health and family planning. This contention overlooks that availability does not mean access, particularly to those who are uninformed or could not afford to buy reproductive health supplies. Availability does not assure adequate and accurate information on family planning and reproductive health which are basic universal human rights.

There are 12.86 million currently married women of reproductive age in the country. But we have a contraceptive prevalence rate of only 49.3% (2006 Family Planning Survey). A little over half of married women do not use any form of contraception, either natural or artificial.

For those who are using any form of contraception, 72% use modern methods with 53% using supply methods like condoms, pills and IUDs and 19% using permanent methods like ligation and vasectomy. Twenty-seven percent of women use traditional methods such as withdrawal and calendar-rhythm and only 0.4% use modern natural family planning like Standard Days, Billings Ovulation and Lactational Amenorrhea Methods.

Critics of the bill claim that instead of allocating billions to reproductive health and family planning, more government funds should be appropriated to help curb heart disease, malaria, tuberculosis and other causes of mortality among women. But if we divide the amount of P2-B, allocated to RH and family planning in the 2008 budget among the 12 million plus women of reproductive age in the country, it would translate to only 42 centavos per woman per day. This is hardy extravagant.

Incidentally, the precedent setting appropriation of P2-B was never released by the Executive and had expired untouched last December 31, 2009.

Additionally, women suffer more from maternal morbidities (illness) than any other illness. The DOH estimates that at 400,000 cases for 2005 alone, maternal morbidities are on the very top of the list of the ten most common causes of morbidity for women in the Philippines.

But more than half of the cases involving maternal morbidity could be prevented through effective family planning according to the UNICEF, WHO and UNFPA.

A law that will help prevent 200,000 pregnancy and childbirth related illnesses and countless maternal deaths is definitely not superfluous.

Moreover, proper birth spacing reduces the risk of death in infants by half. This means that almost 8,000 infant deaths each year could be prevented through family planning.

We need to enact a law on reproductive health and population development because it will promote and protect the right to health, the right to informed choice, the right to reproductive self-determination, and the right to sustainable human development.

The bottom line is if women are given the chance to make responsible family planning decisions, they almost always decide to have smaller families and their children will invariably be healthier, better-educated and have at least a fighting chance at living full and dignified lives. Without this ability, most women will often find it more difficult – some may find it even impossible – to finish their education, find remunerative work or have a say in their own future.

RH advocates within and outside Congress are counting on you to support this measure because it is genuinely pro-women, pro-poor and pro-life. We are counting on you because as nurses you know for a fact that RH is essential to women’s overall health and if it is neglected, primary aspects of women’s general welfare and wellbeing will be irrevocably compromised.

Nurses do not only play a central role in health care delivery, they are virtually the cornerstone of our nation’s health care system. The role that nurses play has long been undervalued because no other health care professional has a more all-encompassing role than nurses. This is why we need you as our enduring partners in the campaign to enact an RH law.

I urge you to use your influence wisely to effect positive changes and much-needed improvements on the health care industry and on public health.

Let us nurse together the enactment of a comprehensive, nationwide and aptly-funded RH Law in the forthcoming 15th Congress.