Slipping off her blue flip-flops, Glendolyn Echapare lay down on the leather bed with her left arm above her head. It was a balmy February morning in the Philippines, and the heat of nine people in one examination room was enough to make the still air wet. A fluorescent light blinked, and the doctor applied iodine in a circle on the soft skin of the young woman's inner arm. Six health care workers formed a ceremonious half moon around the bed, issuing encouragement to her and handing medical supplies to the doctor. Next came the anesthetic. Then the doctor smoothly inserted a matchstick-size piece of white plastic under her skin, where it will stay for the next three years.
And thus Echapare, 19 and a teenage mom twice over, was injected with a reversible contraceptive called Implanon at the City Health Office in her hometown Tacloban City. The procedure and medication were both free, thanks to the country's controversial Reproductive Health Law, which promises Filipinas universal access to birth control--at least on paper.
For women like Echapare, free contraception like Implanon is invaluable. Echapare gave birth to her first child five months before Typhoon Haiyan--the deadliest typhoon to hit the Philippines--washed out Barangay 99, her neighborhood in the northern part of the Tacloban. She was considering birth control before the disaster, she said, but she had no access to healthcare after Haiyan: The typhoon damaged or destroyed all the hospitals and clinics in the city. And so a year after the storm, her second child, a daughter, was born.
"I don't want to get pregnant anymore," she said in Waray Waray through a translator. Her priority now is to graduate high school and hopefully become a teacher one day. She loves her kids--her subdued smile becomes radiant when she cradles her daughter--but a third child would make things even more difficult financially.
Echapare's case is far from unique, but the fact that she was able to access treatment makes her one of the lucky ones. Many other women have difficulty obtaining birth control because of obstacles that plague the new Reproductive Health Law. Though President Benigno Aquino III signed the law 2012, it didn't come into effect until last spring, when the Supreme Court finally ruled against a two-year legal challenge from Catholic leaders. But the problems facing the RH Law didn't stop there: Contraceptives are not as plentiful or widespread as demand, the Supreme Court recently imposed a ban on the distribution of Implanon, and administration of the law is still under sway of the Catholic Church.
Meanwhile, teenage pregnancy has more than doubled in the past decade. Ten percent of Filipina teenagers are now pregnant or mothers, and the adolescent birth rate in the Philippines is one of the highest in Asia--53 births per 1,000 women between the ages of 15 to 19. (To put that in perspective: The rate is 26 per 1,000 in the United States, and it's far lower in many other westernized countries.)
I don't want to get pregnant anymore.
The RH Law is supposed to make a wide range of contraceptives free, but there doesn't seem to be enough to go around; in most cases, the government doesn't have the budget to carry out what the law demands. For example, in Eastern Visayas--a region where over four million people live--there were only three million pesos (around $66,500) to spend on contraception for the year, according to Dr. Caren Garado, a representative from the regional Department of Health.
Fortunately for Echapare, her injection was free, but because resources are so limited, the city she lives in relies on medical donations from organizations like USAID to match the demand. However, international support is now trickling out of the country as emergency response efforts wind down (and other world disasters beckon). And things are already starting to look fairly dire: Early in 2015, the Tacloban City Health Office, which serves over 200,000 people, had only 56 Implanon injections, according to resident physician Dr. Danilo Escarma, the doctor who gave Echapare her injection.
Low supply isn't the only obstacle facing women who want birth control: Opposition to contraception runs deep in the culture of the Philippines. The country's population is 80 percent Catholic; more Catholics reside in the Philippines than anywhere except Brazil or Mexico. Catholicism is deeply entrenched in Filipino ethos--Christmas decorations go up before Halloween, voluntary human crucifixion occurs every Good Friday, and divorce and abortion are illegal. When Pope Francis visited this January, the government declared a five-day national holiday. Millions braved the spitting rain in yellow ponchos and swarmed the streets hoping to catch a glimpse of his Holiness in the popemobile; the crowds were so insane that the chairman of the capital city's development authority recommended everyone wear adult diapers.
In all, 80 million Filipinos follow the teachings of the Catholic Church. The Catholic Church, of course, strongly opposes contraception; under its doctrines, only natural family planning--a fancy name for periodic abstinence--is OK. (On his flight back to the Vatican from the Philippines, Pope Francis said good Catholics should practice responsible parenting by not breeding "like rabbits.")
In early 2013, a conservative religious organization called the Alliance for Family Foundation Philippines filed a petition against the RH Law, claiming that the Department of Health has been distributing two kinds of Implanon that the FDA has found can cause abortion.
The Alliance says that Implanon follows under the RH Law's definition for "abortifacient," which includes drugs and devices that prevent the fertilized egg from implanting in the womb (as determined by the FDA). But progestin, the active hormone in Implanon, actually prevents the ovary from releasing eggs in the first place and also thickens the cervical mucus, a natural sperm barrier.
Regardless, this June, the Supreme Court responded to the petition, issuing a ruling that prohibits the Department of Health from "procuring, selling, distributing, dispensing or administering, advertising and promoting the hormonal contraceptive 'Implanon' and 'Implanon NXT.'" In essence, it's now all but impossible for Filipina women to access Implanon due to the Alliance's petition.
Banning Implanon could have a disastrous effect on an already vulnerable population. The pill is the most commonly used type of birth control in the Philippines, but Implanon is very popular with poor women--and they need free contraceptives the most because they are often already struggling to support several children. Implanon is a frequent choice for these women because it doesn't require multiple trips to the clinic; travel can be too expensive for women who live remotely or mothers who are caring for several small children.
Currently, 37 percent of married Filipinas use modern contraception. Another 12 percent use traditional family planning methods that are less offensive to the Church, like abstinence. Some Filipinas avoid sex when they are most fertile by using a string of color-coded beads that resembles a rosary to count the days of their cycle.
In theory, withdrawal or abstaining from sex during ovulation works. In reality, as many as one in four women using natural family planning will get pregnant--after all, these methods are subject to human error. Plus, none of these tactics protect women from sexual assault, and the Philippines' notably harsh abortion law has no exception for pregnancies that result from rape. Despite such heavy restrictions, though, dangerous back alley abortions occur with alarming frequency: The Guttmacher Institute estimates that 610,000 illegal abortions took place in the Philippines in 2012 alone.
In Tacloban, where Echapare lives, women's difficulty in accessing contraception has noticeable effects. Although the city offers a range of family planning options--from natural family planning to contraceptives to irreversible tubal ligation--Tacloban's Officer in Charge of Special Projects for Health, Dr. Gloria Fabrigas, said the "contraceptive prevalence rate" is low. "There are mothers who would really like to get those pills," she said. "The average woman here has five [children], but in the rural areas we have seven, eight, nine, ten."
Despite religious and cultural pressures, many Filipinos--and Catholics--support the Reproductive Health Law. Dr. Escarma, the doctor from the Tacloban City Health Office, said people were divided at first. But, he explained, "We were health workers; we wanted [the law] to be passed because we know the situation, and we were very thankful that it was passed."
The situation, as Dr. Escarma put it, is particularly dire in Eastern Visayas, an area with one of the highest average family sizes and one of the highest maternal death rates in the country. Dr. Escarma said that the law will help the Philippines reduce child mortality, improve maternal health, and empower women--all United Nations Millennium Development Goals--because access to free contraception will reduce the number of unplanned pregnancies.
There are mothers who would really like to get those pills.
Dr. Aileen Espina, acting director at Eastern Visayas Regional Medical Center and a devout Catholic, supports the law as well. "It's a greater sin to have babies you cannot support," she said. But not all medical professionals can separate their religious convictions from their work. "There are some doctors who do not perform bilateral tubal ligation because it is against their religion. It's against their faith--they wouldn't do that," said Dr. Espina. "They say it's a sin."
Tacloban's Dr. Fabrigas is one of the doctors who feel more ambivalent. While she upholds the Reproductive Health Law, she also worries about the message it sends to young women. Sex at a young age, she said, is "gateway behavior" to drug abuse and crime, so she tries to play gatekeeper.
"If we make these commodities [modern birth control] available, we are sending the wrong signals," she said, adding that the city does offer birth control to women, "but it is not given freely."
Instead, now that the six medical centers in Tacloban are all up-and-running again, Dr. Fabrigas is advocating for the construction of a birthing center for teenage moms.
Even when there are no barriers to access, some Filipinas chose not to take modern contraception. Mariel Cinco, 22, is pregnant with her first child and lives at the Caibaan Motocross Bunkhouses, a camp for internally displaced people that is a short tricycle ride from downtown Tacloban City. She shares the third unit of Bunkhouse 27 with her grandmother, mother and several of her ten siblings, where they sleep on blankets on the plywood floor, shred fabric to make stuffing for pillows, and play cards.
Like Echapare, Cinco's mother Archie Cinco-Nabilgas decided to get an Implanon injection. She is a mother of eleven but lost two children to meningitis and had to give her last baby up for adoption because she couldn't afford to take care of her.
Cinco, however, is not considering birth control because she prefers the natural family planning path. "I haven't taken any contraceptives to prevent me from getting pregnant," Cinco said. "My husband and I practice only abstinence." Her baby is due this month.
This work was carried out with the aid of a grant from the International Development Research Centre, Ottawa, Canada.