Unintended Pregnancy and Induced Abortion in the Philippines


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The landmark study that outlines the need for a comprehensive family planning policy in the Philippines to reduce unplanned pregnancies, and prevent induced abortions.

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Unintended Pregnancy and Induced Abortion in the Philippines

  1. 1. Unintended PregnancyAnd Induced AbortionIn the Philippines CAUSES AND CONSEQUENCES
  2. 2. Unintended PregnancyAnd Induced AbortionIn the Philippines:Causes and ConsequencesSusheela SinghFatima JuarezJosefina CabigonHaley BallRubina HussainJennifer Nadeau
  3. 3. AcknowledgmentsUnintended Pregnancy and Induced Abortion in the Philippines; Alfredo Tadiar (retired), College of Law andPhilippines: Causes and Consequences was written by College of Medicine, University of the Philippines; andSusheela Singh, Haley Ball, Rubina Hussain and Jennifer Cecille Tomas, College of Medicine, University of theNadeau, all of the Guttmacher Institute; Fatima Juarez, Philippines.Centre for Demographic, Urban and Environmental The contributions of a stakeholders’ forum were essentialStudies, El Colegio de México, and independent consult- to determining the scope and direction of the report. Theant; and Josefina Cabigon, University of the Philippines following participants offered their input and advice:Population Institute. The report was edited by Susan Merlita Awit, Women’s Health Care Foundation; HopeLondon, independent consultant. Kathleen Randall, of the Basiao-Abella, WomenLead Foundation; Ellen Bautista,Guttmacher Institute, supervised production of the report. EngenderHealth; Kalayaan Pulido Constantino, PLCPD;The authors thank the following current and former Jonathan A. Flavier, Cooperative Movement forGuttmacher Institute staff members for providing assis- Encouraging NSV (CMEN); Gladys Malayang, Health andtance at various stages of the report’s preparation: Development Institute; Alexandrina Marcelo, ReproductiveAkinrinola Bankole, Erin Carbone, Melanie Croce-Galis, Rights Resource Group (3RG); Junice Melgar, Linangan ngPatricia Donovan, Dore Hollander, Sandhya Ramashwar Kababaihan (Likhaan); Sharon Anne B. Pangilinan,and Jennifer Swedish. The authors also acknowledge the Institute for Social Science and Action; Glenn Paraso,contributions of the following colleagues at the University Philippine Rural Reconstruction Movement; Corazon M.of the Philippines: Celia Abbago, Cleopatra V. Alvaro, Raymundo, University of the Philippines PopulationGloria Oracoy, Josephine Parinas, Florence Tolentino and Institute; Rhodadora Roy-Raterta, Family Planningthe team of supervisors and interviewers, for coordination Organization of the Philippines; Carolina S. Ruiz-Austria,of fieldwork, data collection and processing, and research WomenLead Foundation; Joy Salgado, Likhaan; Jojoassistance on the National Survey of Women and the col- Sescon, Remedios AIDS Foundation; Joyce Valbuena,lection of hospital reports; and Francisco de los Reyes for Health Action Information Network; and Georgina Villar,sample design. Thea Initiative.Members of the Project Advisory Panel provided valuable Early drafts of the report benefited from input from Johnadvice and direction: Roberto Ador, Philippine Legislators’ B. Casterline, Pennsylvania State University; Jonathan A.Committee on Population and Development Foundation Flavier, CMEN; Alexandrina Marcelo, 3RG; Junice Melgar,(PLCPD); Honorata L. Catibog, Family Planning Unit, Likhaan; and Carolina S. Ruiz-Austria, WomenLeadPhilippines Department of Health (DOH); Milagros Foundation. Cookee Belen and Alexandrina Marcelo ofFernandez, Philippines DOH; Loreto B. Roquero, Family 3RG coordinated communications and outreach through-Planning Unit, Philippines DOH; Ramon D. San Pascual, out this project. Kathy Toner, Michael Tan and MaiPLCPD; and Carolyn I. Sobritchea, Center for Women’s Taqueban, of The David and Lucile Packard Foundation,Studies, University of the Philippines. The Institutional were especially supportive in organizing the stakeholders’Review Board of the Guttmacher Institute and the follow- forum and in providing comments on drafts of this report.ing members of the local ethical review committee reviewedsurvey protocols and design: Leonardo de Castro, Fogarty This report was made possible by funding from The DavidInternational Center Bioethics Program, University of the and Lucile Packard Foundation. Unintended Pregnancy and Induced Abortion in the Philippines 2 Guttmacher Institute
  4. 4. Table of ContentsExecutive Summary 4Chapter 1: A Critical but Concealed Issue 6Chapter 2: The Scope of the Problem 11Chapter 3: Why Women Have Abortions 15Chapter 4: How and Where Women Obtain Abortions 18Chapter 5: The Consequences of Unsafe Abortion 21Chapter 6: Need for Better Contraceptive Information and Access 24Chapter 7: Addressing Abortion as a Public Health Concernand Social Problem 28Appendix 31Appendix Tables 34References 37 Guttmacher Institute 3 Unintended Pregnancy and Induced Abortion in the Philippines
  5. 5. Executive Summary ach year in the Philippines, hundreds of thousands The average Filipino woman wants 2.5 children. In orderE ■ of women become pregnant without intending to, and to achieve that goal, she must spend more than 19 years many women with unintended pregnancies decide using effective contraceptive methods. to end them by abortion. Because abortion is legal ■ However, nearly half of all married women of reproduc-only to save a woman’s life, most procedures are clandes- tive age have an unmet need for effective contracep-tine, and many are carried out in unsafe circumstances. tion—that is, they are sexually active, are able to haveUnsafe abortion can endanger women’s reproductive children, do not want a child soon or ever, but are nothealth and lead to serious, often life-threatening compli- using any form of contraception or are using traditionalcations. Furthermore, unsafe abortions impose a heavy methods, which have high failure rates.burden on women, their families and society by virtue ofthe serious health consequences that often ensue: These ■ Among women who need but are not using contracep-health problems can keep women from work and school, tives, 76% fear contraceptive side effects, almost half areand treatment can be costly and consume scarce medical ambivalent about becoming pregnant (48%) or exhibitresources at both public and private health institutions. poor planning about when to use contraceptives (41%),Because abortion is highly stigmatized and largely prohib- and 24% mention difficulties in accessing contraceptiveited, information on abortion is difficult to obtain. services.However, new research findings shed light on the causes,level and consequences of abortion in the Philippines. Induced abortion is widespread, and its practice takes many formsUnintended pregnancy is common in the ■ An estimated 473,000 abortions occur annually. One-Philippines, and it often leads to abortion third of women who experience an unintended pregnancy■ Six in 10 Filipino women say they have experienced an end it in abortion. unintended pregnancy at some point in their lives. ■ Women from all segments of society experience abortion. About 1.43 million pregnancies each year—nearly half of Women who have had an abortion resemble average all pregnancies in the Philippines—are unintended. Filipino women: The majority are married, Catholic and■ A higher proportion of pregnancies are unintended in poor. They have some high school education and have Metro Manila than in any other major geographic region, already had several children. and a higher proportion of unintended pregnancies in ■ When asked why they sought an abortion, 72% of Metro Manila end in abortion than elsewhere. women cite the economic cost of raising a child; 54% say■ Some 54% of women who have ended an unintended they have enough children; and 57% report that the pregnancy by abortion were not using any family plan- pregnancy occurred too soon after their last one. ning method when they conceived. Of those who were practicing contraception, three-fourths were using a tra- ditional method. Unintended Pregnancy and Induced Abortion in the Philippines 4 Guttmacher Institute
  6. 6. ■ Most women do not make the decision to end a preg- Action on many fronts is needed to reduce levels nancy alone. Forty-three percent consult their husband or partner, and 25% discuss the matter with a friend or of unintended pregnancy and unsafe abortion in relative. the Philippines ■ Increased use of effective contraceptives would help■ Thirty-three percent of women who eventually complete women achieve their desired family size, and thus pre- an abortion rely on a husband, partner, relative, friend vent unintended pregnancies, which, in turn, would or neighbor, or take steps to end the pregnancy them- reduce the need for abortion and the grave health con- selves; 15% consult a pharmacist; and 15% consult sequences and costs of unsafe abortion. This will either a traditional healer or a street vendor. Only 29% require increasing knowledge about, access to and gov- of women obtain an abortion from a doctor. ernment funding for modern methods, especially among■ Because the cost of relatively safe procedures performed poor and rural women. by trained providers in hygienic settings (4,000–15,000 ■ Increased resources should be directed at improving the pesos, or US$73–273) is often many times higher than quality of postabortion care for women with complica- that of unsafe and less effective methods (costing as little tions by expanding services such as those offered under as US$1), poor women tend to use unsafe methods. the PMAC (Prevention and Management of Abortion and■ Only 30% of women who attempt an abortion succeed in its Complications) program. having one, and many women try again and again to end ■ To ensure that all women receive the care they need, a pregnancy. With each unsafe attempt at ending her medical professionals should be trained to carry out the pregnancy—successful or not—a woman increases the full range of reproductive health services—including risk to her life and health. legal abortions, postabortion care and contraceptive counseling—in a client-centered, compassionate man-Unsafe abortions often put women’s life and health ner.in jeopardy ■ Young people, as well as adults, need complete and■ Eight in 10 women who succeed in ending their preg- accurate information on reproductive health and con- nancy have health complications, and more than half of traception, the risks of unsafe abortion, and the health these women report having severe complications. and societal benefits of family planning.■ The severity of complications varies according to the ■ Policymakers must clarify the legal and medical grounds abortion method women use: Some 70% of women who on which abortion may be allowed and ensure that use massage or insertion of a catheter and 44% of those women are able to access safe, humane abortion who use misoprostol suffer severe complications, com- services to the extent they are permitted. pared with only 13% who undergo dilation and curet- tage or manual vacuum aspiration.■ Poor and rural women often lack access to safer meth- ods and providers, and thus experience higher rates of severe complications than do their wealthier and urban counterparts.■ Because of the high cost of postabortion treatment and the condemnatory attitudes of some medical providers, some women who experience complications do not seek care.■ An estimated 79,000 women were hospitalized because of health complications of abortion in 2000. This translates into an annual rate of 4.5 abortions for every 1,000 women of reproductive age.■ An estimated 800 women per year die from complica- tions of unsafe abortion. Guttmacher Institute 5 Unintended Pregnancy and Induced Abortion in the Philippines
  7. 7. Chapter A Critical but Concealed Issue deally, pregnancy is a wanted and happy event for but were not practicing contraception.6 Small-scale, hos- I women, their partners and their families. Unfortunately, this is not always so. Around the world, millions of women every year become pregnant unintentionally. In the Philippines, as in other countries, some of these women are faced with a difficult choice: to give birth to a pital-based studies carried out in the late 1970s and 1980s demonstrated that abortion was common in rural areas as well, that women used a variety of safe and unsafe techniques to end a pregnancy, and that many women were being treated for complications of induced child that they are not prepared or able to care for, or to abortion, which often had severe consequences for their obtain an illegal, and often unsafe, abortion. health.7 In the Philippines, nearly half of pregnancies are unin- This report provides new in-depth information on the bur- tended, and hundreds of thousands of such pregnancies dens of unwanted pregnancy and unsafe and clandestine end in induced abortion each year.1 Almost all of these abortion that so many Filipino women face. The report’s abortions are illegal because of a colonial-era law that aim is to stimulate informed public discussion of the criminalizes the procedure (see box, page 8). Women issues in order to achieve workable solutions to the prob- obtaining abortions risk prosecution and a prison sen- lem of unsafe abortion and its root cause, unintended tence of up to six years, while anyone providing or assist- pregnancy. ing in the procedure faces a similar sentence, as well as the loss of any medical license.2 Abortion may be obtained legally if it is necessary to save a woman’s life, but in prac- Unsafe abortion threatens women, families tice, this exception is of little use because many doctors and society are unwilling to risk performing the procedure, given the One in every seven pregnancies is terminated by abortion potential for severe penalties.3 The fact that abortion per- each year in the Philippines.8 Some of these procedures sists despite this restrictive atmosphere suggests a disso- are performed by doctors, nurses and midwives working nance between the realities of women’s lives and the poli- in private offices or clinics, but because many health pro- cies and public discourse that surround the issue of abor- fessionals lack necessary training, skills and medical tion.4 equipment, even procedures performed by health profes- sionals can be risky. Abortions performed by practitioners Unsafe abortion places a considerable burden on Filipino with no formal training in abortion provision—pharma- women and society. The first national study on this issue cists, traditional healers, street vendors or pregnant found that in 1994, the prevalence of induced abortion women themselves—are even less safe. Two in three was moderately high by worldwide standards, despite the Filipino women who terminate a pregnancy experience severity of the Philippine abortion law.5 In-depth studies complications, such as severe pain, infection and even done in Metro Manila around that time found that death.9 induced abortion occurred in all population groups, espe- cially among women who did not wish to become pregnant Unintended Pregnancy and Induced Abortion in the Philippines 6 Guttmacher Institute
  8. 8. The State recognizes the sanctity of family life and shall protect and strengthen the family as a basic autonomous social institution. It shall equally protect the life of the mother and the life of the unborn from conception. —Article 2, section 12, of the 1987 Constitution of the Republic of the PhilippinesBecause abortions are largely clandestine, the number of age income levels in the Philippines, abortions performedFilipino women who die due to unsafe abortion is difficult by medically trained practitioners can be very costly.to obtain, but is estimated to be 800 per year.* The World Women must either divert money from essential expendi-Health Organization estimates that in Southeast Asia, tures, such as food and housing costs, to pay for theseunsafe abortion accounts for 19% of all maternal deaths procedures, or resort to a less expensive—but also lessin any given year.10 Preventing risky procedures would effective and more dangerous—type of abortion.certainly help the Philippines reduce maternal ill-health Postabortion complications can add to this cost. Poorand mortality. Doing so would also contribute directly to women, in particular, may have trouble obtaining treatmentmeeting the Millennium Development Goals adopted in for complications and may not seek or delay seeking care2002 by all United Nations member states, including the for this reason. In addition, ill-health following unsafe abor-Philippines, especially the goals of improving maternal tions can have a marked impact on women’s ability to work,health and promoting gender equality. Although the coun- causing further economic strain for them and their families.try’s maternal mortality rate fell from 280 per 100,000 At the national level, unsafe abortion creates a drain onbirths in 1990 to 200 in 2000, it is still far short of the goal the country’s health care system. As one of the 10 mostof 70 set for 2015.11 common reasons for hospitalization at many hospitals inThe decision to end a pregnancy through abortion can have the Philippines,13 treatment for complications of abortiongrave consequences for women and their families, and can requires scarce medical resources (operating rooms, hos-be costly for society as a whole. Women suffering from health pital beds, blood supplies, antibiotics) and personnel.complications following an unsafe abortion may be forced to Thus, these complications exert substantial pressure ontake time away from work or school and may not be able to an already overburdened national health system—pres-care for their families while they recuperate. Even worse, sure that could be largely eliminated by addressing theabortion-related complications may lead to long-term health problem of unsafe abortion head-on.consequences, such as infertility. In the most extreme cases,complications may result in death, leaving families impover- Most abortions stem from unintended pregnanciesished and children motherless and at risk.12 In most cases, women decide to seek abortions becauseInduced abortion and related complications also consume they are faced with unintended pregnancies. The reasonsscarce monetary and human resources. Relative to aver- pregnant Filipino women give for not wanting to be preg- nant vary with their life circumstances: Most often, they or their families are too poor to provide for a child or for*This number was calculated by first multiplying the maternal mortal- another child. Other women already have too many chil-ity rate (source: see reference 11) by the number of births in 2003(sources: National Statistics Office (NSO) and ORC Macro, Philippines dren; become pregnant too soon after the last birth; feelNational Demographic and Health Survey, 2003, Calverton, MD, USA: they are too young; would have to end or, at best, post-NSO and ORC Macro, 2004; and NSO, 2000 Census of Population, CD- pone their work or education; are single; or are in difficultROM, Manila, Philippines: NSO, 2004). This product was multiplied by0.19, the proportion of maternal deaths due to abortion in SoutheastAsia (source: see reference 10). Guttmacher Institute 7 Unintended Pregnancy and Induced Abortion in the Philippines
  9. 9. or unstable relationships.14 When effective modern con- An informed public debate on the issue of unsafetraceptives (largely discouraged by the Catholic Church, abortion is urgently neededwhich plays a prominent role in Philippine society) are not Even though Filipino women have attained nearly univer-used or fail, and an unintended pregnancy results, women sal literacy15 and make up more than half of the country’soften have few options. Thus, the practice of induced abor- vast and vital overseas workforce16 and more than half oftion is largely a result of the difficulties women and cou- the voting population,17 women from all segments of socie-ples face in preventing pregnancies they do not want. ty jeopardize their health and risk legal sanctions to termi-Unintended pregnancy itself reflects the interrelationships nate unintended pregnancies. Yet the cultural and politicalof broader changes that are taking place in Philippine environment that surrounds reproductive health issues insociety and in women’s lives. Urbanization, increasing the Philippines prevents open discussion of unintendedaccess to education, the spread of mass media and the pregnancy. In this restrictive atmosphere, information ongrowing likelihood that a woman will work outside the abortion incidence and practice is piecemeal at best.home or even overseas all create new alternatives and The struggle for sexual and reproductive health and rightssuggest new possibilities for women. To provide the best generates constant political conflict in the Philippines.educational and employment opportunities for their chil- Despite the very conservative position of the influentialdren, parents may want to have small families so they can Catholic Church against modern contraceptives and abor-invest more in each child. Taking advantage of the same tion, the government has acknowledged and made someopportunities, women may also postpone getting married attempts to address the problems of unintended pregnan-and starting a family. While delaying the start of planned cy and unsafe abortion. The Philippines Reproductivechildbearing, later marriage can also lead to an increase Health Program, created in 1998 in response to goals setin unprotected sexual activity among unmarried men and at the 1994 International Conference on Population andwomen, heightening the risk of unintended pregnancies. Development, lists preventing and managing abortion andAt the same time, weak government support for modern its complications as one of 10 reproductive health goals tocontraception and the insistence of the Catholic Church be addressed.18 The Prevention and Management ofon natural family planning methods contribute to low lev- Abortion and Its Complications Policy, instituted in 2000,els of modern contraceptive use and persistent reliance on focuses on improving the quality of postabortion care andless effective methods. Many women use no family plan- counseling.19 The National Family Planning Policy of 2001ning method at all. Often, this is because they lack ade- also mentions preventing abortion and its complications,quate information about their risk of unintended preg- and acknowledges that illegal abortion stems fromnancy or they have not been counseled about all of their unwanted and unplanned pregnancies.20 Such policiescontraceptive options. Whatever the reasons, when cou- indicate an awareness of the ill-health and death thatples want fewer children and fail to practice contraception result from unsafe abortion and an acknowledgment thatconsistently and correctly, a higher proportion of preg- the government and the public have a role to play innancies will inevitably be unintended. addressing these problems. The legal status of abortion in the PhilippinesArt. 256. Intentional abortion.—Any person who shall intentionally cause Any woman who shall commit this offense to conceal her dishonor shallan abortion shall suffer: suffer the penalty of prision correccional in its minimum and medium periods. 1. The penalty of reclusion temporal, if he shall use any violence If this crime be committed by the parents of the pregnant woman or either upon the person of the pregnant woman. of them, and they act with the consent of said woman for the purpose of concealing her dishonor, the offenders shall suffer the penalty of prision 2. The penalty of prision mayor if, without using violence, he shall correccional in its medium and maximum periods. act without the consent of the woman. Art. 259. Abortion practiced by a physician or midwife and dispensing of 3. The penalty of prision correccional in its medium and maximum abortives.—The penalties provided in Article 256 shall be imposed in its periods, if the woman shall have consented. maximum period, respectively, upon any physician or midwife who, takingArt. 257. Unintentional abortion.—The penalty of prision correccional in its advantage of their scientific knowledge or skill, shall cause an abortion orminimum and medium period shall be imposed upon any person who shall assist in causing the same.cause an abortion by violence, but unintentionally. Any pharmacist who, without the proper prescription from a physician, shallArt. 258. Abortion practiced by the woman herself or by her parents.—The dispense any abortive shall suffer arresto mayor and a fine not exceedingpenalty of prision correccional in its medium and maximum periods shall be 1,000 pesos.imposed upon a woman who shall practice abortion upon herself or shall —Revised Penal Code of the Philippinesconsent that any other person should do so. Unintended Pregnancy and Induced Abortion in the Philippines 8 Guttmacher Institute
  10. 10. ChapterThe Philippine government, service providers, nongovern-mental organizations, the media, international agenciesand society in general, however, all need to have specificand up-to-date information to deal forthrightly withunsafe and illegal abortion. This report seeks to fill criticalinformation gaps at the national and regional levels bydocumenting the scope, causes and consequences ofunsafe abortion. It aims to use new evidence to build polit-ical and institutional commitment to addressing the issueof unsafe abortion and its impact on maternal health, byproviding the evidence base for discussion and formula-tion of policies and programs to reduce unintended preg-nancy and improve postabortion care.A guide to this reportThis report draws on research and analysis conductedbetween 2002 and 2005, as well as on data from the1990s, to document the current situation and trends overthe past decade (see box, page 10; and Appendix, page31). Because illegal abortions generally go unreported,information from hospitals was examined to indirectlyestimate the annual number of abortions in thePhilippines. Women’s accounts during a national surveyprovide additional detail to help paint the most completepicture to date of abortion in the country. Because of thedecentralization of the health care system begun in theearly 1990s, it is important to have local information thatcan be used to inform relevant policy and program change.Wherever possible, data are given for the 16 regions indi-vidually; elsewhere, data are given at the level of the fourmajor regions.Chapter 2 describes levels of unintended pregnancy andinduced abortion in the country as a whole and in eachregion. Chapters 3 and 4 explore the characteristics, rea-sons and decision-making processes of women seeking toend a pregnancy, and the methods they resort to. Abortion-related health complications and their treatment are dis-cussed in Chapter 5. In Chapter 6, abortion is placed in thecontext of a more detailed analysis of contraceptive use andunintended pregnancy. Finally, Chapter 7 links the researchevidence to policy and program recommendations. Guttmacher Institute 9 Unintended Pregnancy and Induced Abortion in the Philippines
  11. 11. Data SourcesPRIMARY DATA SOURCES represents this group. The survey obtained information on several top- ics, including the respondent’s demographic and socioeconomic char-The two primary sources of information for this report are a national com- acteristics; her history of fertility, pregnancy and fetal loss; her knowl-pilation of the most recent available hospital reports and the 2004 National edge, attitudes and practices regarding contraception; her experienceSurvey of Women, conducted by the Guttmacher Institute and the with unintended pregnancy and abortion; and detailed information onUniversity of the Philippines Population Institute. abortion-seeking behavior and the procedure’s consequences.■ Hospital reports were used to estimate the incidence of induced abor- Social and demographic information about which women have an abortion tion and related measures. As part of licensing regulations, all hospi- is based on the 15% of women who reported on the questionnaire that they tals in the Philippines must submit to their regional department of had ever had an abortion, while specific information on methods, providers health office an annual report that includes the number of patients and decision making is based either on the 6% who said in the face-to-face treated for each of the top 10 causes of hospital admission. The cen- interview that they had attempted an abortion or on the 2% who reported tral department of health authorized project staff to obtain these hos- succeeding, depending on the topic. pital reports and to analyze them for this project. Project staff collect- ed available reports for all hospitals in the Philippines between 1996 and 2001; they started with the reports available at the central office, ADDITIONAL DATA SOURCES and then obtained nonforwarded reports directly from each of the 16 ■ The 1993 Demographic and Health Survey (DHS), the 1998 DHS and the regional offices. Between May 2003 and February 2004, a total of 2,039 2003 DHS were used to obtain information on trends related to the con- hospitals were identified, and usable reporting forms were obtained text in which women experience unintended pregnancy and induced for 1,658 (81%) of them, representing 89% of all hospital beds. abortion. These surveys are part of an international research effort Estimates were made for hospitals for which reports were missing. An conducted by Macro International in cooperation with national govern- established methodology was used to estimate the total number of ments. The samples are nationally representative and large enough to abortions in the country (see Appendix, page 31). allow for regional estimates, although some change in the definition of■ The 2004 National Survey of Women, a survey of women of reproduc- regions occurred (14 regions in 1993 and 16 in 1998 and 2003). In the tive age, was designed to investigate the abortion-seeking process 1993 DHS, 15,029 women aged 15–49 years were interviewed; in the and the procedure’s health consequences. It has national and region- 1998 DHS, 13,983 women this age; and in the 2003 DHS, 13,633 women al representation. Some 4,094 women aged 15–49, both single and mar- this age. ried, were interviewed. Using the 2000 Philippines census as the sam- ■ The 1990 census and the 2000 census, carried out by the National Statis- pling frame, a stratified, multistage sample was designed. The sample tics Office, were used to obtain population statistics. design used a cluster approach with barangays (administrative units) as primary sampling units. Barangays were randomly selected; house- ■ A 1996 survey of knowledgeable health professionals, conducted by the holds in the selected barangays were chosen by systematic sampling, Guttmacher Institute, was used to discern their perceptions of the con- and an eligible respondent in each chosen household was inter- ditions under which women obtain induced abortions. viewed. Although almost one in 10 Filipinos migrate temporarily to ■ Qualitative studies among women who have had abortions, carried out other countries as contract workers,1 and more than half of these by researchers and nongovernmental organizations, were drawn on for workers are women,2 the sample design of the survey appropriately additional contextual information. Unintended Pregnancy and Induced Abortion in the Philippines 10 Guttmacher Institute
  12. 12. Chapter The Scope of the Problem FIGURE 2.1 nformation on the current level of unintended pregnancy I and abortion is essential for understanding the extent to which women face barriers in planning pregnancies and preventing unintended ones. Evidence on recent trends in these important indicators is also crucial in assessing whether changes in policies and programs are necessary. Nearly half of pregnancies each year end in an induced abortion or an unplanned birth. 3.1 million pregnancies Because induced abortion is highly stigmatized and pun- 15% 15% Induced ishable by law in the Philippines, and because women and Spontaneous abortions abortions providers tend not to report the procedure, it is extremely difficult to directly measure the number of abortions occurring each year (see boxes, pages 12 and 13). 31% However, analysis of hospital reports provides new esti- Unplanned 39% Planned births births mates for 2000, applying a widely accepted methodology (see Appendix, page 31).1 The same methodology was used in an earlier study to measure abortion incidence for 1994;2 therefore, trends from the mid-1990s to 2000 can be assessed. These estimates of abortion are combined with information from national surveys on unplanned childbear- ing to calculate the level of unintended pregnancy. Source Calculations based on data in reference 3. Unintended pregnancy is the root cause of abortion Some 3.1 million pregnancies occur each year in the Philippines. Of these, 15% result in induced abortions, 31% in unplanned births, 39% in planned births and 15% in spontaneous abortions (Figure 2.1).*3 Thus, about 1.43 *Calculation of pregnancy intentions, numbers and rates involved sev- pregnancy for 1994 and 2000. Spontaneous abortions are estimated eral steps. We estimated the annual number of births by applying age- on the basis of biological patterns identified in clinical studies as 20% specific fertility rates for each major region (calculated from 1993 and of live births plus 10% of induced abortions (source: Bongaarts J and 2003 DHS data) to population estimates (census data from the Potter R, Fertility, Biology and Behavior, New York: Academic Press, National Statistics Office) for five-year age-groups of women for 1994 1983). Information on whether pregnancies ending in spontaneous and 2000, respectively. Separately, we obtained the proportion of abortions were wanted is lacking, but a certain proportion would have births that are unplanned—mistimed or unwanted at the time of con- been unintended. Because this proportion is unknown, our estimates ception—from national surveys for 1993 and 1998, and applied these of unintended pregnancy do not include any spontaneous abortions to the estimates of the number of births. The number of unplanned and are therefore underestimates. births is combined with abortions to calculate the rate of unintended Guttmacher Institute 11 Unintended Pregnancy and Induced Abortion in the Philippines
  13. 13. million pregnancies each year—nearly half of all pregnan- TABLE 2.1cies—are unintended. The annual rate of unintendedpregnancy is 81 per 1,000 women of reproductive age, Estimated abortion rate, by survey year and regionmeaning that about 8% of Filipino women aged 15–44conceive every year without intending to do so. Region Estimated abortion rate* 1994 2000About one-third of these women end their pregnancies in TOTAL 25 27abortion. In 2000, women in the Philippines had more METRO MANILA 41 52than 473,000 induced abortions—compared with an esti-mated 400,000 in 1994. Because the population also grew REST OF LUZON 30 27during this period, the rate of induced abortion remained Bicol 20 25essentially constant—25 abortions per 1,000 women in Cagayan Valley 30 341994 and 27 per 1,000 in 2000 (Table 2.1).4 In 2000, CAR 33 34somewhere in the Philippines, a woman underwent an Central Luzon 39 27induced abortion nearly every minute of every day. Ilocos Region 27 38 Southern Tagalog 27 22At the national level, little change occurred between 1994and 2000 in the proportion of all pregnancies that wereunintended or the rate of unintended pregnancy. However, VISAYAS 11 17both indicators increased substantially in Metro Manila. By Central Visayas 6 242000, more than half (56%) of pregnancies in this area were Eastern Visayas 16 17unintended, a substantial increase from 1994 (46%), and Western Visayas 12 10the unintended pregnancy rate was 97 per 1,000 women,up from 68 in 1998.5 The situation differed in the other MINDANAO 18 18major areas of the country. In Rest of Luzon and in ARMM 8 7Mindanao, the proportion of pregnancies that were unin- CARAGA 4 13tended changed little during this period, but the unintend- Central Mindanao 29 26ed pregnancy rate declined somewhat, from 85 to 78 per Northern Mindanao 11 251,000 women in Luzon and from 84 to 80 per 1,000 women Southern Mindanao 23 20in Mindanao, probably because the overall pregnancy ratefell in these regions. Visayas, the area with the highest Western Mindanao 24 13unintended pregnancy rate in 1994, showed the most *Abortion rate is the number of abortions per 1,000 women aged 15–44 per year.improvement, achieving an unintended pregnancy rate of Notes CAR=Cordillera Administrative Region. ARMM=Autonomous Region of Muslim78 per 1,000 women by 2000 (down from 91 per 1,000 in Mindanao. CARAGA=Cagayan Autonomous Region and Growth Area.1994) and experiencing a small drop in the proportion of Sources Major regions: Reference 4. Other regions: Special tabulations of hospital record data from 1993–1995 and 1999–2001.pregnancies that were unintended, from 48% to 44%.Couples in all parts of the country have difficulty Women are often reluctantmanaging the number and spacing of their children to talk about their abortionsSix in 10 Filipino women aged 15–49 say they haveexperienced an unintended pregnancy.6 Overall, in 2003,the average Filipino woman wanted 2.5 children but had3.5.7 This gap between desired and actual family size In countries such as the Philippines, where abortion is illegal, underreport- ing of events in surveys can be a major constraint in carrying out researchremained relatively stable between 1993 and 2003, on abortion. For this reason, the 2004 National Survey of Women used a pairalthough both measures declined. of data collection approaches intended to minimize underreporting and pro-The discrepancy between wanted and actual fertility varies vide a means of assessing the representativeness of the data and quality ofby region; the largest gap between the two rates is experi- the reporting of abortion. First, in a face-to-face interview, women wereenced by women in Eastern Visayas and Bicol, who have asked detailed, direct questions about their experience of abortion and itsan average of about 1.7 children more than they want.8 In circumstances. Second, women were asked to complete a brief, confiden-Metro Manila, the region with the highest proportions of tial questionnaire asking directly if they had had an abortion since 2000; theywomen who are economically better off, unmarried, sealed the questionnaire in an envelope before returning it to the interview-employed and educated, women want only two children er. Only 2% of women reported in the face-to-face interview that they had obtained an abortion. In contrast, 15% of women indicated in the confiden-and have 2.8, on average.9 tial questionnaire that they had done so. This disparity highlights the impor-The proportion who have had a recent unwanted birth is tance of using research methods that overcome women’s reluctance to dis-smaller among women who live in urban settings or who close their experience of abortion.have at least a college education than among those who livein rural settings or who have an elementary or high school Unintended Pregnancy and Induced Abortion in the Philippines 12 Guttmacher Institute
  14. 14. Chaptereducation.10 This is probably due in part to a higher level ofuse of effective contraceptive methods among the urbanand better educated groups. Nationwide, however, 55% ofall married women are at low or no risk of unintended preg-nancy—they are infecund, want a child soon, are pregnant FIGURE 2.2and want the pregnancy, or are able to become pregnantbut do not want a child soon or ever and are using a mod- Between 1994 and 2000, abortion rates did not changeern method of contraception. This leaves 45% of married much nationally, but they increased in Metro Manilawomen with an unmet need for effective family planning— and Visayas.and at great risk for unintended pregnancy—because they 60do not want a child soon or ever, but are not using a con-traceptive method or are using a traditional method.11 55 52 50 No. of abortions per 1,000 women aged 15–44Women who become pregnant when they are not prepared tocare for a child—whether they were not using a contracep- 45tive, were using an ineffective method, were using a method 41incorrectly or inconsistently, or experienced method fail- 40ure—may be highly motivated to prevent an unplanned 35birth. One-fourth of Filipino women who have ever had an 30unwanted pregnancy say they have had an abortion.12 30 27 27 25 25Induced abortion rates vary greatly across regions 20 18 18 17Large differences in the incidence of abortion exist acrossregions. Women in Metro Manila not only experience more 15 11unintended pregnancies than their counterparts in other 10regions, they also terminate such pregnancies more fre-quently. Three in 10 pregnancies in this region end in 5abortion—a proportion twice that in Rest of Luzon, and 0three times that in the other two major regions of the Total Metro Manila Rest of Luzon Visayas Mindanaocountry, Visayas and Mindanao.13 Women from nearby 1994 2000regions who come to Metro Manila seeking better, moreaccessible or more anonymous postabortion care mayaccount for a small proportion of the abortions attributed Source Reference 14. Informed policy making requires to the capital region. In that case, the abortion rate for better recordkeeping Metro Manila may be slightly overestimated, and the rate for neighboring regions somewhat underestimated. However, hospitals are fairly well distributed across the country, so it is unlikely that large numbers of womenTo measure progress toward improving public health—such as reduced travel to the capital for postabortion care.levels of unintended pregnancy and unsafe abortion among Filipinowomen—policymakers must have access to reliable information on the Metro Manila saw an increase in its abortion rate over thepublic’s health needs and the services being provided. In the Philippines, period of 1994–2000, from 41 to 52 procedures per 1,000complications following unsafe abortions (an indicator of levels of these women aged 15–44 (Figure 2.2).14 This indicator also roseprocedures generally) are a leading cause of hospitalization, yet reports in Visayas, from the previously low rate of 11 abortionsthat would permit documentation of these cases (as well as the full range per 1,000 women in 1994 to a still relatively low rate of 17of the causes for hospitalization) are not compiled, processed or tabulated at in 2000. In contrast, abortion incidence did not increasethe national level. In addition to retrieving official reports submitted to the in the other two major geographic areas.national Department of Health, researchers collecting data for this studyhad to visit many regional department of health offices to obtain reports for Large differences are also apparent within these fourthe more than 2,000 hospitals in the country—a process that took several major areas of the country (Table 2.1).15 For instance, themonths. abortion rate in Rest of Luzon in 2000 varied from 22 inImproving government data collection and analysis would enable decision Southern Tagalog to 38 in Ilocos Region; in Visayas, frommakers to develop better-informed public policies, monitor the implementa- 10 in Western Visayas to 24 in Central Visayas; and intion of policies and programs, and evaluate progress. Such results are crit- Mindanao, from seven in the Autonomous Region ofical to efforts to meet the Millennium Development Goals and ensure a Muslim Mindanao (ARMM) to 26 in Central Mindanao.healthier society. Guttmacher Institute 13 Unintended Pregnancy and Induced Abortion in the Philippines
  15. 15. Rates of abortion in each region are expected to be relat-ed to the level of use of modern contraceptives, as well asthe level of unmet need for contraception. Yet in someregions, such as Metro Manila, Ilocos Region and CentralVisayas, even as modern contraceptive use rose between1993 and 2003, abortion rates stagnated or increasedslightly.16 In countries such as the Philippines, wherewomen and couples increasingly want small families, con-traceptive use may not at first keep pace with this grow-ing motivation to control fertility.17 That is, for a transi-tional period of time, the proportion of couples who wishto space their births or end their childbearing but who arenot using modern contraceptives may increase—and as aresult, more couples may experience unintended pregnan-cies and seek abortions. Eventually, evidence from othercountries shows, contraceptive use becomes more wide-spread and abortion rates decline. Unintended Pregnancy and Induced Abortion in the Philippines 14 Guttmacher Institute
  16. 16. Chapter Why Women Have Abortions ilipino women of all ages, in all parts of the country The most common reason is an inability to afford the eco- F and from all educational, economic and social back- grounds have had an abortion at some point in their lives. What are their circumstances and motivations? In most respects, Filipino women who have an abortion are, nomic cost of raising a child, a reason cited by 72% of Filipino women who have attempted to have an abortion. More than half of abortion seekers gave a reason relating directly to unmet need for family planning: Some 54% felt they had enough children, while 57% believed that the on average, just like any Filipino women of reproductive age pregnancy occurred too soon after their last one. Thirty- (Figure 3.1, page 16).1 one percent of women sought an abortion because they ■ Nine in 10 have ever been married or in a consensual feared that a pregnancy would damage their health, and union. another 32% because they felt that their husband, partner or relatives did not want the pregnancy. One in four ■ More than half have at least three children. women tried to end a pregnancy because of problems with ■ Roughly two-thirds are poor.* their partner; that is, their partner had abandoned them, was not their husband or was not deemed to be a good ■ Nearly 90% are Catholic. father. Some 13% of women who ever attempted an abor- ■ Seven in 10 have at least some high school education. tion reported having done so because their pregnancy The proportion of women younger than age 20 is lower resulted from forced sex. among women who have abortions than among all Filipino One characteristic that is closely associated with a women of reproductive age, which is expected, given that woman’s reasons for attempting to end an unintended many adolescent women are not yet sexually active. pregnancy is her age. Larger proportions of older women than of their younger counterparts cite the expense of Women have many reasons for choosing abortion raising a child, the desire to space the births of their chil- Despite the common perception that abortion occurs pri- dren, concern about limiting family size or health worries marily among women who wish to conceal the “dishonor” as strong motivations for seeking an abortion. On the of a nonmarital pregnancy, women’s reports of their mul- other hand, larger proportions of younger than of older tiple and overlapping reasons for having attempted to end women try to terminate their pregnancies because they an unintended pregnancy show that this is not the case.2 want to avoid conflicts with school, have problems with their partner or the man who made them pregnant, or consider themselves too young to have a baby.3 *In order to create a wealth index, we classified respondents into quar- Women’s economic status is also an important factor in tiles, based on their possession of certain amenities (electricity, radio, television, gas or electric stove, refrigerator, electric fan, air condition- why they decide to have an abortion (Figure 3.2, page 17).4 er, washing machine, indoor toilet, tap drinking water inside house- Although the financial cost of raising a child and the hold, cellular telephone, telephone, bicycle, car, household helper or desire to space births or limit family size are among the maid). We define nonpoor women as those in the highest 25% of respondents; the remaining 75% of women are defined as poor. leading reasons cited by both poor women and better-off Guttmacher Institute 15 Unintended Pregnancy and Induced Abortion in the Philippines
  17. 17. FIGURE 3.1The majority of women having abortions are... ...married or ...Catholic in a union 9% Never in a union 13% Other 91% Ever in a union 87% Catholic ...mothers of three or more ...educated children 29% no high school 43% 0–2 children 57% ≥3 children 71% ≥some high school ...poor 32% Nonpoor 68% PoorSource Reference 1. Unintended Pregnancy and Induced Abortion in the Philippines 16 Guttmacher Institute
  18. 18. Chapterwomen who have sought to end a pregnancy, these reasonsare given by larger proportions of poor than of wealthierwomen. By contrast, a larger proportion of better-offwomen say that opposition to the pregnancy by their hus- FIGURE 3.2band, partner or relatives was a motivation. Both poor* and nonpoor women seeking abortion are concerned with the high cost of raising children.Abortion is often a shared decisionMost women do not make the decision to end a pregnancy 100alone. Nearly seven in 10 women who seek an abortiondiscuss their decision with at least one person: Forty- 90three percent consult their husband or partner, some- 80 76times in addition to other people; 25% discuss the matterwith a friend or relative, and not with their husband or % of women seeking abortion 70partner (Figure 3.3).5 In cases where the man responsible 60 60 58for the pregnancy is consulted, three-quarters approve of 60the woman’s obtaining an abortion. Regardless of who isconsulted, the woman typically initiates the discussion 50 48(83% of cases). Seven in 10 women report having had the 40 39final say in the decision to seek abortion.6 40 30 30 20 10 0 Too expensive Too soon after Has enough Husband/other† to raise last pregnancy children does not want pregnancy Poor Nonpoor *See footnote on page 15. †Other includes partner or relatives. Source Reference 4. FIGURE 3.3 Two-thirds of women who attempt an abortion discuss the decision with someone. 32% Do not discuss 43% Discuss with with anyone husband/partner 25% Discuss with others* *Friend or relative. Source Reference 5. Guttmacher Institute 17 Unintended Pregnancy and Induced Abortion in the Philippines
  19. 19. Chapter How and Where Women Obtain Abortions FIGURE 4.1 he process of obtaining an abortion in the T Philippines can be a long and arduous one, and there is no assurance of success. Fewer than one in three women who seek an abortion complete the process.1 Many women endure multiple attempts—some with serious health consequences—before terminating Most women who have an abortion do not obtain it from a doctor. their pregnancy or giving up on obtaining an abortion. 8% Women are so concerned about the consequences of an Other unintended pregnancy that many are willing to risk their 21% freedom, their health and even their lives to end it. Acquaintance* 29% Doctor or nurse Induced abortion in the Philippines takes 12% Self many forms 15% Pharmacist Abortion techniques used in the Philippines range from 6% 9% safe surgical procedures performed in hospitals to highly Vendor Traditional healer dangerous procedures, such as inserting foreign objects into the cervix or ingesting toxic substances. The type of abortion a woman obtains depends on many factors: her access to *Woman obtained an abortion method from her husband, partner, relative, friend or information on available methods; how early in pregnancy neighbor. she decides on and obtains the procedure; her ability to pay Source Reference 3. for it; the method used by the provider she chooses, or that she herself uses; the training and skill of the practitioner; and the conditions under which the procedure takes place poor women than among their nonpoor counterparts (28% (hygienic or not). In places where modern, reliable methods vs. 15%). Such a delay is also more prevalent among older are available, abortion-related complications are largely women (30–49) than among those aged 15–29 (27% vs. 15%). avoidable. But in the Philippines, the type of provider, the One-third of women who eventually complete an abortion gestation at which pregnancy is terminated, the setting and rely on a husband, partner, relative, friend or neighbor, or the methods used vary greatly; these factors play a large role take steps to end the pregnancy themselves (Figure 4.1).3 in determining the level of risk an abortion will entail. Others consult a pharmacist (15%), traditional healer (9%) Most Filipino women who successfully obtain an abortion do or street vendor (6%). Only about three in 10 women go to so within the first trimester of pregnancy.2 However, nearly a general practice doctor, obstetrician-gynecologist or one-fourth of women who eventually end their pregnancy fail nurse to obtain the abortion.* to have the procedure within this safest window of time and have a later—and riskier—one. The proportion delaying an *Estimates in this chapter refer to women’s last attempt at obtaining abortion until the second trimester or later is higher among an abortion, unless otherwise stated. Unintended Pregnancy and Induced Abortion in the Philippines 18 Guttmacher Institute
  20. 20. Chapter Filipino women employ a wide range of methods when attempting abortion1Surgery or “operation” Massage but often risky and ineffective, rather than costlier, safer(D&C or MVA) and more effective procedures.7 Aspirin or other medicationsMisoprostol Eating or drinking traditionalHormonal pills medicine/herbs Better-off women have safer abortions The correlation between women’s ability to pay for anInjectable hormonal Drinking alcohol abortion and the relative safety of the procedure is appar-contraceptive Fasting ent in the different abortion experiences of poor and non-Insertion of a catheter poor women. Financially better-off women tend to have Climbing a treeinto the cervix abortions performed by safer methods, such as D&C or Jumping MVA, whereas poor women often use massage, insertion ofInsertion of other objectsinto the cervix Exercising a catheter or other techniques, including ingestion or insertion of substances purchased on the black market or from street vendors (Figure 4.2, page 20).8 Larger propor-One-third of women report having the abortion in a hos- tions of nonpoor women than of their poor counterpartspital or health center.4 About half of women undergo the are treated by general practice doctors and obstetrician-procedure in their own or someone else’s home, and the gynecologists (55% vs. 17%). By contrast, larger propor-rest attempt an abortion or obtain methods at a pharma- tions of poor women obtain an abortion with the help of acy, from a sidewalk vendor or market, or outdoors (in friend, relative or partner, or induce the abortion them-mountains, forests, backyards or gardens). selves (44% vs. 30%). Furthermore, larger proportions of nonpoor women than of their poor counterparts seek anOne in four women who obtain an abortion have a surgical abortion in a relatively safe environment—in a clinic, hos-procedure, by either dilation and curettage (D&C) or man- pital or health center (60% vs. 21%)—while a larger pro-ual vacuum aspiration (MVA). Another quarter ingest herbs portion of poor women than of nonpoor women attemptor insert them into their vagina. Equal proportions of the abortion at their own or a friend’s house (55% vs.women report using misoprostol (Cytotec) or massage 30%). Thus, poor women are presumably at a higher risk(15%), or insertion of a catheter (15%) to induce abortion. for experiencing postabortion complications than are theirAbout 20% of women use nonabortifacient hormonal drugs wealthier counterparts.(birth control pills or the injectable), aspirin (Cortal), othermedications or drinks (see box). Some women know littleabout what they are ingesting or inserting, and the med-ication they use may actually include stronger drugs than Mary made six attempts before endingthey think, such as misoprostol. Given that some of these her pregnancy successfullymethods are not effective in inducing abortion, it is likely Mary, a married woman in her early 30s, did not tell the man who made herthat some women who have an abortion also go to a clinic pregnant about her desire to obtain an abortion and began the processor hospital for treatment of complications, and that the when she was one month pregnant. In her first attempt to induce abortion,procedure is completed there.5 she took aspirin (costing 3 pesos*) but remained pregnant. She then triedMany abortion providers and methods are unreliable at ingesting local liquor (12 pesos), jumping, taking herbal remedies and get-best and dangerous at worst. But the high cost of a rela- ting a massage from a traditional healer (60 pesos). None of these methodstively safe surgical abortion in a clinic, 4,000–15,000 worked. Mary could not afford a large sum to end the pregnancy but even- tually found a way to pay 3,000 pesos for hospitalization and a surgicalpesos (US$73–273), can prohibit women from accessing abortion. The six attempts at ending her pregnancy took Mary two weeks.safer procedures.*6 For comparison, an herbal drink She experienced severe bleeding and emotional stress after taking aspirin,obtained on the street or a procedure performed by a tra- but no immediate health problems from the liquor, jumping or herbs. Theditional healer can cost around US$1. More than eight in massage caused her moderate pain, severe bleeding and emotional stress.10 women who make a single attempt to end a pregnancy In the days after her surgery, Mary experienced moderate pain, which shespend less than 100 pesos (about US$2), making it clear attributed to the sum of her abortion efforts, but she had no long-term healththat many women resort to methods that are affordable, problems. She did not get any advice from the doctor who performed the surgery on how to avoid or delay getting pregnant in the future. 2004 National Survey of Women*The monthly minimum wage for nonagricultural work ranges from7,958 pesos (US$155) in Western Visayas to 12,219 pesos (US$238) in *Approximately 51 pesos equal US$1.Metro Manila (source: Department of Labor and Employment, NationalWages and Productivity Commission, Current regional daily minimumwage rates, 2001, <http://www.nwpc.dole.gov.ph/rtw.html>, accessedMar. 14, 2006). Guttmacher Institute 19 Unintended Pregnancy and Induced Abortion in the Philippines
  21. 21. Cynthia made five attempts FIGURE 4.2 but remained pregnant Poor women have riskier abortions than their nonpoorCynthia, a single woman in her early 20s, informed her partner of her desire counterparts.to end her pregnancy and had his approval. She was one month pregnant Methodswhen she attempted to stop the pregnancy; however, she failed to induceabortion, despite five attempts. First, she had a massage by a traditional 100healer (costing 80 pesos*). Her successive attempts included drinking an 90herbal concoction, taking a medicinal syrup (100 pesos) and consuminganother herbal drink (200 pesos). She finally ingested misoprostol (200 35 80pesos) but remained pregnant. Throughout the process of seeking an abor- 48 % of women who have an abortiontion, she experienced various health complications: The massage caused 70severe pain and severe emotional stress, the herbal concoction gave hermild pain and severe emotional stress, the medicinal syrup caused moder- 10 60ate pain and severe emotional stress, and the misoprostol caused severepain and severe emotional stress. However, she reported no long-term 50health consequences. 22 40 2004 National Survey of Women*Approximately 51 pesos equal US$1. 55 30 17 20Many women do not succeed in terminating their 10pregnancy on the first try 13Of the women who succeed in ending their pregnancy, 0 Poor Nonpoormany are able to do so only after multiple attempts (seebox, page 19). Just one-fifth of women who attempt to have Herbs/hormonal drugs/other Misoprostol methodsan abortion succeed on the first try. Two-thirds of women Massage/catheter D&C/MVAwho are not able to end their pregnancy on the firstattempt simply give up. Another 16% of women who try tohave an abortion make two attempts to end their pregnan- Providerscy, and about half succeed in doing so at this second 100attempt. About one in 10 make three or more attempts. Asmall minority of women report making four or more 90attempts (some make as many as six); of this group, three 30in 10 succeed, while the others give up and remain 80 44 % of women who have an abortionpregnant (see box).9 With each unsafe attempt at endingher pregnancy—successful or not—a woman increases the 70 5risk to her life and health. 60 10 50 20 40 30 55 17 20 10 17 0 Poor Nonpoor Husband/self/other Nurse/trained midwife Traditional healer/vendor Doctor Pharmacist Source Reference 8. Unintended Pregnancy and Induced Abortion in the Philippines 20 Guttmacher Institute