Written by Elena Masilungan. Originally published on Newsbreak.

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

That it’s illegal exacerbates the situation, say experts

MANILA, Philippines –Amelia, 35, was sure she was dying. She was lying in bed in the emergency room of a busy hospital in Manila. Her dress was drenched in blood. Her stomach was in terrible pain.

It happened almost a year ago. Her husband brought her to the hospital because she had been bleeding for three days. It got to a point when she had to change her sanitary pad every 30 minutes. Paracetamol only made the pain in her stomach worse. “I was so weak I could not even sit up. I got scared and went to the hospital.”

Amelia was suffering from complications due to induced abortion.

When she found out she was pregnant, she began seeing the hilot in their neighborhood thrice a week for three weeks for “massage” sessions. The hilot kneaded, poked and pressed her stomach for 10 to 15 minutes during these sessions. On the fourth week of her “massage” sessions, she started bleeding.

It was painful. It was also a crime.

The country’s penal code, enacted 8 decades ago, punishes with imprisonment women who undergo abortion.

Amelia’s case is by no means unique. A study done by the Guttmacher Institute said that in 2008 alone, 560,000 induced abortions were performed in the Philippines.

Amelia took the risk because she and her husband could no longer afford another—their 9th, supposedly—child to feed. A street vendor whose husband ekes out a living as a “pedicab” driver, Amelia considered her pregnancy as just another expense, “gastos lang.”

During an interview in their one-room shanty in Manila, Amelia was putting to sleep her one-year-old infant. Her two eldest children were not home, but neither were they in school. Her nine-year-old son was working as an errand boy in a nearby restaurant, while her 10-year-old was busy manning a car park by the streets.

Only her seven-year-old daughter was in school. The four other kids were with Amelia’s mother, since Amelia had to work.

Unsafe methods

Because abortion is illegal here, women like Amelia are forced to go to clandestine abortion service providers who use unsafe methods, at great risk to their health and their lives.

The consequences of such procedures can be fatal.

In 2008 alone, 1,000 women died from complications arising from unsafe abortion, according to according to a study made by the Guttmacher Institute. Almost every year, unsafe abortion takes more lives than the dreaded dengue fever, which caused a little over 700 deaths last year.

It is among the top five reasons why the number of mothers dying from pregnancy continues to be fairly high in the Philippines, according to data from the health department.

Making things worse is the attitude of many health professionals toward women who choose to abort their pregnancy. Apart from harboring their own moral judgments, these health practitioners hesitate to treat post-abortion patients for fear of criminal liability.

Amelia was lucky. Timely medical attention helped her survive.

In many cases, the women die because when they suffer from post-abortion complications they delay going to the hospital for treatment.

In an overwhelmingly Catholic country where the Church remains an influential voice, terminating a pregnancy is generally equated with murder. There is very little sympathy for women who opt for it.

Women suspected of having induced abortions often receive unsympathetic treatment if not outright threats from medical professionals. The moral judgment made by medical professionals can be so sweeping at times that even those who had spontaneous abortion are initially suspected of undergoing induced abortion.

As such, they are subjected to the same unsympathetic treatment, until such time that a final diagnosis is made that indicates they had, indeed, suffered from spontaneous abortion.

That’s what you get

Amelia felt the censure almost immediately upon entering the hospital’s emergency room.

It was her husband who explained Amelia’s condition to the nurse at the reception desk. The nurse glared at her for a few seconds, Amelia recalled. She then left and came back minutes later with a doctor who asked Amelia where she was hurting and what she was feeling.

“After answering him, he next asked me in a loud voice if I had an abortion,” Amelia said. “There were people near us who heard him and they all looked at me.” She felt the judgment in their eyes. “They seemed to be saying, ‘that’s what you get for getting an abortion,’” Amelia related in almost a whisper.

Amelia did not answer the doctor directly. She told him was that she had a miscarriage (“nakunan”), or a spontaneous abortion, which happens without medical or surgical interventions. The doctor looked at her and shook his head but said nothing more.

In countries where it is legal, abortion is done through surgery or medication. In the Philippines, women wanting to terminate their pregnancies do it through such means such as an abdominal massage, by inserting hazardous objects in the uterus, by ingesting abortifacient drugs or substances, or even simply by doing intense physical exertion.

Asked why she lied, Amelia explained, “I did not want to admit to the doctor I had an abortion. I don’t think any woman can readily admit that. How can a mother admit to another person that she killed her child?”

After the doctor left her, a nurse sat Amelia in a wheelchair and led her to the obstetric ward. The nurse told her in a sharp tone, “Don’t lie when she asks you if you had an abortion. If you lie, we will report you to the police. Besides, it’s obvious you had one.”

Amelia was burdened with mixed feelings. “I was so scared I might die or if I live, they will get the police to arrest me.” She was also getting furious. “I was bleeding heavily. I could feel the blood trickling down my legs. My dress was also soaked in blood,” she narrated. “I knew they were deliberately delaying treating me because I had an abortion.”

Meantime, the pain kept getting worse. “I kept thinking of my children. The eldest was just 10 years old. What will happen to them if I die?,” she said.

Amelia had reason to be angry.

“I have witnessed many times how the health staff can be very judgmental in dealing with post-abortion patients,” observes an OB-Gyne doctor, who agreed to talk only on condition of anonymity.

Guilty feelings

The doctor, who is a consultant with the Dr. Jose Fabella Memorial Hospital, the largest maternity hospital in Metro Manila, admitted that it is very common to hear “self-righteous remarks” from health professionals when they talk to post-abortion patients. “They make the patients feel guilty for their ‘crime.’”

Dr. Alejandro San Pedro, chair of the Department of Obstetrics and Gynecology of the Bulacan Provincial Hospital, agreed that such situations do happen. “The influence of the Catholic Church is deeply ingrained in some doctors that it affects the way they behave toward their patients,” he said.

The code of ethics of the Philippine Medical Association (PMA) is clear on what it expects from doctors: to provide competent medical care with full professional skill in accordance with current standards of care, compassion, independence, and respect for human dignity.

But in reality, many doctors do not meet this expectation when it comes to dealing with post-abortion patients.

Flora, a 23-year old single mother of three, experienced this when she sought treatment in a private tertiary hospital for high fever, severe stomach cramps, and heavy bleeding after ingesting the drug misoprostol, a drug known for its abortifacient qualities.

“The scolding came first before the treatment,” relates Flora. “The doctor reprimanded me and told me I committed a grave sin. She told me, ‘You may still be alive but your soul is already burning in hell.’”

All Flora could do at the time was cry.

Some doctors we interviewed explained that they resent having to spend crucial time on a patient who is lying about her condition. “Admittedly, you can get impatient,” said Merlinda Montinola, chief resident of the OB-Gyne department of the Philippine General Hospital.

It is frustrating when a patient keeps on denying that she had an abortion when all her symptoms point to that, Montinola said. “You would want to know what she did because the treatment for induced abortion is different from spontaneous abortion.” When no amount of explanation would make the patient tell the truth, Montinola said, “you cannot help but sound irritable and unsympathetic.”
This mood can be aggravated when the doctor is overworked and very tired, she added.

Some doctors admitted threatening their patients that they will be reported to the police just to stop them from lying or from being evasive about their true situation. They clarified, however, that these are often empty threats— meant only to make the patient realize that what she did was illegal and risky.

Hopefully, these doctors said, the patient will be frightened enough and avoid a repeat in the future.

Legal and moral bind

There are doctors who feel they are in a bind when treating post-abortion patients because of the legal responsibility attached to induced abortion.

“Some doctors think that completing an induced abortion and providing post-abortion care mean they are continuing the crime,” according to Junice Melgar, executive director of the Likhaan Center for Women’s Health. The center is a nongovernment organization that promotes the health and rights of disadvantaged women and their communities.

Melgar maintained that these fears are baseless. “The crime has been done already. And doctors are supposed to do their ethical role, which is to treat life-threatening complications.”

The specter of potential criminal liability, however, clearly affects the way health professionals and institutions deal with post-abortion cases.

In a forum on post-abortion care attended by health professionals, the assistant chair of the OB-Gyne department of a tertiary teaching hospital in Metro Manila revealed that they would direct their security guards to have the names of post-abortion patients listed in the police blotter.

The administration of the hospital, which is right across from a police station, was under the impression that they are required to do this. Curiously, no police ever came to the hospital to investigate.

Lawyer Claire Padilla, executive director of the NGO EngendeRights, who was in the same forum, asserted that the law is not categorical in requiring doctors and hospitals to report to authorities women who had induced abortion. This should explain the police’s lack of action against post-abortion patients in the said hospital.

There are doctors as well who refuse to treat post-abortion patients because to do so would be against the dictates of their conscience.

Doctors who admitted they turned away patients in the past told Newsbreak that they referred the cases to other doctors who were less conflicted. Likewise, in situations when they are the only ones available, these doctors said they eventually provide their patients with competent medical care.

In such situations when they are forced by circumstances to attend to post-abortion patients, however, the behavior and attitude of these doctors toward such patients sometimes go against the PMA code.

Training for doctors

Hospitals generally have an accountability mechanism that allows patients to complain if they experienced less than professional behaviors from their staff, including doctors and nurses. It is, in fact, a requirement for PhilHealth accreditation.

Most post-abortion patients, however, ignore these violations of their rights and prefer to suffer in silence.

Dr. San Pedro said training is crucial in changing the way medical professionals perceive women who undergo abortion. “Medical professionals must learn how to respect women and their reproductive rights. Our training when it comes to post-abortion care and treatment is heavy on the biomedical aspect. It’s time to devote as much emphasis on the ethical values of medical professionals in responding to the needs of post-abortion patients,” he explained.

One hospital, the Brokenshires Integrated Health Ministries in Davao City, has been doing this for some time now through its Woman Center. This health institution is managed by the United Church of Christ, a Protestant group.

Brokenshires’ Woman Center conducts regular training for residents, nurses and midwives on ethics and quality of care. The training has a specific section for post-abortion care that incorporates not just clinical discussions of cases but also the ethical practices involved.

“We recognize that even if our personal belief is against abortion, it is not right to reflect this in our attitude toward our patients,” said Dr. Darlene Estuart, project director of the center.

Estuart sees the value of exposing residents to nonclinical work and having them interact with poor women, abused women, and women in prostitution, who comprise a significant number of post-abortion patients.

“By experiencing this, they’ll know first hand these women’s daily struggle and the ordeals they have to go through in life. Hopefully, when someone like them becomes their patient, they’ll be less judgmental, more compassionate, and more respectful to them,” she explained.

(Next: Desperate women seek desperate measures)–Newsbreak