“Reproductive Health”

Whatever the RH bill is for, it is most definitely does not constitute a real commitment towards reproductive health.

As has been discussed here in the past, many of the risks associated with RH bill provisions are being deliberately downplayed or dismissed altogether by RH bill advocates.

Absolute and Relative Contraindications

From the WHO: Medical Eligibility Criteria in the Prescription of Contraceptives.

Hormonal contraceptives have many medical contraindications, but RH bill proponents have not made it clear whether women will be properly screened prior to prescribing contraceptives for them. Screening should require no less than a mammogram. To unknowingly prescribe the pill to a patient with an underlying condition, i.e., breast cancer or cardiovascular disease, can actually increase maternal morbidity. Contraindications are not to be taken lightly which is why they are always printed right on the drug inserts. As hormonal contraceptives will probably be dispensed by barangay health workers, it is unlikely that there will be any extensive screening performed. A woman who has an undetected vascular problem can easily develop an embolism or have a stroke.

One myth that has cropped up is that OCPs only increase the risks of those who are already genetically predisposed to have breast cancer and those who have risk factors. The problem with this is that no one can tell who is predisposed. The use of oral contraceptives is in itself a risk factor which makes one predisposed. Breast cancer receptors are only detected in cancerous breast tissue — WHEN you ALREADY have the cancer — in order to direct treatment. How can this be acceptable public health policy?

Prior to insertion of IUDs, women should be tested for gynecological diseases and disorders; these are absolute contraindications. An underlying malignancy or large myoma, for instance, can only be detected through imaging via ultrasound, X-ray or MRI.

The RH mantra proclaims that all medications have side effects. 1) Contraindications are an altogether different matter. They are not side effects that are manageable and reversible. Contraindications are serious and even potentially fatal. There is a good chance that if the bill passes, hormonal contraceptives, contraceptive patches and injectables will be dispensed indiscriminately. This constitutes gross negligence. 2) While this is true, medicine is prescribed to TREAT a particular condition. In the case of hormonal contraceptives and IUDs, there is no disease being treated. On the contrary, women who are perfectly healthy will be given a medical condition: infertility.

Reference: Sample contraindication literature from Pfizer

Proper Screening Procedures

Each recipient of the hormonal contraceptive must be thoroughly evaluated by extensive diagnostic procedures to rule out contraindications. Testing takes time and money. Our government cannot afford all the necessary tests. Some blood tests (titers) are available only in select hospitals in Manila where they have the technology and capability. They will be too expensive to do otherwise; there is no way these procedures can be done properly in a rural setting. Unless these ‘vans’ provided through the RH bill can be outfitted with an MRI, CTscan, a doppler, 2d-echo, X-ray, blood chemistry tests, etc., then we can confidently say that the RH bill actually increases maternal morbidity and mortality. We cannot rule out heart disease, underlying breast malignancy, deep-vein thrombosis without sophisticated imaging, using equipment heavier than vans and almost as large. Many cities in Visayas and Mindanao do not even have the most basic blood chemistry tests — cancer titer, lipid panel, etc. We don’t have the manpower: only a handful can actually read mammograms in the Philippines. We need to provide electricity first to all barangays to have dedicated mammography units put up. We need radiation technologists in these barangays. We also need two breast imaging radiologists (double reading is the ideal setting) to read the mammograms per. Given our budget and other limitations, RH personnel will be dispensing hormonal contraceptives WITHOUT testing for eligibility, because we do not have the capability nor the manpower at this time. To dispense without first thoroughly evaluating the patient is unethical and dangerous, and goes against the stated goals of the RH bill. And it goes without saying, Php3 billion is not enough to cover all of these. This is not black propaganda. It is the truth, and the public deserve to know.

People need to be aware of the absolute and relative contraindications of prescribing hormonal contraceptives. The only way doctors can safely prescribe hormonal contraceptives is through extensive and expensive lab work. Since doctors cannot haul every woman of child-bearing age to the few hospitals that have these capabilities, they cannot and must not dispense hormonal contraceptives until these tests are performed, if they truly care about women’s health.

Dr. Sandra Villamor, an ophthalmologist practicing in Cebu, conducted an informal interview with many OB-Gyne specialists recently. She relates, “These OB-gyne specialists sheepishly admit that they often overlook the screening process due to lack of facilities in the area where they are practicing. That is a major reason they do not prescribe contraceptives to everyone. They also know that they are leaving themselves wide open to malpractice suits if they do so.”

There are no gray areas in this angle. The pill is not medically safe for every woman out there who wants it.

Historical Data

In a 2004 analysis of the family planning hotline which was part of the Strengthening Social Acceptance
Of Family Planning in the Philippines Project, it is a readily apparent that inadequate advice is being given to people calling in to ask for information about contraceptives and other family planning methods.

From Legal, Ethical and Regulatory Aspects of Introducing Emergency Contraception in the Philippines (note that use of this data from Guttmacher should not be taken as endorsement of their recommendations and practices, which are diametrically opposed to pro-life principles)

Questions Remain

If a physician prescribes oral contraceptives to a patient today who suddenly develops a pulmonary embolism tomorrow due to a pre-existing vascular disease which the physician neglected to screen first, shouldn’t he be held liable?

What will the exact procedure be in dispensing/distributing of the hormonal contraceptives in the RH bill? If a mother in a barrio wants artificial contraceptives, will she be given a pack of OCPs at her barangay health center immediately? What kind of medical assessment will be performed?

Other Issues

  • Non-Coverage of Infertility

    According to the UN guidelines on reproductive health, there should be provisions for infertility treatment

    Reproductive health should also address issues such as harmful practices, unwanted pregnancy, unsafe abortion, reproductive tract infections including sexually transmitted diseases and HIV/AIDS, gender-based violence, infertility, malnutrition and anaemia, and reproductive tract cancers. Appropriate services must be accessible and include information, education, counselling, prevention, detection and management of health problems, care and rehabilitation.

    Nowhere on the RH bill do these provisions appear. The RH bill only covers one end of the spectrum, from prevention of pregnancy via contraception and sterilization. The other end of the spectrum is completely ignored, therefore the bill isn’t really about reproductive health as much as it is about population control. Many cases of infertility can be treated. There are those who can afford to have more than two children (the stated “ideal family size” according to the RH bill) and yet can’t have any. Why aren’t they being helped by the bill?

  • Intra-Uterine Devices

    Many of the problems associated with IUDs are due to the fact that required follow-up checks are not performed as recommended. Are there funds set aside for these check-ups?

  • Oral Contraceptives as Carcinogens, the Latest Report

    Published May 17, 2011: IARC Report on Combined Estrogen-Progestogen Contraceptives

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Posted in The Scientific Perspective, Women's Health

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