Dissecting the

Consolidated RH Bill

Medical, Public Health,

& Bioethical Issues

Dr. Liza C. Manalo, MSc.

Department of Family & Community Medicine
R
Human
H Dignity

Beneficence
B Non-Maleficence

I
L Justice
Allocation of scarce resources
L
S
Autonomy

Bioethical Principles in Medical Practice

 Success can be taught
• The process starts with making people understand that each of us
choose to be victims or victors.
• Poverty is more than a lack of income. It is also the consequence
of specific behaviors and decisions.
• The real long term solution to poverty is not achieved by mere luck
and circumstance. It is achieved by a string of decisions.
• Set backs in life happen, but there is no special formula that magically
brings prosperity and wealth.
• It is the core belief that we, the people, have the power to overcome
wrongs, injustices, and disasters.
• It is the fundamental knowledge that we ultimately have power over
ourselves, our lives, and our pursuit of happiness.
- Reese, Nov, 2008
http://www.digitaljournal.com/article/262211
 The real answer to poverty is a two step process :

• 1st step in helping people rise from despair: instill self worth.
• There is no self worth or self dignity found in a dole-out.
• This does not mean that we don't lend a helping hand; this means that the
helping hand must be accompanied by true compassion that is not attached
to our own personal agenda for the individuals we claim we want to help.
• The first step is by far the toughest. Victory over victim-hood
does not occur overnight, and people have to want that
personal victory before they can find the will to fight for
personal success.
- Reese, Nov, 2008

http://www.digitaljournal.com/article/262211
 The real answer to poverty is a two step process :
2nd: Simply teach the odds to
people each year, from 3rd
grade through high school
graduation, as to who are are
the poor: • How Not to Be Poor:
• High school drop-outs • Stay in School
• Staying single
• Get a Job
• Having children without a
spouse • Get Married
• Working only part time or not • Don't Have Children
working at all Out of Wedlock
- 2001 U.S. Census data - NationalCenter for Policy
Analysis, Jan, 2003
http://www.ncpa.org/pub/ba428/
 Importance of Having
Children to Filipinos
• The Filipinos strive to expand the power of his family and in turn
enhance their welfare through procreation.
• Many children would mean more people supporting the members of it
as a whole.
• In the farming families in the provinces, more children means more hands
to help in harvesting the crops.
• In a typical home, more children would mean more help to do the
household chores.
• When it comes to family protection, the saying "blood is thicker than
water", runs true to Filipinos, the more family members, the more
protection one gets against attacks, to defend them against their
enemies. Certainly an example of "strength in numbers".
• The bigger the family, the better and the prouder their members are
especially when there are family members who are accomplished in
their own fields.
- http://www.western-asian.com/marriage/44-
marriage/103-importance-of-
having-children-to-filipinos
 Improve
Maternal Health
 Many women still deliver without medical
attendance
• Birth attendance by skilled
personnel, a proxy Type of Assistance During Delivery
indicator for MMR, has
only slightly increased 70

from 58.8% in 1990 to 60

59.8
62.3
62.3% in 2006 (FPS) 50 52.8
56.4

Percent
• Most women in rural 40 45.3
41.3
37.1
areas prefer hilots (TBAs) 30 34.5

• Non skilled birth 20

attendance is worst 10
among the poor with the 0
rich more likely to have 1993 1998 2003 2006
skilled attendance at
SBA Non-SBA
delivery than the poor

Everyday another 10 Filipino women die of

complications due to pregnancy and
childbirth.
The main causes of maternal deaths
could have been avoided

Source: Wagner and Claeson. 2004

Eliminating maternal deaths is POSSIBLE
Zero maternal mortality from 1994 up to 2004 Gattaran-
Cagayan, Ara-asan-Surigao del Sur and Isulan, Sultan
Kudarat

• Key elements
• Pregnancy Watch
• Prepaid Perinatal Services
• Upgraded Birthing Centers
• Botica sa Birthing (Pharmacy)
• Walking Blood Bank
• Tambayan sa Birthing (Waiting Home)
• Male Motivators
 Priority interventions on the ground
DELAY # 1 DELAY # 2 DELAY # 3
Deciding to seek Reaching an Receiving EmOC
EmOC EmOC Facility at Facility

• Educate on danger • Improve access to • Ensure availability of

signs and location of transport and skilled birth attendant
EmOC facility communication
• Provide adequate drugs,
systems
• Provide alternatives equipment, blood
for financing • Prepare delivery plan transfusion
(Social/Community during antenatal visits
• Improve quality of
Health Insurance)
services for the poor,
• Establish less educated, and
Community support women who had
group (e.g.. TBA, undergone abortion
BHW)
 At the service level
Increase Demand and Utilization for
Emergency Obstetric Care (EmOC)
• Improve quality of antenatal services
• Information on danger signs and where to go when
complications arise
• Ensure provision of iron and folic acid supplementation
• Rice biofortification
• Distribution in workplace-based settings
• Prepare delivery plans that include options for transport and
financing
• Network with traditional birth attendants (TBAs) to identify danger
signs, plan referrals
 CONSOLIDATED REPRODUCTIVE
HEALTH BILL (HB 4244) is about:
• Education & promotion of safe sex and use of modern
contraceptive devises. (Sec. 13, Mandatory Age-Appropriate Reproductive
Health and Sexuality Education, HB 96 )

• Classifying making family planning supplies as essential

medicine (Sec. 9, Family Planning Supplies as Essential Medicines, HB 96 )

• Promoting a program to “achieve equitable allocation of

resources” when problems pertaining to lack of
“reproductive health” is not as prevalent nor as life-
threatening as our other health problems. (Sec. 3, Guiding
Principles, HB 96)

• Mandatory age-appropriate reproductive health and

sexuality education (Sec. 13, HB 96)
V
i 1.1
Reproductive Health and Population and
o Development Act of 2010 is about
education & promotion of safe sex and
l use of modern contraceptive devises.
a See Sec. 13, Mandatory Age-Appropriate Reproductive Health and Sexuality
Education, HB 96

t
i
o
n
V 1.1 What is wrong with “safe sex” and the use
of contraceptives?
i • Contraceptives are not effective in blocking out STDs.
o • The inherent naturally occurring flaws in natural rubber
(latex) are up to 5 microns inches in size. The average
l sperm is about 50 microns in diameter, and the average
AIDS virus is about 0.1 micron in size. An AIDS virus can
a pass through a latex flaw.
t
i - Dr. C. Michael Roland of the
U.S. Naval Research Lab,
o Washington D.C, Rubber
World, June, 1993
n
V What is wrong with “safe sex” and the use
of contraceptives?
1.1
i • There is no absolute guarantee that one will not get sexually
o transmitted
used.
diseases (STDs) and HIV even when condom is

l • Most experts believe that the risk of getting HIV/AIDS and

other sexually transmitted diseases can be greatly reduced

a • In other words, sex with condoms isn't totally "safe sex,"

if a condom is used consistently and correctly.

but it is "less risky" sex.

t • The most reliable ways to avoid transmission of STDs are
to abstain from sexual activity, or to be in a long-term
i partner.
mutually monogamous relationship with an uninfected

o - Centers for Disease Control (CDC) & US FDA

n
 What is wrong with “safe sex” and the use
V 1.1 of contraceptives?
i • There is no absolute guarantee that one will not get genital
HPV, the most common sexually transmitted infection, even
o when condom is used.
• For those who choose to be sexually active, condoms
l may lower the risk of HPV. To be most effective, they
should be used with every sex act, from start to finish.
a Condoms may also lower the risk of developing HPV-
related diseases, such as genital warts and cervical
t cancer. But HPV can infect areas that are not covered
by a condom - so condoms may not fully protect
against HPV.
i • People can also lower their chances of getting HPV by
being in a faithful relationship with one partner; limiting
o their number of sex partners; and choosing a partner
who has had no or few prior sex partners.
n - Centers for Disease Control and Prevention (CDC)
 When Does Human Life Begin?
A Scientific Perspective
• The scientific evidence supports the conclusion that a zygote is a human
organism and that the life of a new human being commences at a
scientifically well defined “moment of conception.”
• Based on universally accepted scientific criteria, a new cell, the
human zygote, comes into existence at the moment of sperm-
egg fusion, an event that occurs in less than a second.
• Upon formation, the zygote immediately initiates a complex
sequence of events that establish the molecular conditions
required for continued embryonic development.
• The behavior of the zygote is radically unlike that of either
sperm or egg separately and is characteristic of a human
organism.

• Condic M, 2008, The Westchester Institute For Ethics & the Human Person
 When Does Human Life Begin?
At Fertilization
• Keith L. Moore, Before We Are Born: Essentials of Embryology, 7th edition. Philadelphia,
PA: Saunders, 2008. p. 2.
• T.W. Sadler, Langman's Medical Embryology, 10th edition. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006. p. 11.
• Keith L. Moore, The Developing Human: Clinically Oriented Embryology, 7th edition.
Philadelphia, PA: Saunders, 2003. pp. 16, 2.
• Ronan O'Rahilly and Fabiola Miller, Human Embryology and Teratology, 3rd edition. New
York: Wiley-Liss, 2001. p. 8.
• Essentials of Human Embryology, William J. Larsen, (New York: Churchill Livingstone,
1998), 1-17.
• Carlson, Bruce M. Patten's Foundations of Embryology. 6th edition. New York: McGraw-
Hill, 1996, p. 3
• http://www.clinicquotes.com/site/story.php?id=28
 When Does Human Life Begin?
From the Pro-choice side: Acknowledgments of
life before birth

• "A facet that makes the obstetrician's burden unique in the whole field of medicine
is his double obligation; he simultaneously cares for two patients, the mother and
the infant...The essential step in the initiation of life is by fertilization, the
penetration of the ovum by a spermatozoa and the fusion of the two cells into a
single cell."
- Dr. Alan Guttmacher, Pregnancy and Birth: A Book for Expectant Parents New
American Library, Jan, 1962. He was the president of Planned Parenthood

• "Let me say something shocking. I am perfectly willing to grant that life begins at
conception...let's not pretend it [abortion] is not a form of killing."
- Pro-Choice activist and supporter Norman Mailer to David Frost on PBS

• "Fertilization, then, has taken place. A baby has been conceived."

- Planned Parenthood's former medical director Mary Calderone, M.D. (Quoted by
pro-choice author Magda Denes. Appears in "The Zero People: Essays on Life" by
Jeffrey Hensley, Servant Publications (March 1983) p 9.

• http://www.clinicquotes.com/site/story.php?id=28
V 1.1 What is wrong with “safe sex” and the use
of contraceptives?
i
• Some contraceptives have post-fertilization effects.
o
l • (OC)
Although the primary mechanism of oral contraceptives
is inhibition of ovulation, other alterations include
changes in the cervical mucus, which increase the
a difficulty of sperm entry into the uterus, and changes in the
endometrium, which reduce the likelihood of implantation.
t - Physicians’ Desk Reference & Drug Facts and
i Comparisons

o
n
V What is wrong with “safe sex” and the use
of contraceptives?
1.1
i• Some contraceptives have post-fertilization effects
o • “In IUD users, the low recovery of ova from the uterus, as well as the
lack of hCG rise in more recent studies of IUD users, suggest that the
major postfertilization effect is destruction of the early embryo in the
l Fallopian tube, in the same way that the major prefertilization effect is
likely to be destruction of sperm and ova.
• For the copper IUD, this embryocidal effect may be more a result of
a inflammation and direct toxicity, whereas with the progestin IUDs it
may result more from inhibition of transport through the Fallopian tube,

t along with prevention of implantation, preventing long-term viability of

the embryo.”

i • Stanford and Mikolajczyk, American Journal of Obstetrics &

Gynecology, December 2002

o
n
V
i
Reproductive Health and Population and
o Development Act of 2010 is about
l classifying making family planning
supplies as essential medicine
a See Sec. 9, Family Planning Supplies as Essential Medicines, HB 96

t
i
o
n
Criteria for Drug Selection into the Essential Drug
List and the National Drug Formulary
(WHO Technical Report Series No.825, The Use of Essential Drugs)
Relevance to disease Indicated in the treatment of prevalent diseases
Efficacy and safety Based on adequate pharmacologic studies especially among
Filipinos
Quality Must meet adequate quality control standard including
stability &, when necessary, bioavailability
Compliance with WHO Certification Scheme on the Quality
of Pharmaceutical Products Moving in International
Commerce
Cost of treatment regimen

Appropriateness to the
capability of health workers
at different levels of health
care

Local health problems

Benefit/Risk ratio
V What is wrong with classifying family
planning supplies as essential medicines?
i
o • Most normal, low-risk pregnancy, per se, is not
a disease, and as such does not need
l medicines, except for iron and folic acid
supplementation.
a • Hence, the only “essential” medicines
during pregnancy would be ferrous sulfate
t and multivitamins.

i
o
n
V What is wrong with classifying family
planning supplies as essential medicines?
i
o• Combined Oral Contraceptives (COC) are not safe, as they
are classified as carcinogenic to humans by the World Health
l Organization
• The International Agency for Research on Cancer (IARC),
a the cancer research agency of WHO, in its press release of
the 29th of July 2005, informed of the publication of a
monograph on the carcinogenicity of combined estrogen-
t progestogen oral contraceptives (COC) and combined
estrogen-progestogen menopausal therapy (HRT), based
i on the conclusions of an international Working Group of 21
scientists from 8 countries.
o • http://www.who.int/reproductivehealth/publications/agein
g/cocs_hrt_statement.pdf
• http://www.iarc.fr/en/media-centre/pr/2005/pr167.html
n
 What is wrong with classifying family
V planning supplies as essential medicines?
i• Combined Oral Contraceptives (COC) are not safe, as there is
sufficient evidence in humans for their carcinogenicity
o • Estrogen-progestogen oral contraceptives were classified
in the Group 1 of carcinogenic agents, after a thorough
l review of the published scientific evidence.

a • This evaluation was made on the basis of increased risks

for cancer of the breast among current and recent users
t only, for cancer of the cervix and for cancer of the liver in
populations that are at low risk for hepatitis B viral infection.

i • IARC Monographs on the Evaluation of Carcinogenic Risks to

Humans Volume 91 (2007)
http://monographs.iarc.fr/ENG/Monographs/vol91/mono91-6E.pdf
o • The Lancet Oncology, Vol 6 August 2005
http://oncology.thelancet.com

n
 What is wrong with classifying family
V planning supplies as essential medicines?
i• Combined Oral Contraceptives (COC) are not safe, as
o women who were current or recent users of birth
control pills had a slightly elevated risk of developing
l breast cancer.
• from the analysis of 54 epidemiological studies conducted by the
a Collaborative Group on Hormonal Factors in Breast Cancer on
53,297 women with breast cancer and 100,239 women without
t breast cancer

i • The risk was highest for women who started using OCs as teenagers.
• Lancet 1996; 347:1713–1727.

o
n
V What is wrong with classifying family
planning supplies as essential medicines?
i
• Combined Oral Contraceptives (COC) are not safe, as
o the risk for breast cancer was highest for women who
l used OCs within 5 years prior to diagnosis,
particularly in the younger group
a • From the National Cancer Institute (NCI)-sponsored study
among women ages 20 to 34 compared with women ages
t 35 to 54.
• Althuis MD, Brogan DD, Coates RJ, et al. Breast cancers among
i very young premenopausal women (United States). Cancer Causes
and Control 2003; 14(2):151–160.

o • http://www.cancer.gov/cancertopics/factsheet/Risk/oral-
contraceptives

n
V What is wrong with classifying family
planning supplies as essential medicines?
i
o• Contraceptive hormone use is linked to
cardiovascular disease.
l • Newer generation oral contraceptives (OC) indicate a persistent

a increased risk of venous thromboembolism for current users.

• Current guidelines indicate that, as with all medication, contraceptive

t hormones should be selected and initiated by weighing risks and benefits

for the individual patient.

i • Women 35 years and older should be assessed for cardiovascular risk

factors including hypertension, smoking, diabetes, nephropathy, and
other vascular diseases, including migraines, prior to OC use.
o • Shufelt & Bairey Merz, J Am Coll Cardiol. 2009 Jan

n
V What is wrong with classifying family
planning supplies as essential medicines?
i
o• Intrauterine devices (IUDs) are not safe
• During the use of a copper IUD, menstruation tends to be longer with
l a greater loss of blood; in 70% of women who use a hormonal IUD
oligomenorrhea or even amenorrhoea develops. In the first weeks
a after IUD insertion, there is an increased risk of pelvic inflammatory
disease (PID).

t • Summary of the practice guideline 'The intrauterine device' from

the Dutch College of General Practitioners, 2009

i • A World Health Organization multi-centre study established that pelvic

inflammatory disease (PID) risk is temporally related to IUD insertion

o procedures.
• Shapiro, Reprod Health Matters. 2004 May
n
V What is wrong with classifying family
planning supplies as essential medicines?
i
o• Intrauterine devices (IUDs) are not safe
• In 15 studies comparing IUD performance in parous vs. nulliparous

l women, nulliparous women had higher rates of expulsion and removals

due to bleeding and pain.
• Hubacher, Contraception. 2007 Jun
a • Uterine perforation is a rare yet serious complication and is usually seen
during insertion of the IUD.

t • Koltan et al, J Chin Med Assoc. 2010 Jun

• There are about 70 cases in the literature of IUDs that have migrated into
the bladder. The resulting bladder perforation can be complete or partial.
i • Istanbulluoglu et al, J Chin Med Assoc. 2008 Apr
• There is a reported case of a colon penetration by a copper IUD.
o • Arslan et al, Arch Gynecol Obstet. 2009

n
V Unjust
Distribution of Benefits &
i Burdens
o
l Reproductive Health and Population and Development Act of
a 2010 is about promoting a program to “achieve equitable
allocation of resources” when problems pertaining to lack of
t “reproductive health” is not as prevalent nor as life-threatening
as our other health problems.
i See Sec. 3, Guiding Principles, HB 96

o
n
 Top Ten Leading Causes of Morbidity and
Mortality in Low-Income Countries
(WHO, 2004)
Deaths in millions
% of deaths

Lower respiratory infections 2.94 11.2

Coronary heart disease 2.47 9.4
Diarrheal diseases 1.81 6.9
HIV/AIDS 1.51 5.7
Stroke & other cerebrovascular diseases 1.48 5.6

Chronic obstructive pulmonary disease 0.94 3.6

Tuberculosis 0.91 3.5
Neonatal infections 0.90 3.4
Malaria 0.86 3.3
Prematurity and low birth weight 0.84 3.2
V What is wrong with giving
priority to reproductive health ?
i
o • “Eight of the 10 leading causes of morbidity in the Philippines are
caused by infections:
• Acute lower respiratory tract infection and pneumonia
l • Acute watery diarrhea
• Bronchitis/ bronchiolitis
a • Influenza
• Tuberculosis
• Malaria
t • Acute febrile illness
• Dengue fever
i • Among these communicable diseases, pneumonia and tuberculosis
continue to be among the 10 leading causes of mortality, causing a
significant number of deaths across the country.”
o -World Health Organization (WHO) Western Pacific Region Report

n
V What is wrong with giving
priority to reproductive health ?
i
o• “Financial resources allotted by foreign donors to assist the
Philippine Government’s programs could actually be better
l spent in other pursuits than purchasing contraceptives.”
• “It is also of value to demystify our perceptions about the role of
a contraceptives in women’s health, women’s rights, and healthy
families. To equate access to contraceptives with the reduction in
t maternal morbidity and mortality is simplistic.”
- former Department of Health (DOH) Secretary Manuel M. Dayrit, MD, MSc
i Philippine Daily Inquirer, 9/20/04

o
n
V
i
o
l Reproductive Health Population and
Development Act of 2010 is about ensuring
a people’s access to medically safe, legal,
effective, quality and affordable reproductive
t health goods and services .
i See Sec. 20, Implementing Mechanisms, HB 96

o
n
V What is wrong with access to reproductive
health goods and services?
i
o • Indiscriminate access to reproductive health goods and
services without full disclosure of the potential for post-
fertilization effects of hormonal contraceptives
l constitute a violation of informed consent.
• The available evidence supports the hypothesis that when
a ovulation and fertilization occur in women taking oral
contraceptives (OCs), post-fertilization effects are operative on
t occasion to prevent clinically recognized pregnancy.

Oral contraceptives directly affect the endometrium. These
effects have been presumed to render the endometrium
i relatively inhospitable to implantation or to the maintenance of
the preembryo or embryo prior to clinically recognized
pregnancy.
o • Larimore & Stanford, Archive of Family Medicine, Feb
2000

n
V What is wrong with access to
reproductive health goods and services?
i
• Women who believe that human life begins at fertilization
o and those who consider it is important to distinguish
between natural and induced embryo loss are less likely
l to consider the use of a method with post-fertilization
effects.
• In a cross-sectional survey of 755 women, aged 18-49, from
a Primary Care Health Centers in Pamplona, Spain, 40% of
women would not consider using a method that may work after
fertilization but before implantation and 57% would not
t consider using one that may work after implantation.
• de Irala et al, Biomed Central Women's Health 2007
i • Among 618 women ages 18–50 in family practice and
obstetrics and gynecology clinics in Salt Lake City, Utah, and
Tulsa, Oklahoma, USA, 34% reported they believed that life
o begins at fertilization and would not use any birth control
method that acts after fertilization.
• Dye et al, Biomed Central Women's Health 2005
n
A
l Fertility control should…
t • Be reliable
• Be harmless
e • Be immediately reversible
• Be inexpensive
r • Not detract from the pleasure of sexual intercourse
• Encourage a good emotional and sexual relationship
n between partners
• Be due to the existence of a serious motive for avoiding the
a birth of another child e.g., illness in the mother or children
(genetic disorders), extreme poverty, etc.
t • Be respectful of the Moral Law, while searching for the most
adequate means of avoiding births
i
v
e
 Evaluation of the Effectiveness of 12-month
Multi-center Natural Fertility Regulation
Program in China
• Women of different social/education status, strata and ethnic groups in rural
and urban China readily understand the meaning of the mucus patterns
described in the Billings books and all of them accept the method.
• The method-related pregnancy rate of the Billings Ovulation Method™ user
group was zero and their continuation rate was significantly higher than
those in the IUD group.

• 37,000 BOM teachers trained

• 2.7 Million fertile couples in regular use
• Success rate 99%
• Abortion rate dramatically reduced
• 32% of infertile couples give birth

Shao-Zhen QIAN et al, 2003

 Use-effectiveness of fertility awareness
(Billings' Ovulation Method) among
the urban poor in Delhi slums

• The continuation rate of 91.86% for 12 months with a standard error

of 0.67% was surprisingly high for a sample with low literacy and
occupational status, low female work participation rates, small family
size and a preference for sons with low motivation to use other
methods.
• The 1 year efficacy rate (life table analysis) was 99.86%.
• The 1-year use-effectiveness rate was 97.43% for the 5,752 cohort.
• Dorairaj, Soc Action, 1984
Based on the presented evidence,
it is hereby recommended…

NO to RH Bills!!!
The end does not justify the proposed means which are:
 Not reliable
 Not harmless
 Not immediately reversible
 Not inexpensive
 Not respectful of every Filipino’s beliefs and moral values
The youth is the hope of
the fatherland.
-Jose Rizal

This is no longer a statement.

It has become a challenge...