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Analyzing Data and
Policy Trends in
Adolescent Pregnancy
and Contraception
in the Philippines
The State of the Region Report on Sexual
and Reproductive Health and Rights:
International Conference on Population
and Development (ICPD+25)
asian-pacific resource & research
centre for women
Any part of the text of the publication may be translations through mechanical, electrical, or electronic photocopied, reproduced, stored in a retrieval system, or means should acknowledge Likhaan and ARROW as the transmitted in any form by any means, or adapted and source. A copy of the reproduction, adaptation, and/or translated to meet local needs, for non-commercial and translation should be sent to Likhaan and ARROW. In non-profit purposes. However, the copyright for images cases of commercial usage, Likhaan and ARROW must be used remains with the respective copyright holders. All contacted for permission at office@likhaan.org and forms of copies, reproductions, adaptations, and arrow@arrow.org.my.
Analyzing Data and Policy Trends
in Adolescent Pregnancy and
Contraception in the Philippines
A national report contributing to:
The State of the Region Report on Sexual and Reproductive
Health and Rights: International Conference on Population
and Development (ICPD+25)
Published April 2019 by:
Likhaan Center for Women's Health, Inc. (Likhaan)
27 Ofelia St., Barangay Bahay Toro,
Quezon City 1106, Philippines
(63 2) 454-3854 • (63 2) 926-6230
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Asian-Pacific Resource and Research Centre for Women (ARROW)
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Telephone: (603) 2273 9913/ 9914
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Production Team
Writers: Junice Lirza D. Melgar • Alfredo R. Melgar • Joycelyn Salgado •
Erickson R. Bernardo
Reviewers: Prof. Elizabeth Aguiling-Pangalangan • Dr. Rita Mae C. Ang-Bon, MD •
Shamala Chandrasekaran • Dr. Natasha Ann R. Esteban-Ipac, MD •
Dr. Bernabe R. Marinduque, MD • Dr. Josefina Natividad, Sc.D. •
Sai Jyothirmai Racherla
Copy editors: Joycelyn Salgado • Erickson R. Bernardo
Layout: A.R.Melgar
Photos: Pepito Crizaldo (cover) • Mark John Abellon • A.R.Melgar • Likhaan photos
Printer: Sta. Ana Printing Press
Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines
Content
Acknowledgements............................................................................................................4
Acronyms.........................................................................................................................4
Executive Summary...........................................................................................................5
Introduction......................................................................................................................6
Methodology.....................................................................................................................8
Findings
Demographic and Health Data and Trends........................................................................9
Laws and Policies on Adolescents' Access to Contraceptive Information and Services............15
Summary of Findings...................................................................................................25
Discussion......................................................................................................................26
Conclusion......................................................................................................................30
Recommendations...........................................................................................................30
Endnotes........................................................................................................................31
References......................................................................................................................32
Annex 1: Data Tables.......................................................................................................33
Acknowledgments
Likhaan gratefully acknowledges the financial and form of this project—all remaining errors
support provided by our sister organization and ommissions are of course completely ours.
ARROW, without which this research project Finally, we thank the people, mostly young
would not have come to light. We also thank all women, who shared their stories and images to
the reviewers and commenters who generously enrich this publication.
provided their expertise in improving the content
Acronyms
ABR Adolescent Birth Rate CHO City Health Office IUD Intrauterine Device
ADEPT Adolescent Health Education CSE Comprehensive Sexuality LGU Local Government Unit
and Practical Training for Education MOP Manual of Operations
Health Care Service Providers CSO Civil Society Organization NDHS National Demographic and
AFHF Adolescent Friendly Health DHS Demographic and Health Health Survey
Facility Survey NGO Non-Government Organization
AFHS Adolescent Friendly Health DepEd Department of Education PDP Philippine Development Plan
Services DOH Department of Heath PHO Provincial Health Office
AHDP Adolescent Health and DSWD Department of Social Welfare POA Program of Action
Development Program and Development RH Reproductive Health
AIDS Acquired Immunodeficiency EO Executive Order RPRH Responsible Parenthood and
Syndrome FDA Food and Drug Administration Reproductive Health
AJA Adolescent Job Aid FP Family planning SDGs Sustainable Development
AO Administrative Order HEADSSS Home, Education, Activities, Goals
ARH Adolescent Reproductive Drugs, Sexuality, Suicide and STI Sexually Transmitted Infection
Health Safety TBCs Teenagers who have Begun
BCC Behavior Change HIV Human Immunodeficiency Childbearing
Communication Virus UNFPA United Nations Population
ICPD International Conference on IEC Information, Education and Fund
Population and Development Communication WHO World Health Organization
CRC Convention on the Rights of the IRR Implementing Rules and
Child Regulations
4
Executive Summary
Executive Summary
The Program of Action (POA) of the International Conference on Population and
Development (ICPD) declared that adolescents have the right to sexual and
reproductive health (SRH) information and services tailored to their age and needs.
It provides that sexually active adolescents will require a special approach to
family planning (FP) information, counseling and services which safeguards their
rights to privacy, confidentiality and informed consent.
The goal of this study is to assess the ICPD Key findings include the following: 1) The ABR
POA’s objectives and recommended actions that is high and the rate of decline is very slow
address adolescent SRH issues through the compared to all other age groups; 2)
promotion of responsible sexual and Adolescents have much slower declines in the
reproductive behavior and the substantial proportion of births that are unintended; 3)
reduction of adolescent pregnancy. Along these There is strong evidence that the rate of
objectives, the Philippine government targets unprotected sex is a better predictor of ABRs
the following by 2022: reduce the adolescent than sexual activity per se; 4) Modern
birth rate (ABR) to 37–40, from 57 births per contraceptive use is continually rising, but more
1000 women in 2013; reduce the proportion of than half of sexually active adolescents are still
adolescents who have begun childbearing to non-users of modern contraceptives; 5) Policies
6%, from 10.1% in 2013; decrease the unmet on adolescents’ use of contraceptives have
need for modern FP to less than 5%, from 35% regressed from 1998 when Adolescent RH was
in 2013; and increase the contraceptive included in the Department of Health’s (DOH’s)
prevalence rate (CPR) to 65%, from 43% in 10-element RH Program until 2014 when the
2015. RH Law explicitly disallowed FP provision to
minors in public facilities unless they had
We implemented a two-pronged approach to
parental or guardian consent; 6) The DOH
the study. We utilized STATcompiler, the online
technical guidelines mainly promoted absti-
database of demographic and health surveys
nence or are silent about contraceptives; 7)
(DHS), to organize and consolidate data that
Religious doctrines and religious morality have
are relevant to adolescent’s SRH. We tapped all
been cited as the underlying principles in two
six Philippine surveys (DHS 1993, 1998,
policies.
2003, 2008, 2013 and 2017) to explore data
patterns and trends. We also conducted a policy The study concludes that the Philippines did not
review focused on a subset of documents meet the ICPD POA objectives of addressing
recently reported on by Melgar J. and adolescents’ SRH needs and reducing the
colleagues in the 2018 article “Assessment of adolescent birth rate significantly. This is mainly
Country Policies Affecting Reproductive Health because government did not adopt a special
for Adolescents in the Philippines.” Finally, we program for sexually active adolescents,
integrated the data and policy reviews to including information, counseling and services
present an informed evaluation of the current that guaranteed their right to privacy and
status of adolescent pregnancy and confidentiality.
contraception in the Philippines.
5
Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines
Introduction
The ICPD POA is a pivotal document that Adolescent RH (ARH) was one of 10 elements
affirmed people-centered development and the in the RH program established by the DOH in
centrality of reproductive health and rights in 1998 following the ICPD.10 In the beginning,
development strategies. Key among the goals of the program was mainly implemented by local
the ICPD were to reduce maternal and infant government units (LGUs), the Commission on
mortality and achieve gender equality and Population and Development (PopCom), and
equity and women’s empowerment. NGOs supported by the UNFPA. Among NGOs,
ARH services included the conduct of gender
In the Philippines, implementation of the ICPD
and sexuality education for adolescent girls and
POA has been difficult and slow and associated
boys; the provision of integrated RH services
with mixed results. For example, the infant
including contraceptive services and supplies;
mortality rate declined by 45% from 40.5 per
the training of peer counselors; and advocacy
1000 in 1990 to 22.2 in 2017;1 while the
for the RH Bill and ARH. The RH program of
maternal mortality ratio declined by only 25%
the DOH became the template of the RH Bill
from 152 per 100 000 in 1990 to 114 in
filed in 2001, which became law in 2012.
2015.2 Key challenges to the implementation of
the program are the strong opposition to FP and In 2012, the National Youth Commission
reproductive rights by ultra-conservative triggered an alarm over the adolescent birth rate
Catholic groups; a health system that is of 53 per 1000, which was reported then as
fragmented and inequitable; and a general lack the highest among six major economies in
of appreciation for gender-responsive and rights- Southeast Asia.11 This was echoed in 2013 by
based approaches to health and development. PopCom and many other LGUs, especially
cities, thereby adding to the clamor for the
Specific to adolescents, the ICPD POA declared
urgent passage of the RH Bill.12
that adolescents have the right to RH
information and services tailored to their age During the 12 years that the bill moved through
and needs, including FP. Adolescents are Congress, the specific program changed from
defined by the WHO as persons between ages “adolescent reproductive health” to “adolescent
10 and 19. Sexually active adolescents will and youth reproductive health guidance and
require a special approach to FP information, counseling” and “reproductive health education
counseling and services which safeguards their for … adolescents.”13 It is uncertain what or
rights to privacy, confidentiality and informed who the driver of the change was, but it reflects
consent while acknowledging the rights and the significant religious-cultural resistance to
duties of parents. adolescents’ sexuality and use of contraceptives,
particularly by the Catholic Church leadership.
Another area of change is on parental consent
Indicator Baseline Current % Change for minors (i.e., below age 18) requesting
Total fertility rate, 1993 & 2017 contraceptives. The RH Bill was initially silent
(average no. of births per woman)3 4.1 2.7 -34.1%
on the issue, implying that no consent is
Adolescent birth rate, 1993 & 2017
(births per 1000 women)4 50 47 -6.0% needed. Conservative legislators successfully
Demand for FP satisfied by modern methods, pressed for a written consent requirement in
1993 & 2017, as percentage5 government facilities.14 Progressive legislators
• all women 15-49 35.8 56.1 56.7% fought for and won an exception clause for
• married (includes live-in) women 15-49 35.4 56.9 60.7%
• all female adolescents 15-19 18.9 43.7 131.2% minors who have had a pregnancy or
• married female adolescents 15-19 19.3 46.6 141.5% miscarriage. This exception, however, was
• sexually active unmarrried female adolescents 15-19 NA 13.8 NA struck down as unconstitutional by the Supreme
Live births delivered by Court in its 2014 decision.15 Government health
skilled provider, 1993 & 2017 (% of births)6 52.8 84.4 59.8%
facilities are now required to ask for written
Infant mortality rate, 1990 & 2017
(per 1000)7 40.5 22.2 -45.2%
parental consent from all minors who ask for
Neonatal mortality rate, 1990 & 2017
contraception, even from those who have
(per 1000)8 19.3 13.6 -29.5% children or have been pregnant.16
Maternal mortality ratio, 1990 & 2015 Apart from the 2013 to 2014 halt as the
(maternal deaths per 100 000 live births)9 152 114 -25.0%
Supreme Court ruled on the constitutionality of
6
Rationale, Aims and Objectves
the RH Law, it was stopped again from 2015 to The RH Law as the application Had I known that
2017 based on a new legal challenge by of ICPD in the Philippines is
religious anti-FP groups. The Court ordered the integrated with the Sustainable young women
Food and Drug Administration (FDA) to redo its Development Goals (SDGs)
process of certifying contraceptive products as through the Philippine Deve- could use pills, I
non-abortifacients, and the DOH to stop from lopment Framework (“Am-
buying and distributing implants even if these bisyon Natin 2040”) of the would have used
had been approved earlier by the FDA. In late National Economic Develop-
2017, the FDA certified 51 contraceptives ment Authority. The Frame- it and not gotten
including implants as non-abortifacients. work’s Agenda 10 calls for
Earnest implementation of the law began only strengthening of the imple- pregnant and
in 2018. mentation of the RH Law “to
enable especially poor couples with a child at 16.
The Supreme Court interventions mainly
to make informed choices on
restricted access to contraceptive products and
financial and family planning.” I wish they would
services, but not access to RH information,
The Philippine Development
education and communication (IEC) services
Plan 2017-2022 also affirms let young people
and materials. Subsequent annual reports of RH
that the “country is committed
Law implementation from 2015 to 2017
to address maternal and
know these
—based on facility and DHS data—show slow
reproductive health and
improvement in key RH outcomes, including the
accelerate the fulfillment of
things when they
adolescent birth rate.17 The slow improvement
women’s rights.”19
in ARH contrasts with widespread IEC and do not want to be
“demand generation activities” for all, including
adolescents. Annual RH reports are done by the pregnant.
National Implementation Team convened by the
DOH in 2014, comprised of national -AG, 17, single mother
government agencies, civil society organizations from a poor community
(CSOs) and development organizations.18
in Malabon
Rationale, Aims and Objectives
The goal of the project is to monitor how the be achieved by 2022:21
Philippines is implementing the objectives and
• Reduce adolescent birth rate to 37–40, from
recommended actions of the ICPD POA that
57 per 1000 in 2013;
apply to adolescents. Generally, POA 7.17
exhorts countries to act to meet the FP needs of • Reduce the percentage of adolescents who
the population as soon as possible, and provide have begun childbearing to 6%, from 10.1%
universal access to a full range of contraceptive in 2013;
methods by 2015. Specific to adolescents, POA • Decrease unmet need for modern FP to less
7.44 aims to address adolescent SRH issues than 5%, from 35% in 2013; and
through the promotion of responsible sexual and • Increase CPR to 65%, from 42.8% in
reproductive behavior. POA 7.46 recommends 2015.
that countries promote the rights of adolescents
To reduce teen pregnancies and improve health
to RH education, information and care and
outcomes from these pregnancies, the WHO
greatly reduce the number of adolescent
recommends the following strategies: reducing
pregnancy, while POA 7.47 recommends
marriage before age 18; creating understanding
programs to meet the requirements of sexually
and support to reduce pregnancy before age 20;
active adolescents for special FP information,
increasing contraception by those at risk of
counseling and services.
unintended pregnancies; reducing coerced sex;
Parallel to these goals and recommended reducing unsafe abortion; and increasing the
actions are the following key targets in the use of antenatal, childbirth and postnatal care
Philippine Development Plan (PDP)20 and the among adolescents.22
National Objectives for Health (NOH) that must
7Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines
Keeping these global and national quantitative contraceptive use as reported in national
and qualitative targets in mind, this monitoring demographic and health surveys.
report provides evidence on how well
2. Analyze the policy environment around
adolescents are protecting themselves from
access to contraceptive information and
early and unintended pregnancy, and whether
services.
and how government policies are enabling them
to resort to such protection. The specific 3. Recommend strategies and interventions for
objectives of the report are as follows: addressing adolescent pregnancy in relation to
the use of contraceptive information and
1. Analyze the trends in adolescent fertility,
services.
unintended pregnancy, sexual initiation and
Methodology
We utilized the DHS Program STATcompiler, an programmes on ARH: the Responsible
online database of demographic and health Parenthood and Reproductive Health Law, as
surveys (DHS), to organize and consolidate data modified by Supreme Court decisions; the
that are relevant to adolescent’s SRH.23 We abortion section of the Revised Penal Code; the
tapped all six Philippine surveys, namely DHS President's Executive Order No. 12;
1993, 1998, 2003, 2008, 2013 and 2017. Implementing Rules and Regulations of the RH
We made full use of the relatively large number Law, including changes mandated by the
and regularity of these surveys to explore data Supreme Court; the DOH’s Administrative Order
patterns and trends. We compared adolescents on Adolescent Health and Development; the
with all the other age groups, the baseline with DOH’s Guidelines on the Adoption of Baseline
the latest data (i.e., 1993 vs. 2017), and Primary Health Care Guarantees for All
calculated the average annual percentage Filipinos which mentions contraceptives for
change. If available, we compared data sets of adolescents; the latest edition of the Philippine
adolescent subgroups (e.g., one-year age Clinical Standards Manual on Family Planning;
groups). We converted data into line and bar Manual of Operations for the Adolescent
charts to enhance the recognition of patterns Health and Development Program; guidelines
and trends. Supporting observations accompany for Adolescent Friendly Health Facilities;
the charts. Numerical values and percentage Adolescent Health Providers’ Training and
changes are organized in tables in Annex 1. Resource Materials; and the Department of
Education’s Policy Guidelines for the
For the policy review, we focused on a subset of
Implementation of Comprehensive Sexuality
documents recently reported on by Melgar J.
Education. Finally, we integrated the data and
and colleagues in the 2018 article “Assessment
policy review to present an informed evaluation
of Country Policies Affecting Reproductive
of the current status of ARH in the Philippines
Health for Adolescents in the Philippines.”24
and recommend strategies and interventions for
Specifically, we reviewed the following
accelerated progress.
documents that directly control policies and
When I was 14, I got pregnant. I had an unsafe
abortion and almost died from the complications.
I know now that had I used contraceptives,
I would not have gotten pregnant, and would have
avoided being placed in a very precarious
situation.
- C age 19, now in a live-in relationship with one child
8Teenagers participating in a community education session on sexual and reproductive health issues.
Findings
A. Demographic and Health Data and Trends
1. Adolescent birth rates (age-specific fertility rates, 15-19)
The Philippines' adolescent compared to other age groups rage, the percent decline
birth rate is high and has in the country. It is premature among adult women reached
stagnated over the past two to conclude that the teen birth 1.5% to 3.7% while that of
decades. It was 50 and 46 in rate is receding. The longer adolescents was close to zero.
1993 and 1998 (births per pattern presents a more accu- (Bracketed figures in charts
1000 women aged 15–19), rate picture. From start to end below show the average
climbed continuously until it of a 24-year period (1993– annual percent change—posi-
reached 57 in 2013, and 2017), birth rates declined by tive numbers for increases and
returned to 47 in 2017. (See 31% or more among adult negative ones for declines. The
Figure 1; data tables of all women 20 to 49, and a mere calculation method is des-
charts are in Annex 1 and use 6% among adolescents. cribed in Annex 1.)
the same identifying number. Calculated as an annual ave-
Unless stated otherwise, data 250
for adolescents, teens or [-1.9%] 25-29
teenagers refer to females aged [-1.5%] 20-24 200
15–19.) The current rate is [-1.9%] 30-34
Births per 1000 women
higher than the average for the 150
WHO's South-East Asia and [-1.9%] 35-39
Western Pacific regions, 100
estimated in 2018 at 33 and [-0.3%] 15-19
14 respectively.25 50
[-2.2%] 40-44
The 2017 decline is the [-3.7%] 45-49
0
largest ever for adolescents, 1990 1995 2000 2005 2010 2015 2020
but is markedly small when
Figure 1. Birth rates (age-specific fertility rates) 15–49, by age groups
9Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines
70 Urban and rural areas
Rural [-1.3%]
60
Rural areas had near constant
birth rate declines from 1993
Births per 1000 women
50
to 2017 (Figure 2). In con-
40 trast, urban rates steadily
30 increased from 1998 to 2013.
Urban [0.7%] It declined in 2017, but the
20
urban rate is still above the
10 lowest recorded in 1998. As a
0 result, the large gap between
1990 1995 2000 2005 2010 2015 2020 the two areas narrowed from
Figure 2. Adolescent birth rates, by residence 36 births per 1000 in 1993 to
13 in 2017.
1%
Birth rate increasing Moreover, the reduction
0% among rural adolescents was
-1% nearly at the same pace as all
other age groups in all areas
-2% (Figure 3). Only urban adoles-
Birth rates decreasing -3% cents registered an increasing
trend in the 24-year period.
Urban/Rural -4%
15-19 20-24 25-29 30-34 35-39 40-44 45-49
From these data, it is clear
Figure 3. Average annual percent change in birth rates, 1993–2017
that urban areas are critical to
adolescent birth rate reduction.
Wealth quintiles
There are large wealth-related rates than wealthier ones. The Another notable pattern is the
gaps in birth rates (Figure 4). gap has somewhat narrowed upward trend among the
Poorer adolescents have higher in the past 24 years, owing to middle and stagnant rates
declines in the poorest two among the fourth and
[-1.0%] Lowest 140 quintiles and stagnation in the wealthiest quintiles. These
(poorest) 120
highest two. In 1993 for groups had an average annual
example, adolescents in the percent change of 1.4%,
100
bottom quintile had 122 more -0.5% and 0.3% respectively.
Births per 1000 women
[-1.3%] Second 180 births (per 1000) compared to It appears that adolescents
[1.4%] Middle 60 those in the top. This gap was with more resources and
40
reduced to 65 in 2013 and 85 opportunities are not in their
[-0.5%] Fourth
in 2017. The larger gap in the usual pattern of achieving
20
[0.3%] Highest last survey was caused by a better health progress.
0 worrisome increase among the
1990 1995 2000 2005 2010 2015 2020
poorest, opposite the decline
Figure 4. Adolescent birth rates by wealth quintiles
in all other groups.
Education
180 Adolescents with the least quintiles. These patterns indi-
160 education (none or primary cate that education or years of
140 only) have very high birth rates schooling impact birth rates
[1.9%] No education or primary (Figure 5). Their 2017 rate is
120 independent of women’s socio-
Births per 1000 women
100
three times that of adolescents economic status. For example,
reaching secondary school and women in school may have a
80
[0.3%] Secondary education almost nine times the level of stronger incentive to postpone
60
those with higher education. childbearing or marriage. A
40
[0.6%] Higher education In the last 24 years, birth rates reverse relationship may also
20
0 increased among those with be at play—early pregnancy
1990 1995 2000 2005 2010 2015 2020 least education, opposite the interrupts schooling, and raises
Figure 5. Adolescent birth rates by education level attained downtrend in the two poorest the risk of stopping altogether.
10Demographic and Health Data and Trends
2. Unintended births (mistimed or not wanted at all)
In 1993, adolescents had the
best record of unintended
births (i.e., lowest percentage; [-2.1%] 40-44
Figure 6). After 24 years [1.5%] 45-49 60%
however, other age groups [-2.1%] 35-39
50%
achieved far greater progress
[-3.0%] 30-34
[-1.7%] 25-29
in reducing unintended births. 40%
[-0.8%] 20-24
Thus by 2017, adolescents [-0.4%]Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines
4. Adolescents’ sexual activity
In all survey years, the great 10). As discussed earlier,
majority of female adolescents annual adolescent birth rates
have not yet had sex (Figure remained high but essentially
100% unchanged in the last 24
9). However, this proportion is
90% decreasing. The percentage of years. Sexual activity rates and
adolescents who ever had sex annual birth rates are derived
80%
rose continuously from 1993 using different methods, which
70% to 2013, and fell slightly in means figures cannot be mixed
Never had sex
2017. The same pattern holds in calculations. The divergent
Had sex >1 year ago 60%
Had sex >4 weeks to 1 year ago true if we limit the count to trends are, however, too
50% noticeable and important to
Had sex in last 4 weeks those who had sex within the
Had sex within past 1 year 40% last year—fewest in 1993 ignore.
(7%), peak in 2008 to 2013
30% Rates of unprotected sex may
(13%), and a slight dip in
be a better predictor of birth
20% 2017 (11%).
rates.† DHS data do not have
10% However, the evident trend of such an indicator, but
0% rising sexual activity did not respondents were asked about
1993 1998 2003 2008 2013 2017 produce a matching pattern of their current use of a method
Figure 9. Adolescents' sexual activity, females 15–19 to prevent pregnancy, and
increasing birth rates (Figure
about the timing of their most
recent sex. The difference
between the two, which we
call modern contraception gap
(MCG) in this paper,‡ will be
14% 140 used here as a proxy measure
Had sex within the last year (%)
of unprotected sex.§ In Figure
12% 120
10, the fluctuating but
10% 100 essentially flat movement of
Births per 1000 women
8% 80 the MCG is very similar to the
Modern contraception gap (%)* trend of adolescent birth rates.
6% 60
The substantial similarity, we
4% Annual birth rates 40 believe, provides strong
2% 20 evidence that unprotected sex
* Difference between % who had sex in the last 4 weeks and
% currently using any modern contraceptive (all females 15-19) is a better predictor of
0% 0
adolescent birth rates than
1990 1995 2000 2005 2010 2015 2020
sexual activity per se.
Figure 10. Adolescents' sexual activity, contraception and birth rates
† As used in this paper, unprotected sex unprotected sex. We calculated MCG sexual activity.” However, authors of
is sexual intercourse without the use by subtracting the percentage of all this paper were concerned that the
of a modern contraceptive method. female adolescents currently using TBC rate includes a large number of
‡ In the 2017 DHS, non-pregnant any modern contraceptive from the past pregnancies and live births (i.e.,
respondents were asked: “Are you or percentage of all female adolescents teen mothers) which may have
your partner currently doing who had sex within the last four occurred years prior to the recent
something or using any method to weeks. unprotected sex being analyzed (last 4
delay or avoid getting pregnant?” § An expert reviewer correctly alerted weeks). For example, in the 2017
Later, regardless of pregnancy status, us about the different methodology survey, 7.0% were teen mothers, more
all respondents who ever had sex used in calculating birth rates and than four times the 1.6% currently
were asked: “When was the last time sexual activity. She also pointed to pregnant teens. To balance all these
you had sexual intercourse?” From the rate of TBCs (teenagers who have concerns, we decided to continue
these questions, we can expect that a begun childbearing) as the more using the annual birth rates and limit
calculated ‘modern contraception appropriate measure to use in relation ourselves to making observations
gap’ (MCG) will include sexually to sexual activity because the latter, if about the consistency and direction of
active pregnant women. Thus, the unprotected, can lead to early trends.
MCG figure will probably be slightly childbearing, and the TBC rate “is
higher than rate of women having also an individual-level variable like
12Demographic and Health Data and Trends
5. Contraceptive knowledge and practices
Knowledge of modern contraception
Nearly all married (formal or of knowledge measured was 2017), correct answers by
cohabiting) adolescents know very basic. Respondents were adolescents increased from
of at least one modern method only asked if they have heard 41% to 53% (Figure 11).
of contraception. The propor- of each FP method in a list. However, adolescents still
tion was lowest in 1993 at lagged behind all the other age
More plausible knowledge
89%, and reached close to groups by 14 to 18 percentage 100%
rates can be inferred from the
100% from 1998 onwards. points in 2017. 90%
proportion of all women who 80%
However, one should be agreed or knew that people 70%
cautious about these extremely can protect themselves from 60%
high figures. First, only a small HIV by using condoms. A basic 25-49 50%
minority of adolescents were knowledge about condoms 20-24
40%
married or living in union— should include its protective 15-19
30%
only 7–10% in all six surveys. function against pregnancies 20%
Knowledge data for 90% or and sexually transmitted 10%
more of teenagers are therefore infections (STIs). In the four 0%
2002 2006 2010 2014 2018
unavailable. Second, the level surveys with data (2003–
Figure 11. Agreed or knew that condoms provide HIV protection, women 15-19
Use of modern contraception
Adolescents' current use of Pills ranked consistently on top users in the last four surveys.
modern contraceptives rose as the most favored modern In 2017, implants made a
from less than 1% in 1993 to method. Injectables, condoms notable entry to the important
almost 3% in 2017 (Figure and IUDs were important group of second choice
12). The proportion of sexually second choices. Added methods.
active adolescents also together, these three methods
increased in the same period. approximately equaled pill
10%
Traditional
Use of traditional contraception 9% Had sex in last 4 weeks Breastfeeding
8% Rhythm
From 1993 to 2013, Among traditional methods,
7% Withdrawal
traditional method use equaled adolescents relied mainly on
6% Modern
modern method use (Figure withdrawal. It is such an LAM
5%
12), with a difference of less important practice that in all 4% Implant
than a third of a percentage the surveys, withdrawal ranked Current contraceptive use Condom
3%
point. Traditional method use number one or two among all IUD
2%
suddenly dropped in 2017 to methods, traditional or Injectable
1%
Pill
just one-fourth of modern modern. In three surveys 0%
method use. The change is (2003–2013), withdrawal 1993 1998 2003 2008 2013 2017
important, but it is too early to outranked pills as the top Figure 12. Current use of contraception by female adolescents 15–19 compared to sex in the
call it a trend. method of choice. last four weeks
Ideal number of children 4.5
[-0.9] 45-49
Adolescents have responded groups. As a result, it is fair to [-0.8] 40-44 4.0
with the lowest ideal number describe adolescents now as [-0.7] 35-39
3.5
of children in all the surveys wanting just two children;
[-0.6] 30-34
Ideal no. of children
[-0.5] 25-29 3.0
(Figure 13). Similar to other those aged 35 and above as [-0.6] 20-24
age groups, the number they wanting three; and the rest [-1.0] 15-19 2.5
want have gone down wanting two or three.
2.0
continuously over the last 24
years. In the 2017 survey, 1.5
adolescents recorded a 1.0
noticeably steeper decline 1990 1995 2000 2005 2010 2015 2020
compared to all the other Figure 13. Women's ideal number of children, by age groups
13Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines
Demand for FP satisfied by modern methods
Surveys determine through a modern methods at or near satisfied percentage was
set of questions if women want 100% (i.e., equivalent to zero substantially lower than the
to space their future unmet need for modern rest in 1993; hardly any
childbearing by two years or contraception). progress occurred up to 2008;
more, or stop them altogether. then rapid advances took place
Except for adolescents and
This is the demand for FP. It from 2008 to 2017. The
those aged 45 to 49, all age
should ideally be satisfied by relatively fast progress since
groups started in 1993 with
2008 is consistent with the
demand satisfied at around
60% decline in sexual activity
30% to 40%, progressed con-
coupled with a constant
50%
tinuously, and ended in 2017
[0.2%] 45-49 increase in modern contra-
[1.5%] 40-44
with near 60% levels (Figure
ceptive use that occurred in
[1.8%] 35-39 40% 14). The achievements are still
[2.2%] 30-34 that period (Figure 12).
[2.6%] 25-29
far from ideal, but there is
30% However, one must recognize
[3.5%] 20-24 continuing albeit slow prog-
that adolescents are essentially
[4.5%] 15-19 20% ress. In contrast, those aged
playing catch up. They need to
45 to 49 ended with a worse
10% match the levels achieved by
level than when it started 24
other age groups, and those
0% years ago.
percentages are still very far
1990 1995 2000 2005 2010 2015 2020
Adolescents had a very dif- from ideal.
Figure 14. Demand for FP satisfied by modern methods, by age groups
ferent pattern. Their demand
Attitudes towards contraceptive use by minors
In the 2017 survey, Figure 15). Only those with no the survey did not differentiate
respondents were asked if they education differed from the minors by relevant categories
agree that minors 15-17 who average (54%). All the usual (e.g., have had a pregnancy,
want to use contraception disaggregation—by age, resi- cohabiting, etc.) but asked
should seek written parental dence, wealth and education only about minors in general.
permission. A large majority —produced no substantial
agreed (71% average; see response variation. However,
100%
90% Age Groups Education Wealth Quintiles Residence
80%
70%
60%
50%
40%
30%
20%
10%
0%
19 0-24 5-29 0-34 5-39 0-44 5-49 on s 1-6 7-10 e 11 ndary llege est nd dle ourth ghest an Rural
15- 2 2 3 3 4 4 cati e s Grad co Co Low Seco Mid F Hi Urb
o edu Grad Grade t-se
N Pos
Figure 15. Percentage who agree that minors who want contraception should seek written parental permission
6. Adolescents’ Abortion and Miscarriage
Induced abortion is severely recorded age-related reasons: most important reasons for
restricted in the country (i.e., avoiding school disruptions; having an abortion.
there is no explicit provision in problems with partners; and
being too young to have a There are no estimates of
law that allows its use), hence
baby. All women interviewed miscarriage rates among
the scarcity of data. In a 2004
—adolescents included—cited adolescents in the Philippines.
study, 46% of abortion
attempts occurred in women economic reasons and being
younger than 25. The survey unmarried or too young as the
14B. Laws and Policies on Adolescents' Access
to Contraceptive Information and Services
The Philippines follows a government system
with separation of powers among three branches
—the executive, legislative and judicial.26 The
system creates a hierarchy of policies or orders
emanating from these three.
The legislative branch creates laws. However,
the judiciary's Supreme Court can declare all or
parts of laws as unconstitutional, voiding or
modifying them accordingly. The executive
branch (President and department heads)
frequently issues orders and implementing rules
and regulations (IRRs) to carry out laws. These
issuances have various names—such as
presidential executive orders, IRRs,
administrative orders and department orders
—but are essentially of the same nature: a
command and guide to implement the law.
Finally, other government agencies and officials
lower than department heads also issue
guidance documents. For the purpose of this
study, we focused on technical guidelines that
consolidate current knowledge, standard
procedures and practices, and the like.
Examples include clinical practice guidelines,
job aids, curriculum, and manuals of
operations.
Applying the legal hierarchy to the ARH
policies, we organized this review from top to
bottom. We started with laws, including rulings
by the Supreme Court as appropriate; then we
moved on to implementing orders issued by the
Presidential or department heads; and lastly we
looked at technical guidelines issued by the
health and education departments.
A teen mother with her child, after getting an injectable contraceptive in an NGO-led “Family Planning Fair.”
15Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines
1. Responsible Parenthood and Reproductive Health Law, as
modified by the 2014 Supreme Court decision
The RH Law is grounded on the principles of cation to be taught by “trained teachers in all
human rights, including the right to equality and schools and alternative learning systems” and
nondiscrimination; the right to health including that RH be “integrated in subjects such as:
RH; the right to education and information; and values formation; self-protection against discri-
the right to choose and decide in accordance mination, sexual abuse, gender-based violence
with one's religious convictions, ethics, cultural and teen pregnancy; physical, social and
beliefs, and the demands of responsible emotional changes in adolescents; women's
parenthood.27 These rights include reproductive rights and children's rights; responsible teenage
health rights, defined as “the rights of behavior; gender and development; and
individuals and couples, to decide freely and responsible parenthood.”33
responsibly whether or not to have children; the
There is no mention of ARH services in the RH
number, spacing and timing of their children; to
package. Moreover, the Supreme Court struck
make other decisions concerning reproduction,
down as unconstitutional34 a provision that
free of discrimination, coercion and violence; to
allowed minors to access contraceptive services
have the information and means to do so; and
in government facilities without parental
to attain the highest standard of sexual health
consent if they had ever been pregnant, as
and reproductive health.”28 “Humane, non-
quoted below (emphasis supplied):
judgmental and compassionate” post-abortion
care29 is included in a package of 12 RH care All accredited public health facilities shall
provide a full range of modern family planning
interventions that include FP, maternal health methods, which shall also include medical
care, prevention and management of STIs, and consultations, supplies and necessary and
reasonable procedures for poor and
others.30 The law mandates the State to marginalized couples having infertility issues
guarantee “universal access to medically-safe, who desire to have children ….
non-abortifacient, effective, legal, affordable, No person shall be denied information and
and quality” RH care services, methods and access to family planning services, whether
supplies. The State must provide “information natural or artificial: Provided, That minors will
not be allowed access to modern methods of
and access, without bias” to all FP methods, family planning without written consent from
including “natural” and modern, “which have their parents or guardian/s except when the
been proven medically safe, legal, non- minor is already a parent or has had a
miscarriage.
abortifacient, and effective in accordance with
scientific and evidence-based medical research The Revised IRR following the 2014 Court
standards such as those registered and decision states that all adolescent minors
approved by the FDA.”31 seeking contraceptive services in public health
facilities must have written parental or guardian
Key provisions generally applicable to all age
consent.35
groups include the hiring of skilled birth
professionals to administer emergency obstetric The Supreme Court also struck down as
medicines; upgrading of facilities and personnel; unconstitutional the penalty on health providers
access to all methods of FP; and mobilization of who refuse to perform RH procedures on minors
social health insurance (PhilHealth) to pay for who lack parental consent.36 In its original form,
life-threatening RH conditions. Generally appli- the RH Law declared the following in its section
cable restrictions include the prohibition of on Prohibited Acts (emphasis supplied):
induced abortion and access to abortifacients in In the case of minors, the written consent of
compliance with the Revised Penal Code; and parents or legal guardian … shall be required
only in elective surgical procedures and in
the prohibition on government hospitals to
no case shall consent be required in emergency
“purchase or acquire by any means emergency or serious cases
contraceptive pills, postcoital pills, abortifa-
cients … and their other forms or equivalent.”32 Complying with the Court's ruling, the Revised
IRR removed the above clause. The RH Law is
Specific to adolescents, the law includes now effectively silent on the treatment of
“adolescent and youth reproductive health providers in relation to their parental consent
guidance and counseling” and ARH education in practices.37
the list of “RH care elements.” It also mandates
“age- and development appropriate” RH edu-
16Laws and Policies on Adolescents' Access to Contraceptive Information and Services
2. Abortion section of the Revised Penal Code
The Revised Penal Code of 1930 defines the Penalties for voluntary abortion The RH Law's IRR
crimes of infanticide and abortion separately. (i.e., with woman’s consent)
Abortion is criminalized under several range from prison terms of clearly states that
categories, namely: intentional abortion; around one to six months for a
unintentional abortion; abortion practiced by the pharmacist; two to six years adolescents must
woman or her parents; abortion practiced by a for the woman who had an
physician or midwife; and dispensing of abortion; and four to six years be provided with
“abortives” by a pharmacist. There is no ground for doctors or midwives
under which abortion is explicitly allowed. performing the abortion.38 information and
3. Presidential Executive Order No. 12 guidance on FP,
The current Philippine President issued in with maximum benefits for FP
January 2017 Executive Order No. 12 (EO12) services. but minors must
aimed at attaining and sustaining “zero unmet
need for modern family planning” for all poor
Specific to adolescents, EO12 get parental
orders the Department of
households by 2018 and for all Filipinos
thereafter.39 EO12 is based on the rights to FP
Education (DepEd) to imple- consent to access
ment “gender-sensitive and
and RH services; the government's 10-point
socio-economic agenda which includes enabling
rights-based” Comprehensive “health products”
Sexuality Education (CSE); the
poor couples to make FP and financial planning
choices; and the Philippines' commitment to the
National Youth Commission to and “procedures”
integrate ARH in youth
2030 SDG goal of ensuring universal access to
SRH care services and rights.
development agenda and for FP in
strategies; and PopCom to
EO12 orders the DOH, PopCom and the assist couples and women to government
Department of Interior and Local Government to achieve their desired fertility
implement comprehensive strategies to achieve and reduce the incidence of facilities.
universal access to RH services and integrate teen pregnancy.
them with local development and investment
plans. It orders PhilHealth to create a package
4. Implementing Rules and Regulations of the RH Law, including
changes mandated by the 2014 Supreme Court decision
The IRR gives specific guidance on the content and lead healthy lives. Public and private
of ARH services, parts of which were modified schools are to be made into “venues for
after the 2014 Supreme Court decision. The development” that provide supportive environ-
IRR clearly states that adolescents must be ment and services. Specifically, there must be
provided with information and guidance on FP,40 counseling and psycho-social support services;
but minors must get parental consent to access information on the prevention of risky behaviors,
“health products” and “procedures” for FP in including addiction; information on prevention,
government facilities.41 Consent for minors diagnosis and management of STIs; and
abused by their parents may come from persons information and referral to service providers on
or institutions designated by the courts or by all RH concerns.42
other laws and regulations. Parental consent is
The IRR orders the DOH to coordinate with
automatically waived in emergencies.
local governments and integrate RH care services
To implement age- and development- —including a full range of FP services, maternal
appropriate RH education in public and private health care, and emergency obstetric and
schools, DepEd is ordered to develop the neonatal care—into Service Delivery Networks
curriculum and teaching materials, and to train from the primary to hospital levels. Specific to
public and private educators to ensure these adolescents, it provides for “adolescent health
outcomes for learners: awareness of children’s and reproductive/fertility awareness” at the
rights; scientifically accurate and evidence- barangay or health outpost level and
based knowledge of the reproductive system; “adolescent counseling” in other primary care
and the capacity to make intelligent decisions facilities.43
17Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines
“Adolescents need 5. DOH’s 2013 Administrative Order (AO) on Adolescent
Health and Development
to be recognized by The National Policy and adopt healthy behaviors, avoid risky behaviors
the members of Strategic
Adolescent
Framework
Health
on
and
and participate in community development.48
The 2013 AO is based on the rights of children,
their family Development44 was issued in
including the right to nondiscrimination, respect
March 2013—a period after
for privacy and confidentiality, information, “life-
environment as the RH Law was passed but
saving” interventions and participation. It
before the Supreme Court
provided for enabling strategies, such as access
active rights holders ruled on its constitutionality. It
to quality and adolescent-friendly health
updated the DOH policy on
services, a health insurance package for
who have the Adolescent and Youth Health
adolescents, the training of providers and
which defined 10 elements of
resource mobilization. It assigned functions to
capacity to become the DOH’s RH Program,45 and
many other government agencies, including the
rephrased ARH to “services for
PhilHealth, DepEd, the National Statistics Office
full and responsible adolescent and youth.46 The
and the Commission on Human Rights, with the
2013 AO focused on
citizens, given the adolescents 10 to 19 and
DOH and its central agencies as the lead. FP is
assigned to local governments, specifically the
aimed to achieve several
proper guidance health outcomes including
role to design, fund, implement and monitor
adolescent health and development programs,
healthy development and
and direction.” nutrition, SRH, and reduction
including the purchase and distribution of FP
goods and supplies.49
of substance abuse, injuries,
-CRC* as quoted in DOH's violence and other causes of The framework was revised by a 2017 Manual
MOP adolescent mortality and mor- of Operations (MOP) which now covers the
bidity. It also recognized the entire health system, expands the number of
risks of early sex and aimed to indicators, and describes many ways and
delay sexual initiation.47 The strategies of establishing, running and
2013 AO’s strategic frame- implementing adolescent health programs.50
work focused on achieving the However, the approach to adolescent “family
key behavioral objectives for planning” remains the same.
adolescents, which are to
increase utilization of services,
6. The DOH’s Guidelines on the Adoption of Baseline
Primary Health Care Guarantees for All Filipinos
These Guidelines (AO 2017- The first will be funded by the DOH and local
0012) define a set of primary governments; the last two by PhilHealth.
health care interventions based
For adolescents 10 to 19, the AO guarantees
on the life stages that would
RH education as a population intervention. As
be “guaranteed” as health
services for well individuals, the AO guarantees
entitlements and matched with
SRH screening, education and counseling
financing mechanisms.51 The
services, including the provision of condoms,
life stages are pregnancy,
pills, modern NFP, DMPA and IUD—as long as
childhood (from 0 to 19,
the consent requirement is met.
including adolescence), early
adulthood (20-59) and late This AO, however, is now modified by the
adulthood (over 60). Health Universal Health Care Law passed in February
interventions are classified into 2019 which adds more details to the meaning
three categories: population- of population and individual services.52 As the
level interventions; primary Implementing Rules and Regulations are still
care services for well being drafted, the package of guaranteed
* CRC General Comment No. 4: Adolescent
Health and Development in the Context of the individuals; and primary care service, including for adolescents, could change.
Convention on the Rights of the Child services for sick individuals.
18Laws and Policies on Adolescents' Access to Contraceptive Information and Services
7. Philippine Clinical Standards Manual on Family Planning (2014)
The Standards Manual includes a section on Female or male sterilization is not
“Special Populations” which includes recommended, unless the client is fully
adolescents. 53 It explains the safety of counseled. Following appropriate and proper
contraceptives for young people, that counseling, sterilization can be performed on
adolescents often do not have the medical older adolescents after the client provides
conditions that limit the use of certain informed consent. In addition to client’s
contraceptives in older clients. It explains the consent, the Standards Manual now states that
specific conditions and circumstances of spousal consent is required in compliance with
adolescents that affect method suitability, such the 2014 Supreme Court decision.55 According
as the risk of some groups to HIV and other to the manual:
STIs; their low pain threshold which results in Involving the client’s spouse in counseling is
high discontinuation rates; the unpredictability helpful, as spousal consent is now being
required by service providers. However, FP
of sexual intercourse which makes daily service providers should ensure that the
regimens inappropriate; and teens in decision to undergo sterilization is voluntarily
relationships who may prefer more effective or made (not pressured or forced) by the client.
longer-acting methods. The Standards Manual The Standards Manual recommends the use of
recommends short-acting contraceptives such emergency contraceptive methods, such as
as condoms, combined pills, progesterone-only levonorgestrel and Yuzpe methods, for all
pills and injectables, and fertility-awareness- women-victims of violence.56
based methods; and long-acting ones like
implants and IUDs.54
8. Manual of Operations (MOP) for the Adolescent Health and
Development Program (AHDP)
The 2017 MOP modifies the strategic chance to express their views freely and their
views should be given due weight, in
framework of the 2013 AHDP from behavior accordance with Article 12 of the [Rights of the
change to a health system approach.57 The Child] Convention. However, if the adolescent
framework aligns the program with three is of sufficient maturity, informed consent shall
be obtained from the adolescent her/himself,
aspects of health care: 1) the three basic while informing the parents if that is in the best
strategies of health promotion, prevention and interest of the child.”
medical treatment; 2) the building blocks of the
Rights are complemented by “adolescent
health system such as governance, human
responsibilities.” These include their respon-
resources, and organization of health care
sibilities to respect other children and their
delivery; and 3) the social determinants of
parents, to learn, to help others, and to care for
health. The MOP also provides detailed steps
the environment.
and options, including how to develop a
program, how to manage a program, what • It responds to the issue of parental consent
training courses and tools for health providers for adolescents by exploring the option of
are available, how to make facilities adolescent- proxy consent by the Department of Social
friendly, how to establish a service delivery Welfare and Development (DSWD) and
network, how to monitor and evaluate these educating parents.
programs, and more. The resulting program It cites the law on the “Special Protection of
monitoring indicators are detailed and complex. Children Against Abuse, Exploitation and
The following are the distinctive features of the Discrimination” that mandates the DSWD to
MOP: “assume legal guardianship if there is suspicion
of abuse or any pressing needs in regards with
• It upholds the rights of the child and recog- the health conditions of adolescents, e.g.,
nizes their evolving capacity.58 access to HIV-testing.”59 It also emphasizes
Adolescents need to be recognized by the that parents be educated about adolescence,
members of their family environment as active
rights holders who have the capacity to become the health risks they face, preventive services,
full and responsible citizens, given the proper and the laws governing these services. It states
guidance and direction. Before parents give that parents need to be clarified that:
their consent, adolescents need to have a
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