Analyzing Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines - The State of the Region Report on Sexual and ...

 
Analyzing Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines - The State of the Region Report on Sexual and ...
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
Analyzing Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines - The State of the Region Report on Sexual and ...
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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 ...
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
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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
Analyzing Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines - The State of the Region Report on Sexual and ...
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
Analyzing Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines - The State of the Region Report on Sexual and ...
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
Analyzing Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines - The State of the Region Report on Sexual and ...
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
Analyzing Data and Policy Trends in Adolescent Pregnancy and Contraception in the Philippines - The State of the Region Report on Sexual and ...
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

                                                                                                                         7
Data 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

8
Teenagers 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

                                                                                                                                                                                              9
Data 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.

10
Demographic 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

12
Demographic 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

                                                                                                                                                                                              13
Data 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

14
B. 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.”

                                                                                                                                                                   15
Data 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-

16
Laws 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

                                                                                                                           17
Data 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.

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Laws 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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