The Health Benefits of Family

Planning and Reproductive Health

Key Facts:
• More than 400,000 women suffer from maternal morbidities every year.
• Women suffer more from maternal morbidities than any other illness.
• Around 200,000 maternal morbidities—up to half the total—can be prevented through
effective family planning.
• Eleven women die each day from pregnancy and birth complications. Most of these
deaths are preventable.
• Proper birth spacing reduces by half the risk of death for newborns and infants. More
than 7,800 infant deaths can be prevented yearly through family planning.
• Poor women and infants carry the most risk of death and disability from lack of access
to reproductive health services.
• For every peso spent in family planning, around 3 to 100 pesos will be saved in
maternal care costs for unintended pregnancies.
• At least 5.5 B (billion) pesos are spent each year in health care costs for managing
unintended pregnancies and its complications. An annual budget of 2 to 3 B pesos for
FP is a cost-effective public health measure.

1. More than 400,000 women suffer from maternal morbidities

every year in the Philippines.
These are life-threatening complications from pregnancies and deliveries that often require
hospital care. The 2005 World Health Report of the WHO (p. 62) has stated that globally, around
80% of all maternal deaths are the tragic end results of the following complications:

hemorrhage or severe bleeding;

sepsis (bloodstream infection);

hypertensive disorders of pregnancy like eclampsia and pre-eclampsia;

prolonged or obstructed labor; and

complications of unsafe abortion.

The remaining 20% of maternal deaths are caused by existing illnesses that are exacerbated by
pregnancy or its management. Examples common in the Philippines include anemia, tuberculosis,
malaria, cardiovascular disorders and diabetes (DOH 2005a, p. 208 & 248).

Most of these morbidities require life-saving emergency obstetric care from primary level
hospitals. Other interventions like caesarean section (CS) deliveries and blood transfusion require
secondary to tertiary level facilities (UN Millennium Project 2005, pp. 83-84).

The Department of Health and international health authorities agree on the magnitude and
severity of this problem. The DOH (2005a, pp. 207-208) estimates that there are three million
pregnancies every year, each one of which "entails risks to both the mother and the unborn."
UNICEF, WHO and UNFPA estimate that "at least 15 per cent of all pregnant women develop

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 serious complications that are often unpredictable and require life-saving access to quality
obstetric services."* (1997, pp. 3-4)

2. Women suffer more from maternal morbidities than any other

illness.
If the estimated number of morbidities is compared with the Department of Health’s list of
notifiable diseases, then maternal morbidities clearly surpass the number of females that are sick
each year with other serious illnesses like pneumonias, bronchitis, diarrheas, hypertension,
influenza, or tuberculosis (see Figure 1).

Figure 1. Maternal Morbidities Compared to the Top Ten Female Morbidities of 2005
Maternal Morbidities 400,000
ALRI and Pneumonia 328,956
Bronchitis/Bronchiolitis 308,930
Acute Watery Diarrhea 278 ,958
Hypertension 214,220
Influenza 205,419
TB Respiratory 44,440
Diseases of the Heart 15,324
Mala ria 15,003
Chickenpox 14,748
Dengue Fever 9,434

Source: DOH 2005 b

3. Around 200,000 maternal morbidities—up to half the total—

can be prevented through effective family planning.
When unintended pregnancies occur, some women resort to induced abortion while others carry
their pregnancy to term. A proportion of all these pregnancies lead to serious obstetric
complications. Using data from a study by the Guttmacher Institute (Singh S et al. 2006) and the
estimate of the UNICEF, WHO and UNFPA that at least 15 per cent of all pregnant women
develop serious complications, the following table shows that half of all maternal morbidities are
from women with unintended pregnancies, and are therefore preventable through family planning.

Table 1. Maternal Morbidities from Intended & Unintended Pregnancies

Maternal Morbidities
No. %
Intended/Planned Pregnancies
● carried to term (1,209,000 x 15% complication rate) 181,350
● hospitalized for spontaneous pregnancy loss 26,092
Subtotal 207,442 48%
Unintended Pregnancies (Preventable Through FP)
● carried to term (961,000 x 15% complication rate) 144,150
● hospitalized for induced abortion 78,901
Subtotal 223,051 52%
Total 430,493 100%
Sources: Singh S et al. 2006 and calculations from UNICEF, WHO, UNFPA 1997

*
15% x 3 million pregnancies = 450,000 estimated maternal complications. This estimate is consistent with
another estimate shown in Table 2.

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 The WHO provides a similar, global analysis in its 2005 World Health Report, where it states that
Unintended and unwanted pregnancies—owing to unmet need for
contraception, to contraceptive failure, or to unwanted sex—if brought to term,
carry at least the same risks as those that are desired and deliberate. It is
estimated that up to 100 000 maternal deaths could be avoided each year if
women who did not want children used effective contraception. When maternal
illnesses are also taken into account, preventing unwanted pregnancies could
avert, each year, the loss of 4.5 million disability-adjusted life years.

4. Eleven women die each day from pregnancy and birth

complications. Most of these deaths are preventable.
An estimated 4,100 maternal deaths occurred in the Philippines in 2000 (WHO, UNICEF & UNFPA 2004).
This is equivalent to one out of every seven deaths of women of reproductive age (National Statistics
Office - NSO 2004), making maternal death a grave risk for women in this age group.

Most of these deaths are preventable: up to half by reducing unintended pregnancies through
family planning as discussed in the previous point; and the other half substantially reduced by
making each pregnancy and childbirth safer, through key interventions like skilled birth
attendance and access to emergency obstetric care. Many progressive countries have succeeded
through these approaches. For example, total maternal deaths in all the developed regions—which
includes Europe, Canada, US, Japan, Australia and New Zealand—number only 2,500. In the
Southeast Asia region, Malaysia, Thailand and Vietnam—with a combined population more than
twice that of the Philippines—had a total of only 2,740 maternal deaths.

Table 2. Maternal Mortality in Selected Countries

Country/Region Population Number of Maternal Lifetime Risk of
(2000, in M) Maternal Mortality Ratio Maternal Death,
Deaths 1 in
Developed Regions 1,194 2,500 20 2,800
Malaysia 22 220 41 660
Thailand 61 520 44 900
Vietnam 80 2,000 130 270
Philippines 76 4,100 200 120
Sources: WHO, UNICEF & UNFPA 2004; UN Population Division 2004

The lifetime risk of maternal death combines the impact of the frequency of pregnancies and the
danger of each pregnancy. Using this measure, the risk faced by women in the Philippines is five
to seven times that faced by women in Malaysia and Thailand. The Philippines is a
disproportionate contributor of maternal deaths in Southeast Asia and the world.

5. Proper birth spacing reduces by half the risk of death for

newborns and infants. More than 7,800 infant deaths can be
prevented yearly through family planning.
A recent review of birth spacing studies published by the WHO in 2006 states that after a live
birth,
the recommended interval before attempting the next pregnancy is at least 24
months in order to reduce the risk of adverse maternal, perinatal and infant
outcomes.
… To summarize, BTP [birth-to-pregnancy] intervals of six months or shorter
are associated with elevated risk of maternal mortality. BTP intervals of around

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 18 months or shorter are associated with elevated risk of infant, neonatal and
perinatal mortality, low birth weight, small size for gestational age, and pre-
term delivery.

Two of the WHO-reviewed studies show that BTP intervals of less than 18 months are linked to a
two-fold increase (1.9-2.6) in neonatal and infant mortality compared to those with an interval of
three years. Data from the NSO's 2003 NDHS (p. 110) support this finding: infants born with a
previous birth interval of less than two years had a mortality rate of 39 per thousand live births
compared to 19—a reduction by half—for those with three years of interval.

How many infant deaths can be prevented through birth spacing? The 2003 NDHS (p. 115) had
estimated that 23.5% of births were of less than 24 months interval, and the NSO registered 1.71
million live births in 2004 (NSO 2008). Putting all these data together, at least 7,800 infant deaths a
year can be prevented through proper birth spacing.*

6. Poor women and infants carry the most risk of death and
disability from lack of access to reproductive health services.
Women want fewer children than they actually get. The poorer they are, the larger the gap
between wanted and actual fertility. On average, every 10 women from the wealthiest quintile will
end up with three extra, unplanned births, while those from the poorest will end up with 21. A key
factor is the inability of poor women to control their fertility through effective FP. Looking at the
demand and use of all methods, surveys reveal a pattern of inequity—the poorer women are, the
larger the unmet need for FP, and the greater the number of unplanned births.

Figure 2. Unmet Need for FP and the Wanted vs. Actual Fertility Gap
26.7

19.6
21
15.0
13.4
12.3 15
% Unmet Need for FP
9
Extra, Unplanned Births 6
(for every 10 women) 3

Wealthiest Fourth Middle Second Poorest

Source: NSO & ORC Macro, NDHS 2003

The calculation of unmet need for FP was done during the period when the public health system
was still distributing donated commodities for free. As a result, equitable access and use of some
FP supplies, like contraceptive pills, were ensured. This is a success story that may now be rolled
back after FP donations have ended. Access to FP supplies may end up like the inequitable access
to the costlier, for-pay tubal ligation which results in poorer women having lesser rates of use. If
pills and other previously donated commodities will no longer be available as free or low cost
health supplies, then the unmet need and unplanned births of poorer women will rise further.

*
1.71 M (registered live births only; NDHS 2003 data on fertility rates combined with NSO population
projections indicate that 2.1 M live births occurred in 2000, according to Singh S et al 2006) x 23.5%
(proportion of all births with <24 months interval) x 39/1000 (mortality rate of infants with < 24 months
interval) x 50% (mortality risk reduction if birth spacing of less than 2 years is increased to 3 years)

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 The World Health Organization (2005) and the UN Millennium Project (2005) Task Force on
Maternal and Child Health both recommend the increase in the use of skilled birth attendance and
the availability and use of emergency obstetric care (EmOC) as key strategies to reduce maternal
deaths. Available indicators for these two strategies clearly show that poorer women have less
access to life-saving services. Women among the wealthiest quintile have already surpassed the
2015 MDG target of 90% for skilled birth attendance while the poorest have only reached 25%.
For EmOC, a widely available statistic is the percentage of caesarean section (CS) deliveries,
wherein it is estimated that usage beyond 15% indicates overuse while rates below 5% signals a
dangerous lack of access (UNICEF, WHO, UNFPA 1997). Data from the 2003 NDHS show that the
poorest 40% of women have below-standard access to CS deliveries.

Table 3. Use of Tubal Ligation, Skilled Birth Attendants & CS Delivery by Asset Quintile
Asset Quintile % Had Tubal % Use of Skilled % Caesarean
Ligation Birth Attendant Section Delivery
Wealthiest 11.5 92.4 20.3
Fourth 13.4 84.4 10.8
Middle 11.2 72.4 6.8
Second 7.9 51.4 3.4
Poorest 3.9 25.1 1.7

poorest 40% poorest 60% poorest 40%

had way below below MDG target below minimum
average use for 2005 (80%) recommended by
(10.5%) UNICEF, WHO,
UNFPA (5%)
Sources: NSO & ORC Macro (NDHS 2003); UNICEF, WHO, UNFPA 1997

7. For every peso spent in family planning, around 3 to 100

pesos will be saved in maternal care costs for unintended
pregnancies.
The reimbursement rates of PhilHealth provide a good indicator of the average costs of maternal
care. For normal spontaneous deliveries, PhilHealth (2003) currently pays P4,500. The costs
predictably escalate for pregnancy and delivery complications. Published figures by PhilHealth
include average benefits amounting to P4,974 for dilatation and curettage for abortions (Festin M
2003); P13,413 for hypertension complicating pregnancy and labor (Wagner A et al. 2006); and around
P16,000 for caesarean section delivery (Festin M 2003). PhilHealth also published a scenario in a
2003 circular wherein it will pay up to P19,490 plus P300 per day of confinement in a secondary
hospital for total hysterectomy due to postpartum haemorrhage. These amounts do not even
represent the total health care costs since PhilHealth estimates that the benefits they provide to
members comprise only 30 to 70 percent of the total costs per confinement (Fajardo L 2006).

Compared to maternal care expenses, family planning costs are low. For example, it costs around
P200 to provide an IUD which can last up to ten years; less than P400 for a year's supply of pills
or injectables; less than P600 for a year's supply of condoms; P500 for vasectomy and P1,500 for
tubal ligation in a public hospital (Aquino V, 2008). Concretely, an IUD worth P200 can prevent a
hysterectomy that would amount to at least P20,000 in public health costs plus additional out-of-
pocket spending by the patient and her family.

The DOH is aware of this analysis and has stated in its National Objectives for Health (2005 a, p. 9)
that "a reduction in the actual number of births reduces the need for obstetrical care,
immunization and other maternal and child health interventions."

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Figure 3. Family Planning versus Maternal Care Costs for Unintended Pregnancies

FAMILY PLANNING COSTS (per person)

IUD (good for up to 10 years)
Injectables (supply for 1 year)
Pills (supply for 1 year)
Vasectom y (at PGH)
Condom s (10 pcs/m o, for 1 year)
Tubal ligation (at PGH)

MATERNAL CARE COSTS (per person)

Norm al spontaneous delivery/birth
D&C for abortion (spontaneous & induced)
Hypertensive disorders of pregnancy
Cesarean section delivery
Hysterectom y for postpartum hem orrhage

PhP 0 5000 10000 15000 20000

Sources: Aguino V 2008; Festin M 2003; Wagner A et al 2006; PhilHealth 2003

8. At least 5.5 B (billion) pesos are spent each year in health

care costs for managing unintended pregnancies and its
complications.
Singh et al (2006) estimates that around the year 2000, there were 78,901 hospitalizations for
induced abortions and 961,000 unintended pregnancies carried to term. The 2003 NDHS
estimates that 7.3% of births were done via caesarean section. Using only these two types of
maternal complications (induced abortion and CS deliveries) and the benefit rates of PhilHealth
(which excludes out-of-pocket co-payments by patients), the minimum health care costs for
managing unintended pregnancies and its complications can be estimated as follows:

Table 4. Minimum Health Care Costs for Managing Unintended Pregnancies

Description Number of Cases PhilHealth Benefit Total Cost
per Year Rate per Case (B Pesos)
Hospitalized for abortion complications 78,901 4,974 0.392
Unintended pregnancy carried to term, 70,153 16,000 1.122
caesarean section delivery (7.3% of births)
Unintended pregnancy carried to term, no 890,847 4,500 4.009
caesarean section delivery
TOTAL 5.523
Sources: Singh et al 2006; NSO & ORC Macro 2004; PhilHealth 2003; Festin M 2003

Aquino (2008, p. 31) estimates that from 2.0 to 3.5 B pesos of public funds are needed in 2009 to
finance a range of voluntary family planning services. Such levels of public health spending will
clearly be cost-effective, resulting in health care savings of several billion pesos.

Likhaan ● October 2008

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References
Aquino V. (2008). Completing the Family Planning Equation to Achieve Contraceptive Self-Reliance. PLCPD
Department of Health. (2005a). National Objectives for Health, Philippines, 2005-2010.
Department of Health. (2005b). Field Health Information System Annual Report 2005. National Epidemiology Center.
Fajardo L. (2006 February 24). PhilHealth pays P17.5B in health insurance benefits. PhilHealth News. Retrieved 2
October 2008 from http://www.philhealth.gov.ph/media/news/2006/022406a.htm
Festin M. (2003). Are we doing too many caesarean sections? The HTA Forum, Vol. 1 No. 2
National Statistics Office. (2004). Table 2. Number of Deaths by Age Group by Sex and Sex Ratio, Philippines: 2000.
Retrieved 26 September 2008 from http://www.census.gov.ph/data/sectordata/2000/ds0002.htm
National Statistics Office. (2008). Live Birth Statistics: 2004. Retrieved 30 September 2008 from
http://www.census.gov.ph/data/sectordata/sr08321tx.html
National Statistics Office and ORC Macro. (2004). National Demographic and Health Survey 2003. Calverton,
Maryland: NSO and ORC Macro.
PhilHealth - Philippine Health Insurance Corp. (2003). PhilHealth Circular 25 s. 2003: Supplement to the rules on
PhilHealth's maternity care benefits for hospitals and non-hospital facilities.
Singh S, Juarez F, Cabigon J, Ball H, Hussain R and Nadeau J. (2006). Unintended Pregnancy and Induced Abortion
in the Philippines: Causes and Consequences. New York: Guttmacher Institute.
UNICEF, WHO, UNFPA. (1997). Guidelines for Monitoring the Availability and Use of Obstetric Services.
UN Millennium Project. (2005). Who’s Got the Power? Transforming Health Systems for Women and Children. Task
Force on Child Health and Maternal Health.
UN Population Division. (2004). World Population to 2300. Available at
http://www.un.org/esa/population/publications/longrange2/WorldPop2300final.pdf
Wagner A, Ross-Degnan D, Valera M, Laviña S, Sia I and Galang R. (2006). An Outpatient Prescription Drug Benefit
for PhilHealth Members with Hypertension. p. 5.
WHO, UNICEF & UNFPA. (2004). Maternal mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA.
Available at http://www.who.int/reproductive-health/publications/maternal_mortality_2000/index.html
World Health Organization. (2005). The World Health Report: 2005: Make Every Mother and Child Count. Available at
http://www.who.int/whr/2005/en/index.html
World Health Organization. (2006). Report of a WHO Technical Consultation on Birth Spacing. Available at
http://who.int/reproductive-health/publications/birthspacing/index.html