By Blaine Harden
Washington Post Foreign Service
Monday, April 21, 2008
MANILA -- Maria Susana Espinoza wanted only two children. But it was not until after the birth of her fourth child in six years that she learned any details about birth control.
"I knew it existed, but I didn't know how it works," said Espinoza, who lives with her husband and children in a squatter's hut in a vast, stinking garbage dump by Manila Bay.
She and her family belong to the fastest-growing segment of the Philippine population: very poor people with large families. There are many reasons why this country is poor, including feudal patterns of land ownership and corrupt government. But there is a compelling link between family size and poverty. It increases in lock step with the number of children, as nutrition, health, education and job prospects all decline, government statistics and many studies show.
Birth and poverty rates here are among the highest in Asia. And the Philippines, where four out of five of the country's 91 million people are Roman Catholic, also stands out in Asia for its government's rejection of modern contraception as part of family planning.
Acceding to Catholic doctrine, the government for the past five years has supported only what it calls "natural" family planning. No national government funds can be used to buy contraceptives for the poor, although anyone who can afford them is permitted to buy them. Local governments can also buy and distribute contraceptives, but many lack the money.
Distribution of donated contraceptives in the government's nationwide network of clinics ends this year, as does a contraception-commodities program paid for by the U.S. Agency for International Development. For years it has supplied most of the condoms, pills and intrauterine devices used by poor Filipinos.
"Family planning helps reduce poverty," President Gloria Macapagal Arroyo said in a 2003 speech that detailed her approach to birth control. But she said then and has since insisted that the government would support only family planning methods acceptable to the Catholic Church.
Women not wanting to get pregnant, Arroyo advised, should buy a thermometer and recording charts and abstain from sex when they are outside the "infertile phases of the monthly cycle."
Arroyo, 61 and a grandmother with three grown children, said in 2003 that when she was a young mother, she took birth control pills. She said that she later confessed to a priest.Opposition From the Catholic Church
At the Manila garbage dump, Espinoza said she has been lucky.
A nongovernmental organization with health workers who regularly visit the dump told her that an intrauterine device could prevent her from having another baby. She plans to visit a clinic this month to get an IUD.
The organization that is helping Espinoza agreed to introduce this reporter to her on condition that it not be named. The group's health workers said they fear retaliation and harassment from officials in the national and city government, as well as from the Catholic Church.
In 2005, Catholic bishops in the southern Philippines announced that they would refuse Communion to government health workers who distributed birth control devices.
In the past two weeks, the Catholic Bishops' Conference of the Philippines declined repeated requests for comment on its family planning policies. The church leadership made its last major statement on birth control last fall.
"Chemical agents and mechanical gadgets that make up the cluttered display of contraceptive methods of birth control have caused serious damage in family relationships, disrupting the unity and openness that build family life by the effects that accompany the contraceptive culture which include extramarital relationships, adolescent pregnancies, and even the hideous murderous act of abortion," said Archbishop Paciano Aniceto, chairman of a bishops' commission on family life.Aggressive Family Planning in Thailand
In recent weeks, public alarm in the Philippines over the soaring price of rice has focused attention on the fast-growing population and its dependence on rice imports.
Despite steadily increasing rice harvests, farmers here have been unable to keep pace with domestic demand. Economists here have calculated, though, that the Philippines would not need imported rice if it had managed to control population growth -- like its neighbor Thailand.
In 1970, the population of each country was about 36 million people and growing at about 3 percent a year. But with an aggressive family planning program that provides the poor with free contraceptives, Thailand has since reduced its population growth rate to 0.9 percent. In the Philippines, the rate has declined sluggishly to about 2.1 percent.
There are now about 26 million more people in the Philippines than in Thailand.
"It's a no-brainer," said Ernesto M. Pernia, professor of economics at the University of the Philippines.
The Philippines now produces 16 million metric tons of rice a year -- and needs to import 2 million tons more to meet local demand.
"If the Philippines had pursued what Thailand has done, the Philippines would be only consuming 13 metric tons of rice per annum," Pernia said. "We could be a net exporter of 3 million metric tons."
Besides increased food security, the Philippines could have lifted 3.6 million more people out of poverty if it had followed Thailand's population growth trajectory, according to Pernia's analysis.
"Even when there is widespread corruption, insurgent violence and other powerful reasons for poverty, the evidence from across Asia is that good population policy by itself contributes to significant poverty reduction," he said.Strong Public Support for Contraception
There appears to be widespread public support in the Philippines for modern contraceptives.
Public opinion surveys in recent years have consistently found that about 90 percent of respondents supported government funding of contraceptives for people who cannot afford them.
Surveys by the government also show that poor families have significantly more unwanted pregnancies than richer families -- and much more difficulty finding affordable contraceptives.
The problems the poor face in finding contraception products will increase sharply this year as the Philippine government and USAID end the distribution of donated contraceptives, according to Suneeta Mukherjee, country representative for the U.N. Population Fund. "The poor cannot afford to go somewhere and buy contraceptives," she said. "Many cannot even afford the transportation. By the time they go, they are already pregnant."
The government's plan for "contraceptive self-reliance" anticipates that market forces will make condoms and other products available in shops or that they will be given to the poor by local governments.
But Mukherjee predicted that these new sources will not keep up with demand. "Access to contraceptives will be restricted for most of those who cannot pay and for many who might be willing to pay," she wrote in a February report.
A reduction in the use of contraception -- which is now about 33 percent among women of childbearing age -- will lead to an increase in abortions, Mukherjee predicts.
Abortion is illegal here, but a 2006 study found that there were about 473,000 a year, which accounts for about a third of women with unwanted pregnancies. The study also found that 80 percent of abortions had complications requiring medical treatment.
As for the efficacy of "natural" methods to control population growth, Mukherjee said "it does not work."
At the U.S. Embassy in Manila, an official confirmed that USAID would soon end all donations of contraceptives, after having phased out the program over several years.
But this does not mean less U.S. money for family planning. The official said that USAID has increased its budget, from about $12 million to about $15 million a year, to provide technical assistance to 700 local governments and "to help the private sector to grow the market" for contraceptives.
"We are working in a devolved setting," said the official, who spoke on condition of anonymity. "I am not saying it is a perfect situation."'I Don't Want Any More Children'
In the garbage dump on Manila Bay, Espinoza said she is nervous about getting an IUD. But she sees no alternative. "I already have so many kids I have trouble looking after them," she said.
Until her fourth child was born in October, Espinoza, 26, had time to work as a scavenger in the dump, collecting plastic bottles. On a good 10-hour day, she said, she could collect enough bottles to earn $1. Her husband sells salt and sometimes makes $4 a day.
Espinoza is the oldest of nine children and left school after fifth grade. She grew up in another Manila garbage dump, where her parents also worked as scavengers.
"I don't want any more children," she said. "Life is hard. Rice is expensive."