Family Planning in Cebu City: 1996

Introduction

It was not before 1970 that the government of the Philippines began to actively promote family planing in the country. Prior to 1970, family planning activities were promoted and undertaken by a number of private agencies, but efforts were relatively small and concentrated in urban areas. In the early 1 970s, the government established a Commission on Population (PopCom) charged with the task of formulating population policies, creating mechanisms for their implementation, and supervising, among others, family planning activities. The latter were to be undertaken by all sectors of society: government agencies, public and private enterprises, and schools. This scheme never worked and, by default, PopCom itself assumed the role of family planning provider.

In the course of time, a number of national family planning strategies were designed, but the only one that really took hold in the mid-70s was the so-called Outreach Program which placed family planning promoters and supply depositories into the remotest rural areas. With the demise of the Marcos regime in 1986, most of these efforts were halted. Under President Aquino, family planning activities were entrusted to the Department of Health, which made them a component of its maternal and child health program.

How long it took for family planning to take hold in the Philippines is indicated in Table 1, which lists contraceptive prevalence rates obtained by the National Demographic Surveys of the Philippines since 1968.1

Table 1. PERCENT CURRENTLY MARRIED WOMEN 15-44
PRACTICING CONTRACEPTION,
BY TYPE OF METHOD: PHILIPPINES, 1968-1993

As in countries elsewhere, family planning took hold first in urban areas. One particular aim of the Outreach Program just mentioned was to extent family planning services into rural areas which, until the establishment of Outreach, had barely been touched. By now, the contraceptive prevalence gap between urban and rural areas has considerably narrowed.

According to the 1993 NDS (p.46), the contraceptive prevalence rate at that time in the rural Philippines was 36.8 per 100, compared to 43.0 in the urban areas of the country.

At the present time and despite all attitudinal changes toward family planning in the past, the Philippines has the lowest contraceptive prevalence rate among married women in all of Southeast Asia.

Table 2. CONTRACEPTIVE PREVALENCE RATES
IN THE COUNTRIES OF SOUTHEAST ASIA: 1995

Within the country, contraceptive prevalence differed substantially between regions. As reported by the 1993 NDS (p.46), prevalence rates in 1993 varied from a high of almost 50 percent in Northern Mindanao to a low of 28.5 in Western Mindanao. The Central Visayas Region, in which Cebu City is located, had the second-highest contraceptive prevalence rate among all regions of the country: 46.1.

It is within the just described context that family planning in Cebu City has to be viewed. On the following pages, the results of a small pilot survey of 100 women, including unmarried women, are displayed.2 The data were collected in January of 1996 from women residing in eight barangays of the core (lowland) area of Cebu City, which contains three fourths of all Cebu City residents. With a few modifications, the questionnaire used was that provided by AUICK, but translated into the Cebuano vernacular.

Because of the smallness of the sample, it cannot be expected that distributions of the characteristics of the interviewed women agree with those found in the 1993 NDS or elsewhere, including the report of Padilla, showing family planning statistics obtained from service data of the Cebu City Health Office.3 However, whenever possible, comparisons with family-planning related results from the 1993 NDS are provided. Likewise on account of the small number of respondents, no statistics have been calculated.

1 National Demographic Surveys (NDS) in the Philippines are held every five years. The 1993 NDS is identical with the "Demographic and Health Survey of the Philippines," a joint undertaking of the Philippine National Statistics Office (NSO) and Macro International of Calverton, MD, USA. The results were published by both agencies in "National Demographic Survey 1 993: Philippines." Manila and Calverton, 1994.
2 Unmarried women were included because of teenage and pre-marital fertility, the relatively widespread existence of which has just been confirmed by the Young Adult Fertility Survey of the Philippines.
3 Perfecto L. Padilla. "Study of the Population Dynamics and Urban Conditions, Problems and Services in Cebu City, Philippines." Reproduced in "Population Dynamics and Urban Infrastructure: Second Round In-depth Urban Inquiry." Asian Urban Information Center of Kobe, not dated.

I. BACKGROUND CHARACTERISTICS OF RESPONDENTS

The sample population is composed not of currently or ever married women but of women regardless of marital status. As a comparison of the age distribution of the sample women with that of women 15-49 enumerated in Cebu City during the 1990 Census shows, the sample population is somewhat 'heavy' on women belonging to the oldest reproductive age group, and light on the youngest women of reproductive age.4

Table 3. AGE STRUCTURES OF SAMPLE AND 1990 CENSUS
WOMEN: CEBU CITY (percent)

Two thirds (66) had been born in Cebu City, 17 had migrated from Cebu Province, and the remaining 17 hailed from outside Cebu Island. Of the migrants, 15 had come from urban places, and 19 from rural ones.

Three quarters of the respondents were currently married; all of the teenage women with the exception of one were not.

Table 4. RESPONDENTS, BY CURRENT AGE AND MARITAL STATUS

More than one half of all married respondents had been married during the 1980s (44), 20 during the preceding decade, 6 in the 1960s, and 9 in most recent years.

The average number of years of schooling of the sample respondents was above the national average: some nine years. Women with some college (including some currently in college) represented the largest educational group; eleven others had graduated from college, and another 2 had had some graduate training. Those with elementary schooling only made up one third of the sample.

The sample is almost evenly divided between those with, and without a job, as Fig.1 documents. The majority of those with work hold sales and service jobs.

Fig.1. RESPONDENTS, BY CURRENT OCCUPATION

4 The interviewers were instructed to find respondents with an age structure resembling that of the Cebu census women. When they had to replace teenage women because of too many refusals to be interviewed, they increased only the number of women 45-49 to leave the age groups of women 20-44 as stipulated.

II. FERTILITY

Of the 100 sample respondents, 82 reported to have had a live birth. All respondents without children (18) were below 25 years of age and evenly divided into teenagers and women 20-24. Three of the teenagers reported to have a child, and ail three of them likewise reported not to be married.

The total number of living children ever born to the 82 respondents who reported at least one live births is 356, the mean number per respondent with live birth 4.3, and the range of live births per woman extends from one child to 15.

Table 5. RESPONDENTS, BY NUMBER OF CHILDREN EVER BORN

Differential fertility according to background characteristics is difficult to measure with a small sample. Table 6 shows the mean number of children ever born by three different characteristics: place of birth of respondent (Cebu City - outside), education (elementary, high school and incomplete college, college degree and more), and work status (working - not working).

Table 6. MEAN NUMBER OF CHILDREN EVER BORN,
BY SELECTED CHARACTERISTICS*

The figures in Table 6 point in the expected direction for place of origin and education; for current work status, one would expect the opposite result.

Of the 356 live births to the 82 sample respondents reporting a live birth, 326 were still alive at interview time (January 1996). The 28 child deaths were reported by 19 women, 13 of whom reported 1 child death, two women 2 deaths, one woman 3 deaths, and another woman 4. The latter woman (with 4 deaths) had borne a total of 10 children, but the woman who reported to have lost 3 children had borne a total of only 4.

Table 7. RESPONDENTS, BY NUMBER OF CHILDREN STILL LIVING

The data seem to indicate an inverse relationship between mother's education and child death. Among the sample respondents, child deaths were concentrated among mothers with elementary education only.

With respect to the place where the respondents had delivered their most recent live births, a surprisingly large proportion (51 out of 82) answered with 'Hospital'; the remaining 31 others indicated 'At Home under the supervision of a Midwife.' Hospital delivery seemingly is related to social standing. By using educational attainment as indicator of the latter, Table 9 suggests a positive relationship between education and hospital delivery.

Table 8. MOST RECENT BIRTHS, BY EDUCATION OF MOTHER AND PLACE
OF DELIVERY (percent)

The same relationship is indicated in the 1993 NDS, as Table 9 shows. However, the proportions of deliveries that took place at home and in hospitals is almost reversed: three fourths of ail births nationwide were delivered at home, and only one fourth in a health facility. In Cebu City in 1996, two thirds of all deliveries took place in a hospital.

Table 9. LIVE BIRTHS DURING FIVE-YEAR PERIOD PRECEDING SURVEY,
BY EDUCATION OF MOTHER AND USUAL PLACE OF DELIVERY:
PHILIPPINES, 1990

About ten years ago, the situation in Metro Cebu had been similar to the national situation in 1993:

Table 10. LIVE BIRTHS BETWEEN 1 MAY 1983 AND 30 APRIL 1984,
BY PLACE OF DELIVERY: METRO CEBU, 1983/84

In 1983/84, a major kind of delivery attendant in Metro Cebu had been the mananabang, a traditional birth helper, who was called to assist in one third of all deliveries. The other two thirds had been shared by physicians (33 %), midwives (27 %), and nurses (2 %).

When asked whether they thought that the were given sufficient health and social care, the vast majority of the respondents (80 percent) answered in the affirmative. Surprisingly, the 20 'complainers' were not among women with large numbers of children but among the low-parity women and women without any child.

During the survey, respondents with living children were asked not only about their actual fertility experiences but also how many additional children they would want and what they considered the ideal number of children to have. To the first question, 65 women answered with 'none', 10 with 'one', three with 'two', and two with 'three'. Of the women who said they wanted more children, only two had more than 3. As one would expect, the number of additional children wanted decreased with the number of children currently alive.

Table 11. PERCENT OF WOMEN NOT WANTING ADDITIONAL CHILDREN,
BY NUMBER OF LIVING CHILDREN

To the second question, what they considered the ideal number of children to have, the answers given demonstrate the positive correlation between actual number of living children and the ideal number.

Table 12. MEAN OF IDEAL NUMBER OF CHILDREN,
BY NUMBER OF LIVING CHILDREN

Ideally, some concordance should be expected between answers given by the same respondent to questions concerning number of children wanted and ideal number of children. Experiences in the past have shown that this expectation is often not met. Table 13 shows the number and percent of respondents in the Cebu pilot survey whose answers to both questions do, and do not agree. The number of children wanted is defined as actual number of living children plus additional children wanted.

Table 13. NUMBER AND PERCENT OF RESPONDENTS WITH LIVING
CHILDREN, BY AGREEMENT BETWEEN ANSWERS TO
QUESTIONS ABOUT IDEAL NUMBER OF CHILDREN AND
NUMBER OF CHILDREN WANTED*

The figures in Table 11 document a surprisingly high degree of concordance: close to 50 percent. Whether or not a tendency exists for the ideal number of children to be below the actual number, the data at hand do not permit to state.

III. FAMILY PLANNING

All respondents were asked how they felt about using family planning in any form. Five respondents claimed that they were against it, but the vast majority exhibited a positive attitude by expressing in one form or another that they considered it a necessary practice.

The five respondents who expressed negative attitudes toward family planning included two teenagers, one without child and one with, a 23 year old woman with no child, and two women in their late forties, one of whom had borne 8 children, and the other 4. At some time in the past, the latter had practiced family planning; the other four women never had.

Of the entire sample, 47 were currently practicing family planning, 22 were previous users, and 31 never users.

Table 14. RESPONDENTS, BY FAMILY PLANNING PRACTICE
AND AGE

The 1993 NDS found that 38 percent of all women 15-49 had been ever users of family planning, and 24.2 percent current users in 1993. Since the NDS definition of ever users combines previous and current users, the 1996 Cebu City rate of 69 percent is substantially higher, still higher than the 1993 NDS percent of ever users among currently married women, which is 61.1. The Cebu figure agrees with the earlier made observations that contraceptive prevalence rates tends to be higher in urban than rural areas and that the Central Visayas region has one of the highest prevalence rates among all regions of the country.

The never users were primarily young women below age 25 (75 percent of all never users), all of them never married, and most of them with no child (18 of them). However, the never users also include a few high-parity women, two of them in their late forties, (one with 11, the other with 8 children), and two in their late twenties, (of whom one had 10, and the second 8 children). Three of the older high-parity women had incomplete elementary education, and the fourths had gone for two years to high school.

When asked why they never practiced family planning, two thirds (21) of them replied with 'no possibility of conceiving', two respondents stated that they wanted children, and 8 (25 percent) were afraid of side effects. Among previous users, the reasons for current non-use were distributed similarly: 60 percent saw no possibility of conceiving, and one fourth was afraid of side effects. One additional reason given by one woman was based on religious consideration.5 Table 15 details the reasons for never use or current non-use by age of respondent.

Table 15. RESPONDENTS, BY REASON FOR NEVER OR
NOT CURRENTLY PRACTICING FAMILY PLANNING, AND AGE

The reason of 'no chance of conceiving' sounds strange when given by young women. Of the 34 respondents who quoted that reason, 10 were teenagers, and another 10 between the age of 20 and 25. The explanation for the strange answer of these respondents is most likely that they did want to point out that they were incapable of conceiving but that for them conception was unthinkable because they were not married (as shown in Table 4, 11 of the 12 teenage respondents were unmarried, as were 9 of the 20 respondents aged 20-24.

For comparative purposes, Table 16 lists the reasons for not using contraceptive methods given by 3,433 currently married women during the 1993 NDS.

Table 16. PERCENT OF CURRENTLY MARRIED WOMEN
WHO ARE NOT PRACTICING FAMILY PLANNING,
BY MAIN REASON FOR NOT PRACTICING AND AGE: PHILIPPINES, 1993

The NDS figures do not show large proportion of women claiming incapacity of conception. This supports the explanation offered above, viz. the Cebu respondents either did not understand the question clearly or were unable to express themselves in an unequivocal manner. The NDS show a large proportion of older women, for whom the incapacity response makes sense. They likewise confirm the relative absence of a 'religious' impediment toward the use of contraceptives, a fact the Cebu data suggest. The Cebu data concerning fear of side effects and the wish to have more children are not as clear as the NDS data, but are not inconsistent with NDS findings. The latter display clear patterns: younger women are more concerned about health than older ones, and larger proportions of young (and low-parity) women want to have more children than older women.

Table 17 (see following page) contains a cross tabulation of the Cebu respondents by family planning use and selected background characteristics.

Among the 100 sample respondents, those who had not be born in Cebu City had a larger proportion of ever users than Cebu-born women; education-wise, women with elementary and complete college education were more frequent among the ever-users than women with high school and some college education, and more currently working women were or had been users than not-working ones. Use of contraception seems to be increasing with number of children ever born. Among current users, background characteristics operate in the same way as they do among ever-users. Some of these 'relationships' are in a more precise way stated in the 1993 NDS, which shows that, among currently married Filipino women, contraceptive use increases with education and number of children ever born for the first three children; from the fourth child onward, the relationship is reversed.

Table 17. RESPONDENTS, BY FAMILY PLANNING USE
AND SELECTED BACKGROUND CHARACTERISTICS (percent)

With respect to methods used, the questionnaire question "What method are you using?" was interpreted to mean "what method are you currently using?" As result, no information is available as to methods used by previous users.

The 1993 NDS, the latest available source of comparison for the 1996 Cebu data, provides family planning use statistics for all women 15-49 and for currently married women. In its analysis of the Philippine situation, the 1993 NDS concentrates on currently married women since they are those among all women who are most at risk of bearing a child. To keep the Cebu data comparable with those of the 1993 NDS, the following tabulations are for currently married women 15-49, of which there are 75 in the sample of the 100 Cebu women interviewed.

When asked, what family planning method the current users were using, the largest proportion (one fifth) answered with calendar rhythm. This particular method is usually classified as traditional, implying that it is less effective than modern methods. During the first decades of its existence, the Philippine family-planning program did not consider rhythm of any form worth of support. It was only in the 1980s that the family planning agencies changed their minds because a family planning method acceptable to a population, regardless of its effectiveness, is more effective than any effective methods not accepted and used by a significant portion of the population. Table 18 displays all methods used by the Cebu respondents. For comparative purposes, corresponding figures from the 1993 NDS are likewise shown.

Table 18. PERCENT OF ALL CURRENTLY MARRIED WOMEN 15-49,
BY CONTRACEPTIVE METHOD USED, CEBU CITY SAMPLE 1996,
AND NATIONAL SAMPLE, 1993

The Cebu contraceptive prevalence rate of currently married women is substantially higher than the 1993 national rate. This also holds when the methods are classified as modern and traditional', the prevalence rate of modern methods in Cebu City is 39.9, that of traditional methods 21.3.6 The corresponding figures from the 1993 NDS are 24.9 for modern, and 15.1 for traditional methods.

Somewhat surprising for a largely Catholic country is the relatively frequent use of female sterilization. In both the Cebu City and the national sample, it ranks high in terms of frequency of use. In contrast to female sterilization, male sterilization is hardly ever used because it does not go well with the macho image that the Philippine male likes to idealize. In the 1993 NDS, the prevalence of male sterilization was 0.4 percent, compared to 11.9 for female sterilization. By Cebu City respondents, it was not reported at all.

Not considered a legal family planning practice in the Philippines is abortion.7 Despite the illegal status of abortion in the country, 3 of the 100 women interviewed admitted quite freely to having undergone induced abortions.

An approximate idea as to how family planning practice in Cebu has changed over time can be gained by comparing the 1996 figures of Cebu City with 1984-85 figures for Metro Cebu, based on data collected in the context of the Cebu Longitudinal Health and Nutrition Survey. The data were obtained from 2,695 currently married women.8 The contraceptive prevalence rate for all methods used at that time was 41.8, some 32 percent lower than the rate suggested by the 1996 Cebu City pilot survey.

The change that occurred over the past 12 years was not one only in terms of the overall contraceptive prevalence rate but also in terms of method mix, a fact that a study of Table 19 will confirm.

Table 19. PERCENT OF CURRENTLY HARRIED WOMEN 15-49,
BY CONTRACEPTIVE METHOD USED: METRO CEBU, 1984-85

In 1984-85, the ratio of modern over traditional methods in Metro Cebu was 1:1; in 1996, it had changed (in Cebu City) to 2:1. Methods like withdrawal and abstinence declined in importance, while pills and sterilization increased in use.

Tables 20 and 21 compare age patterns of method use between the 1996 Cebu City Sample and the 1993 NDS. Despite the smallness of the Cebu City sample,the two data sets show some common features.

Table 20. PERCENT OF CURRENTLY MARRIED WOMEN 15-49,
BY AGE AND CONTRACEPTIVE METHOD USE: CEBU CITY, 1996

Table 21. PERCENT OF CURRENTLY MARRIED WOMEN 15-49,
BY AGE AND CONTRACEPTIVE METHOD USE: NDS, 1993

Both tables show (1) that contraceptive use (all methods) begins slowly at the youngest reproductive ages, reaches a peak at ages 30-35, and declines thereafter; (2) never-users are concentrated among the women of youngest and oldest reproductive age; (3) rhythm and (of course) sterilization are methods for women in the later reproductive years, while pills are preferred by younger women; and (4) IDDs are more or less evenly distributed over the reproductive age range.

Some differences in contraceptive use by socioeconomic characteristics are suggested by the Cebu City data. Whether or not these differences are significant, the data from the small sample at hand do not permit to test.9 The populations compared include only currently married users aged 15-49, totalling a mere 47.

Table 22 compares family planning users born in Cebu City with those who came to the City later in life. The table suggests that native Cebuanas tend to be more conservative, relying on traditional methods as rhythm and, from among the modern methods, the pill, which does not require any intervention by a health provider. By contrast, family planning-practicing 'new-comers' to the City tend to be more daring and rely primarily on IUDs and sterilization.

Table 22. PERCENT OF CURRENTLY MARRIED FP USERS 15-49,
BY PLACE OF ORIGIN AND CONTRACEPTIVE METHOD USED

Table 23, showing method use by education, does not reveal any clear pattern. Women with high school education and some college appear, in the Cebu City data, as a more conservative education group, relying primarily on rhythm and the pill. Some 60 percent of women with elementary education, by contrast, make use of IDDs and sterilization. The number of college graduates is too small for making even a suggestion.

Table 23. PERCENT OF CURRENTLY MARRIED FP USERS 15-49,
BY EDUCATIONAL ATTAINMENT AND CONTRACEPTIVE METHOD USED

A clearer difference is evident between women who work and those who don't. The non-working women are the more 'conservative' contraceptive users banking heavily (more than 50 percent) on rhythm. Working women, by contrast, use all methods but prefer sterilization and the IUD.

Table 24. PERCENT OF CURRENTLY MARRIED FP USERS 15-49,
BY WORK STATUS AND CONTRACEPTIVE METHOD USED

5 It is interesting to note that only one out of 53 respondents who were not practicing family planning gave religion as reason. This finding is consistent with findings made in other Philippine surveys.
6 The 1993 NDS counts among the modern methods Pill, IUD, Injections, diaphragm/foam/jelly, condoms, and sterilization, and among the traditional natural family planning, withdrawal, and 'others'.
7 Though abortion is considered illegal, it is, in most known instances, not sanctioned by the government.
8 The Cebu Longitudinal Health and Nutrition Study interviewed respondents 14 times over a two-year period. The data shown here are taken from the sixth survey round, which extended from 1984 to 1985.
9 1993 NDS data that can be used for comparative purposes are not available.