Manila - Josie Dequito looks decades older than her actual age. With no teeth, sunken eyes and hollowed cheeks, the 40-year-old mother could easily be mistaken for a 60-year-old.

"Life is really difficult," she said as she prepared assorted goods that she will sell door-to-door all day around San Andres Bukid, a slum village in Manila City. "I have to earn extra because of my big family."

"Sometimes, I get home really, really tired but I still have to take care of my children," she said. "They are still young. My husband helps a lot, but he also has no job right now."

Dequito has 11 children - the eldest, a 19-year-old daughter, the youngest a two-year-old son.

She said she only wanted to have four children and that most of her pregnancies were "accidents" because she could not afford to pay for contraception.

Like Dequito, many women in Manila City are in a similar situation - with bigger families than they can afford to have - due to a lack of free family planning services at government health centres.

The problem began in 2000 when former Manila City mayor Lito Atienza, a staunch pro-life advocate, issued an executive order "discouraging" the promotion and distribution of artificial contraception in the city.

With the order, essential family planning services, including free supplies of condoms and birth control pills, disappeared from city health centres, according to a study entitled "Imposing Misery."

Providers also refused to provide women basic information about family planning, added the study, which was conducted by three reproductive health rights groups including the New York-based Center for Reproductive Rights in 2007.

With about 70 per cent of Filipinos relying on the public sector for family planning services, including female sterilization, oral or injectable contraception and intrauterine devices, the "contraceptive ban" has produced devastating effects on women's health and quality of life, the study said.

Of the dozens of women interviewed for the study in San Andres Bukid, all have at least four children more than they planned and now face financial difficulties raising a larger family.

Tina Montales, 36, a mother of eight, wanted to have a tubal ligation after her fourth pregnancy but could not because the local hospital no longer offered the service after Atienza's order.

The local health centre also stopped providing the contraceptive pills she used to get for free.

"My children are malnourished," she told the study authors. "Oftentimes, they miss a meal. I give each of my children 5 pesos (10 US cents) for school allowance. I feel sorry for them because I can't buy them school shoes."

Montales worries about getting pregnant again, and the anxiety has strained her relationship with her husband.

The study said that in some cases, women's refusal to have sex with their partners have even resulted in sexual violence.

While new Mayor Fred Lim was elected in 2007, he has not revoked Atienza's order but allowed non-government organizations and private groups to hold family planning seminars as well as distribute free contraceptives.

Likhaan, a women's health organization that was part of the study, said they have asked Lim to revoke Atienza's order.

"Mayor Lim made it clear that he will not use public funds for family planning programmes," said Joy Pacete, a spokeswoman for Likhaan. "So the NGOs are just filling in the gaps right now. We still need to get the ban revoked."

Pacete said since there is no initiative from the city government, health centres rely on donations for their supply of condoms, contraceptive pills and other means of contraception.

"There is no steady supply," she said. "Since most women who need the free supplies are poor, they are unable to buy on their own because they would rather buy rice with their money than get contraceptives."

With the help of Likhaan, a group of women in Manila City have filed a case at the Supreme Court asking it to repeal Atienza's order and set a legal precedent that will deter other local government units from issuing similar orders.

Population control is a controversial issue in the Philippines, where the influential Roman Catholic Church opposes any campaign that promotes the use of artificial contraception.

The Philippines' population is currently estimated at 90 million. By 2010, the figure is projected to reach 94 million, according to government data. (dpa)