André Junqueira Caetano PUC-MG and Cedeplar-UFMG Seminar on Reproductive Health in Latin America London School of Economics, September 20 th 2007 Differentials in demand and supply of female surgical sterilization: Belo Horizonte e Recife, 2002

Outline The trend in the contraceptive mix –The spread of female sterilization in Brazil –The two sterilization patterns The 1997 regulations of the family planning law and its limitations SRSR Project - Belo Horizonte and Recife, 2002 –Contraceptive mix –Sterilization features (type of hospital, delivery type, arrangement/payment) –Logistic analysis Chance of sterilization Sterilization features Desire for children and preferred future method

Spread: Percentage of current users among married women aged years by region - Brazil, 1986 and 1996 Sources: DHS 1986 and 1996.

Spread: Percentage of sterilization among married women aged years – Brazil, 1986 and 1996 Sources: DHS 1986 and 1996.

Spread: Percentage of sterilization among current users married and aged years – Brazil, 1986 and 1996 Sources: DHS 1986 and 1996.

Spread: Ratio between sterilized women to current users of pill among women aged years - Brazil, 1986 and 1996 Sources: DHS 1986 and 1996.

Patterns of female sterilization NortheasternSoutheastern Sterilization more likely to be the method of choice Sterilization less likely to be the method of choice Sterilization more likely to be carried out in a public hospital or in a private hospital affiliated to the public system Sterilization less likely to be carried out in a public/affiliated hospital Sterilization less likely to be related to C-Section delivery as compared to the SE More likely to be during a C- section (successive c-sections) Sterilization more likely to be arranged by a doctor/politician as compared to the Southeast More likely to be paid Lack of choice, Sterilization culture C-section practice

The 1997 regulations of the Family Planning Law To demand the procedure: at least 25 years old or two children To supply the procedure: hospital must be authorized by the state health authority –60-day waiting period - counseling Supply of non-definitive methods Sterilization cannot be performed until the 42th day after the delivery Payment ceiling of 40% of deliveries by C-section in public hospitals Ensure informed choice Reduce unnecessary cesareans

Limitations and drawbacks of the regulations Low number of hospitals authorized to perform sterilization as well as spatial concentration in the major urban areas Criteria used by doctors tend to be more restrictive than the law requirements in the Southeast and more liberal in Northeast (lack of law enforcement) High proportion of women (as well as men) not going through the whole process set to obtain the surgical sterilization (time of counseling?) Frustrated demand for female sterilization in general and for postpartum in particular?

Contraceptive Indicators - BH and Recife, 2002 Indicators BH 2002 Recife 2002 SE (mun. > 1 million) 1996 NE (mun. > 1 million) 1996 Current users among married women aged years (%) Sterilization among married women aged years (%) Sterilization among current married users aged years (%) Ratio between sterilized women to current users of pill among women aged years 1,33,21,93,7 Sources: SRSR 2002, DHS 1996.

Married15-49 years, sterilized women by type of hospital where the procedure took place Married, years, sterilized women by type of hospital where the procedure took place Source: SRSR 2002.

Married sterilized women aged yearsby whether procedure was related to a C-section Married sterilized women aged years by whether procedure was related to a C-section Source: SRSR 2002.

Married15-49 years, sterilized women by type of payment/arrangement of the procedure Married, years, sterilized women by type of payment/arrangement of the procedure Source: SRSR 2002.

Binomial logistic analysis Model I: to be or nor to be? –Sample: current married women aged years (1126 cases) –Response variable: surgically sterilized (yes/no) –Control variables: age, parity, schooling years, municipality –Results Municipality (p-value=.0001)Municipality (p-value=.0001): women from Recife are 3.7 times more likely to be sterilized. Model II: to be in Recife as compared to Belo Horizonte –Sample: current sterilized married women aged (400 cases) –Response variable (Recife/BH) –Control variables: those in model I plus type of hospital, relation to delivery, arrangement/payment –Results Relation to delivery (p-value=.0233): the chance of sterilization during a delivery by C-section is 71% higher in Recife as compared to Belo Horizonte Arrangement/payment (p-value=.0028): the chance of sterilization as favor is 61% higher in Recife as compared to BH

Percentage distribution of reproductive intentions by parity among married women aged years Source: SRSR Intention - Parity Belo HorizonteRecife Total Total Any/more children No/No more children Sterilized Total 100 (n=181) 100 (n=142) 100 (n=143) 100 (n=466) 100 (n=164) 100 (n=131) 100 (n=144) 100 (n=439)

Preferred future and current method among married women aged with two or more live births who wanted no more children - BH and Recife, 2002 Source: SRSR Preferred future method (%)Current method (%) Female sterilization10,6 (n=18)92,9Other methods 57,7 (n=97)97,4Other methods No method16,9 (n=29)68,2Male sterilization Do not know14,8 (n=25)80,4No method Total100 (n=168)-

Final remarks The analysis of the 2002 data for Belo Horizonte and Recife indicates that the reproductive health and contraceptive use is not substantially different from what the 1996 DHS data unveiled –Female sterilization is the most used method –Its provision is predominantly paid or arranged by a doctor or a politician, related to a C-section delivery and carried out in public/affiliated hospitals –As far as SE and NE major urban areas are concerned prevalence of sterilization and who arranged or paid for the procedure define the two patterns –The majority of the users of non-definitive methods buy them in drugstores This year the Ministry of Health launched a new FP program that is basically the increase of funds and incentives to supply non-definitive methods through the public health care delivery services on a larger scale and on more regular basis.