André Junqueira CaetanoAndré Junqueira CaetanoPUC-MG and Cedeplar-UFMGPUC-MG and Cedeplar-UFMG

Seminar on Reproductive Health in Latin AmericaSeminar on Reproductive Health in Latin AmericaLondon School of Economics, September 20London School of Economics, September 20thth 2007 2007

Differentials in demand and Differentials in demand and supply of female surgicalsupply of female surgical

sterilizationsterilization: Belo Horizonte e : Belo Horizonte e Recife, 2002Recife, 2002

OutlineOutline• The 1986-1996 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: Spread: Percentage of current users Percentage of current users among married women aged 15-49 among married women aged 15-49 years by region - Brazil, 1986 and 1996years by region - Brazil, 1986 and 1996

74

80

73

80

65

81

53

6863

72

66

77

0

10

20

30

40

50

60

70

80

90

100

%

South SP/RJ MG/ES/CO Northeast North Total

Region

1986

1996

Sources: DHS 1986 and 1996.

Spread: Percentage of sterilization Spread: Percentage of sterilization among married women aged 15-49 among married women aged 15-49 years – Brazil, 1986 and 1996years – Brazil, 1986 and 1996

Sources: DHS 1986 and 1996.

18

2932

37

26

47

25

4442

51

27

40

0

10

20

30

40

50

60

%

South SP/RJ MG/ES/CO Northeast North Total

Region

1986

1996

Spread: Spread: Percentage of sterilization Percentage of sterilization among current users married and aged among current users married and aged 15-49 years – Brazil, 1986 and 199615-49 years – Brazil, 1986 and 1996

Sources: DHS 1986 and 1996.

24

36

4447

40

59

46

6467

71

41

52

0

10

20

30

40

50

60

70

80

%

South SP/RJ MG/ES/CO Northeast North Total

Region

1986

1996

Spread: Spread: Ratio between sterilized Ratio between sterilized women to current users of pill among women to current users of pill among women aged 15-49 years - Brazil, 1986 women aged 15-49 years - Brazil, 1986 and 1996and 1996

Sources: DHS 1986 and 1996.

0,4

0,9

1,3

1,7

1,1

2,4

1,4

3,5 3,4

4,6

1,1

1,9

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

4,5

5,0

South SP/RJ MG/ES/CO Northeast North Total

1986

1996

Patterns of female Patterns of female sterilizationsterilization

Northeastern Southeastern

•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 The 1997 regulations of the Family Planning LawFamily 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 Limitations and drawbacks of the regulationsof 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 sterilizationin general and for postpartum in particular?

Contraceptive Indicators - BH and Contraceptive Indicators - BH and Recife, 2002Recife, 2002

Indicators BH

2002Recife 2002

SE (mun.

> 1 million)

1996

NE (mun.

> 1 million)

1996

Current users among married women aged 15-49 years (%)

84 86 86 78

Sterilization among married women aged 15-49 years (%)

30 46 41 49

Sterilization among current married users aged 15-49 years (%)

36 53 48 62

Ratio between sterilized women to current users of pill among women aged 15-49 years

1,3 3,2 1,9 3,7

Sources: SRSR 2002, DHS 1996.

MarriedMarried, 15-49 years, sterilized 15-49 years, sterilized women by type of hospital where women by type of hospital where

the procedure took placethe procedure took place

Source: SRSR 2002.

54,4

45,6

60,2

39,8

57,8

42,2

0

10

20

30

40

50

60

70

%

Belo Horizonte Recife Total

Public/Affiliated

Private

Married sterilized women aged 15-49 Married sterilized women aged 15-49 yearsyears by whether procedure was by whether procedure was

related to a C-sectionrelated to a C-section

Source: SRSR 2002.

51,348,7

60,5

39,5

56,7

43,3

0

10

20

30

40

50

60

70

%

Belo Horizonte Recife Total

Yes

No

MarriedMarried, 15-49 years, sterilized women 15-49 years, sterilized women by type of payment/arrangement of the by type of payment/arrangement of the

procedureprocedure

Source: SRSR 2002.

67

4

29

1

42

24

29

5

52

16

29

3

0

10

20

30

40

50

60

70

%

Belo Horizonte Recife Total

Patient paid

Doctor/Politician

Public health care system

Other

Binomial logistic analysisBinomial logistic analysis• Model I: to be or nor to be?

– Sample: current married women aged 15-49 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 15-49 (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 Percentage distribution of reproductive intentions by parity among married women intentions by parity among married women

aged 15-49 yearsaged 15-49 years

Source: SRSR 2002.

Intention - Parity

Belo Horizonte Recife

0-1 2 3 + Total 0-1 2 3 + Total

Any/more children

61 14 3 29 68 10 2 28

No/No more children

37 53 30 40 28 25 20 25

Sterilized 2 33 67 32 4 65 78 47

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 Preferred future and current method among married women aged 15-49 with two or more married women aged 15-49 with two or more live births who wanted no more children - BH live births who wanted no more children - BH

and Recife, 2002and Recife, 2002

Source: SRSR 2002.

Preferred future method (%) Current method (%)

Female sterilization 10,6 (n=18) 92,9 Other methods

Other methods 57,7 (n=97) 97,4 Other methods

No method 16,9 (n=29) 68,2 Male sterilization

Do not know 14,8 (n=25) 80,4 No method

Total 100 (n=168) -

Final remarksFinal 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.