André Junqueira Caetano PUC-MG and Cedeplar-UFMG Seminar on Reproductive Health in Latin America
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Transcript of André Junqueira Caetano PUC-MG and Cedeplar-UFMG Seminar on Reproductive Health in Latin America
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.