Brazil - BRAZZIL - Sterilization: No Way Our - Brazilian Population

For many Brazilian women, getting sterilized is just one more chapter in their lives: get married, have two kids and have your tubes tied, just like Mom, Sis or the lady down the street. The most recent data on the subject do not deny it: 40.1% of Brazilian women in relationships (whether legally married or not) have been sterilized. Among Brazilian women in general, sterilization, which is used by 27.3%, is also the most frequently utilized contraceptive. The National Survey on Demography and Health, made in 1996 by Bemfam (Sociedade Civil para o Bem-Estar Familiar no Brasil—Civil Society for Family Welfare in Brazil) asked about the birth control methods of women between the ages of 15 to 49. Compared to a similar survey in 1986 (see table) it is obvious that the number of sterilizations has increased.

Researchers, authorities and feminist movements all agree that Brazil is overusing sterilizations to the point of enormous and worrisome abuse. This is even more troubling considering the rising rate of people with AIDS and the Brazilian government's desertion of the public health arena. "The expansion of the method cannot be the result of women's natural choice," concluded Rita Baldiani, coordinator of the 1996 survey.

Brazil never had an official birth control policy—except by omission. "Birth control came here from abroad, financed by international organizations and implemented by family planning clinics," said José Aristodemo Pinotti, head of gynecology at the Hospital das Clínicas at the University of São Paulo (USP). He remembers that many doctors received equipment and money from North American organizations for each sterilization the doctors performed. These services multiplied principally in the '70s and '80s, along with the training of professionals and agreements with businesses, unions and the public sector itself.

"It was believed that the bigger the population, the greater the barrier to development and the possibility of social tension," explained sociologist Maria Izabel Baltar da Rocha, of the Center for Population Studies at the University of Campinas (Unicamp). In other words, however radical this may seem to be, the increase in the number of poor people was considered a threat that needed to be controlled. "They started to distribute pills and tie tubes. These are two wide-ranging and efficient birth control methods that have nothing to do with a true family planning program," Pinotti concluded.

According to Pinotti, family planning "means adapting to each woman's individual case in each phase of her life the best method that prevents an unwanted pregnancy, without harming her health or taking away her freedom of choice." This is the main reason to be alarmed at the rising rate of sterilizations in Brazil: sterilization is not part of a comprehensive health care program that guarantees information and access to all birth control methods. Sterilization is almost an imposition on women. "Today, controlling fertility is occurring at the cost of bodily harm to women," declared nurse Rosa Godoy, head of the Public Health department at the USP School of Nursing.

"Almost all of the women who seek us out only know about the pill and sterilization," said physician Maria José Araújo, of Coletivo Feminista Sexualidade e Saúde (Feminist Sexuality and Health Collective), a non-governmental organization in São Paulo. The collective offers a different medical procedure: patients participate in decisions, are guaranteed space to speak about what they think and feel, learn how to examine themselves and can take part in support groups and seminars. "After we introduce other methods and discuss them, the majority of our patients decide not to be sterilized," Maria José added. At the Hospital Pérola Byington (Centro de Referência da Mulher do Estado de São Paulo — Women's Referral Center of the State of São Paulo), the results are similar.

"Before having a consultation, patients participate in a group meeting, where they receive information about various birth control methods and can speak about their problems and moral convictions," Pinotti explained. In the end, sterilization is almost always left aside. Nevertheless, information and dialogue are not enough. At Pérola Byington, male and female condoms, pills, IUDs (intrauterine devices) and diaphragms, among others, are distributed to patients for free. At Coletivo Feminista, various types of contraceptives are offered at low cost and, if necessary, donated.

But these two services are an oasis in Brazilian health care. The prevalent desert can be perceived in the example of the São Paulo metropolitan area. Hospitals are included in statistics of family planning services. Half of the health centers do not have a gynecologist, and have lacked birth control pills for a year.

"People are learning that they cannot rely on public service," stated Sara Romera Sorrentino, from the Women's Health department of the São Paulo State Secretariat of Health. Women then buy pills direct from the pharmacy, even though they often have health conditions that make the pill a bad choice for them or do not know how to use the pill correctly. Therefore, the method frequently fails. "At this time, they opt to get their tubes tied. They arrive at the doctor with their minds already made up," Sara said.

For Edna Roland, president of Fala Preta—Organização de Mulheres Negras (Black Speak—Organization of Black Women), "sterilization is sold as the perfect, definitive, safe and inoffensive method." A complete mistake. This is the second big reason for concern: Brazilian women are being sterilized without guidelines and complete access to information. "When done without the necessary technique, sterilization can affect ovarian circulation, cause alterations in sexual life and hasten menopause," Pinotti declared. The main side effect is also never discussed. "It's regret," said Rosa Godoy, of the USP nursing school. In practice, tube-tying is irreversible. The woman loses her reproductive capacity forever.

"A woman should only find herself in this type of decision as a last resort, when she feels completely clarified and sure about what she's doing," said Rosa. After all, she may want to become pregnant again— especially if one of her children dies or if a new relationship starts. If their circumstances allow it, many women try to reverse the sterilization and resort to artificial insemination services. The risks of these procedures are rarely discussed when choosing a birth control method.

On the other hand, doctors almost never associate the prevention of pregnancy with preventing STDs (sexually transmitted diseases), such as AIDS and cervical cancer. "How do you convince a sterilized woman that she needs to use a condom to protect herself from illnesses?" Edna Roland asked. "When she has the sterilization, she thinks that she doesn't need to worry about risks anymore. Preventing STDs is a factor that must weigh in the choice of the birth control method. The doctor needs to make it clear to the patient," she concluded.

For the time being, tying tubes now pushes women to another risk: cesareans. Determined to be sterilized, patients turn for help in the majority of cases to a hospital associated with the federal government SUS (Sistema Único de Saúde—Unified Health System) But, despite being so widely diffused, sterilization was not allowed, except when the patient's health was threatened. Sterilizations could only be done with the patient's written consent and the endorsement of the hospital's ethics committee. This derives from a restriction set by the Conselho Federal de Medicina (Federal Council on Medicine) and the Ministry of Health. The restriction is based on an interpretation of the Brazilian Criminal Code that forbids all injuries that cause the loss or disabling of a bodily function. This restriction has now been knocked down by the Brazilian Congress, when it refused to allow President Fernando Henrique Cardoso to veto articles of the family planning law.

The new law has not yet gone into effect, and sterilization is still not widely available. However, the Bemfam survey shows that almost 71% of Brazilian women who were sterilized had the procedure in government-operated facilities. How? The majority paid for doctors "off the books" (the third big reason for worry) and took advantage of the occasion of a cesarean operation (fourth reason, but not in order of magnitude).

According to Pinotti, who is also a federal representative, Brazil has a rate of three times more cesareans than necessary. In this type of operation, maternal mortality is three to ten times greater than in natural childbirth. Infant mortality is four to eight times greater. "In other words, women and children are dying because of cesareans. And many of the cesareans that are done without medical indication have the search for sterilization behind them," Pinotti said. The cesarean occurs to allow the tying of the ovarian tubes. According to the Bemfam survey, almost 60% of the women who have been sterilized did so when they had a cesarean. It is also known that in the majority of cases, they had to pay (perhaps $600 or $700) for the sterilization. Cesareans also are a heavy burden on the public coffers. In research that was revealed in December 1996, the Fundação Oswaldo Cruz (Oswaldo Cruz Foundation) verified that the SUS needlessly spent in 1995 between $17.8 million and $83.4 million on this type of surgery.

Doctors, according to Pinotti, are motivated by economic interests, but also by thoughtlessness due to their upbringing. Edna Roland agrees. "Many doctors see their patients as poor, ignorant women, with little autonomy about their bodies and lives," said the president of Fala Preta. According to her, the doctor "withholds the central power in the health care process. Often, the doctors prefer to recommend a procedure that depends on them and not on the woman." There are also vestiges of a controlist mentality: in order to reduce poverty, it is necessary to decrease the number of poor people. The doctor thinks that he or she is doing a good deed. A big lie, according to Edna. "Brazilian women have less and less children, and they are still poor. The solution to poverty is not to reduce the number of children, but to redistribute the country's resources."

But certainly many women and men want to plan and prevent pregnancy and have smaller families—a recent cultural change that has been stimulated by the entry of women in the workplace and accentuated by the difficulty to produce and bring up children (there is a lack of prenatal health care, an insufficient number of daycare centers and schools, lack of support from partners). "The decision must be the woman's or the couple's," said Regina Coeli Viola, of the Brazilian Health Ministry's Coordenação Materno-Infantil (Mother-Child Coordination), along with other specialists. The State should not intervene to stimulate or control fertility. However, it must guarantee a comprehensive healthcare program for women, in which conception and contraception are a constant part. Access to information about contraception, as well as to all existing means of birth control, must also be assured. In this type of program, the objective is not to reduce population growth (although this may be one of the results), but to reduce illnesses and deaths among women and children.

The good news is that this project already exists. It is the bold and ambitious Paism (Programa de Atenção Integral à Saúde da Mulher—Program of Integral Attention to Woman's Health) was established by the Brazilian Ministry of Health in 1986. The bad news is that it has advanced little. In and out of the government, the beckoning path to defeat sterilization abuses is the widespread introduction of Paism. The new law, which allows extensive and judicious access to sterilization, will not change reality by itself. "All of these years, the restriction did not prevent sterilization abuse, and regulation alone will not prevent it," said Regina.

Birth Control in Brazil
In percentage

.............................................All women ...............Women in Relationships

.............................................86.............. 96 ..............86 ................96

Any method .......................43.5 ............55.4 ...........66.8............. 76.7

Female sterilization .............17.2 ............27.3 ...........26.9 .............40.1

Pill .....................................17.0 ............15.8 ...........25.2 .............20.7

Condom............................. 1.1.............. 4.3............. 1.7................ 4.4

Withdrawal......................... 3.2 ..............2.1 .............5.0 ................3.1

Charts and Temperature...... 3.0.............. 2.0 .............4.3 ................3.0

Male sterilization.................. 0.5 .............1.6............. 0.8................. 2.6

Injections............................ 0.4.............. 1.1 .............0.6 .................1.2

IUD ....................................0.7.............. 0.8............ 1.0 ..................1.1

Other (herbs, teas..).............. ..................0.2 ....................................0.3

Diaphragm, foam and tablets 0.1 .............0.1 ..............0.0 .................0.1

In 1986 women between the ages of 15 to 44 were studied

In 1996 women between the ages of 15 to 49 were studied

Sources: PNSMIPF, 1986 and PNDS, 1996

One-way Street

The number of Brazilian women who are being sterilized is growing, more because of misinformation and negligence of public health than because of personal choice

Immaculada Lopez