Elza Berquó

Unwanted caesarean sections among public and private patients in Brazil: prospective study

Abstract Objective: To assess and compare the preferences of pregnant women in the public and private sector regarding delivery in Brazil. Design: Face to face structured interviews with women who were interviewed early in pregnancy, about one month before the due date, and about one month post partum. Setting: Four cities in Brazil. Participants: 1612 pregnant women: 1093 public patients and 519 private patients. Main outcome measures: Rates of delivery by caesarean section in public and private institutions; womens preferences for delivery; timing of decision to perform caesarean section. Results: 1136 women completed all three interviews; 476 women were lost to follow up (376 public patients and 100 private patients). Despite large differences in the rates of caesarean section in the two sectors (222/717 (31%) among public patients and 302/419 (72%) among private patients) there were no significant differences in preferences between the two groups. In both antenatal interviews, 70-80% in both sectors said they would prefer to deliver vaginally. In a large proportion of cases (237/502) caesarean delivery was decided on before admission: 48/207 (23%) in women in the public sector and 189/295 (64%) in women in the private sector. Conclusions: The large difference in the rates of caesarean sections in women in the public and private sectors is due to more unwanted caesarean sections among private patients rather than to a difference in preferences for delivery. High or rising rates of caesarean sections do not necessarily reflect demand for surgical delivery. What is already known on this topic In Brazil, one quarter of all women deliver in the private sector The rate of caesarean deliveries in the private sector is extremely high (70%) and more than twice that in the public sector, where rates have recently fallen due to a new policy Previous studies in which women were interviewed after birth showed that a substantial proportion of private patients who have caesarean sections would have preferred normal delivery What this study adds In two antenatal interviews, preferences regarding type of delivery were nearly identical among public and private patients and strongly favoured vaginal births Contrary to popular belief, middle and upper class women in Brazil do not want to deliver by caesarean section

Reproductive rights of women and men in light of new legislation on voluntary sterilization in Brazil

O objetivo deste trabalho e analisar os impactos e as possiveis mudancas que a implementacao da nova legislacao sobre planejamento familiar teve nas praticas reprodutivas, especialmente na esterilizacao voluntaria, e observar se os diretos reprodutivos de mulheres e homens tem sido satisfeitos. A abordagem metodologica e baseada em uma pesquisa follow-up, aplicada a uma amostra de 159 individuos durante seis meses e em seis diferentes capitais de estado. Alem de verificar se os criterios estabelecidos na lei estavam sendo seguidos pelo setor publico de saude, nos analisamos o tempo de espera entre a solicitacao pela esterilizacao e a realizacao da cirurgia, utilizando analise de sobrevivencia. Adicionalmente, foram realizadas entrevistas com profissionais de saude, as quais sao muito elucidativas dos procedimentos adotados na pratica da esterilizacao. Os resultados mostram que, por diferentes motivos, a lei mudou pouco a pratica usual da esterilizacao e ainda nao satisfaz os direitos reprodutivos de mulheres e homens no Brasil.This paper aims to analyze the impacts and possible changes that the implementation of a new Brazilian family planning law has on reproductive practices, especially voluntary sterilization, and to determine whether mens and womens reproductive rights are being respected. The methodological approach is based on a six-month follow-up survey taken monthly, applied to a sample of 159 individuals in six contextually different State capitals. Besides verifying whether the health sector is complying with the criteria set by the law, we analyze the waiting time between the request for sterilization and the surgery itself, utilizing survival analysis. We also conduct interviews with health professionals, shedding light on the procedures adopted in the practice of sterilization. For various reasons, the law has produced little change in the usual practice of sterilization, besides failing to satisfy individual reproductive rights.

Frustrated demand for postpartum female sterilization in Brazil

During the last three decades, Brazilians have relied almost exclusively on two contraceptive methods, the pill and female sterilization, with sterilization use increasing over time. Until a new law was passed in 1997, sterilization was virtually illegal and not covered by either public or private health insurance. It was, however, frequently provided in public and private hospitals in conjunction with a cesarean section. The new law regulating sterilization provided for reimbursement for interval sterilizations by public health insurance, but placed restrictions on availability intended to reduce the use of cesareans. These restrictions included the prohibition of postpartum sterilizations. This paper focuses on womens sterilization intentions during pregnancy and their experiences postpartum. In a prospective study of 1612 pregnant women carried out in four Brazilian cities, there was substantial demand for postpartum sterilization in both the private and public sectors among women who wanted no more children. However, public patients were much less likely to be sterilized than private patients. Thus, the new law may not have reduced inequities in access or, paradoxically, the incentive for unnecessary cesarean sections.

Notes on the female condom: experiences in Brazil

A nationwide effort to introduce the female condom (FC) into public health services was undertaken in Brazil in 1998–99. To this end, the Ministry of Health sponsored a national research group of public health professionals, aided by local field workers and supervisors, to conduct a preparatory study at 20 sites in six cities. Clinic health workers were trained to conduct the study. Following an educational session, 2382 women volunteered to use the FC and to report their experiences at follow-up. Among those seen at 15 days, 1782 had used the FC at least once; among those seen at the 90-day follow-up, 1453 women had used it at least once, while 1296 of them liked it and wished to continue its use. Among these 1296 women, barrier use at last intercourse (either with a male or a female condom) was more than double at 90 days what it had been at baseline: 70% compared with 33%. Clinics providing active health-education activities achieved higher rates of follow-up and of FC acceptability. These findings suggest that in Brazil, the introduction of the FC at public health centres could lead to high initial adoption rates and that continued use would be effective in encouraging safer sex. The level of health education and type of clinic are likely to influence the effectiveness of a future programme.

Fecundidade em declínio: breve nota sobre a redução no número médio de filhos por mulher no Brasil

This article analyses data concerning fecundity in Brazil presented in PNAD 2004, which sustained reduction in birth rates. It suggests that, in years to come, diminutions could come out mainly among the poorest, responsible for a significative reduction in the average number of children per woman.

Gênero, sexualidade e saúde reprodutiva: a constituição de um novo campo na Saúde Coletiva

During the 1980s the historical political and cultural conditions were created for establishing a new thematic field in Public Health. The previously prevailing perspective was maternal and child health in which women were studied but where the real focus was on childrens health with an emphasis on biological theories for the explanation of phenomena. Differences between sex although present in most of the studies tended to be considered as natural and social inequalities were interpreted exclusively in terms of the class dimension. With the emergence of womens studies and subsequently gender studies there was a new focus on social relations based on perceived differences between the sexes thus helping expand the understanding of the health-disease-health care process. The sharp drop in fertility encouraged new studies on reproduction incorporating socio-cultural theories into the understanding of its relations to health. The emergence of AIDS challenged the traditional epidemiological focus on infectious diseases requiring interdisciplinary approaches and conferring legitimacy to studies on sexuality and the socio-anthropological interpretation of the phenomenon. (excerpt)

Notas sobre os diferenciais educacionais e econômicos da fecundidade no Brasil

No Brasil, assim como em outros paises, com a fecundidade em transicao ou quase em seu final, a educacao e o rendimento se apresentam negativamente correlacionados com o nivel da fecundidade. Com a queda desta ultima, apesar de certa tendencia de convergencia nas taxas entre os grupos socioeconomicos, observa-se que a fecundidade ainda mantem um diferencial bastante elevado entre as mulheres pertencentes as categorias extremas destes grupos populacionais. Assim, apesar de a taxa de fecundidade de periodo (TFT) ter alcancado nivel abaixo da reposicao entre 2000 e 2010, chegando de fato a 1,9 filho por mulher em media, em 2010, conforme dados do Censo Demografico, nao e surpreendente encontrar variacoes importantes em torno dessa media nacional, diante da diversidade de comportamentos e diferencas no acesso aos meios contraceptivos e de interrupcao da gravidez. Em trabalhos anteriores, Berquo e Cavenaghi (2004; 2005) buscaram quantificar, localizar e qualificar os grupos que ja se encontravam com fecundidade abaixo do nivel de reposicao e aqueles que ainda estavam com taxas de fecundidade elevadas, no periodo de 1991 a 2000. Para atualizar estas informacoes e entender as tendencias recentes dos diferenciais de fecundidade no Brasil, as autoras desenvolvem o projeto Mapeamento socioeconomico e demografico dos regimes de fecundidade no Brasil em 2010,

Sobre o sistema internacional de pesquisas em demografia e saúde reprodutiva

A elevacao das taxas de crescimento dapopulacao mundial, em particular nos pa-ises em desenvolvimento, provocada pelodeclinio da mortalidade e estabilidade dosniveis de fecundidade, ganhou grande vi-sibilidade a partir da decada de 1960.Tratava-se do inicio, nas regioes menosdesenvolvidas, da chamada transicaodemografica, a qual, segundo a experien-cia historica dos paises ricos, estaria com-pletada com o descenso das taxas defecundidade, o que frearia o ritmo do cres-cimento da populacao.Instalava-se assim, em especial nospaises do norte, a preocupacao, em certoscasos alarmista, com a famigerada “explo-sao demografica” e com a necessidade demedidas de controle da natalidade.Tratava-se, por outro lado, de um peri-odo caracterizado por grande carencia deinformacoes confiaveis sobre taxas brutasde natalidade e especificas por idade damae. O sub-registro de nascimentos esta-va presente em aproximadamente 66% dapopulacao mundial, enquanto nas regioesmais desenvolvidas registros confiaveiscorrespondiam a 100% das ocorrencias

A Abep no contexto político e no desenvolvimento da demografia nas décadas de 1960 e 1970

This article analyzes the context of the founding of ABEP in 1976 and the historical period during which this occurred, specifically, from the mid-1960s to the late 1970s, including the organization’s first national convention, held in 1978. To construct this context, the authors discuss several aspects of the debate that was going on in Brazil regarding the question of demographic growth, with emphasis on the political discussion occurring in the Brazilian Congress as of the second half of the 1960s. The authors also present a history of the emergence of technical and academic institutions that dealt with the field of Demography in Brazil at that time. The underlying objective of the article is to seek a clearer understanding of how an association based on stimulus and resources from abroad – in an international environment with great concern over demographic growth - and operating under an authoritarian military regime (although this latter was beginning to open up during the period studied) resulted in a broad and pluralistic organization of Demography in terms of the approaches used and the themes treated