The Persistence of Outmoded Contraceptive Regimes: The Cases of Mexico and Brazil

Citation: Potter, Joseph E. The Persistence of Outmoded Contraceptive Regimes: The Cases of Mexico and Brazil.
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Tagged: uw-madison (RSS), wisconsin (RSS), sociology (RSS), demography (RSS), prelim (RSS), qual (RSS), WisconsinDemographyPrelimAugust2009 (RSS)

Summary

Much of the literature on fertility decline has focused on the importance of interpersonal exchange through social networks. Potter argues that there is ample reason to explore the problems as well as the opportunities that networks and diffusion pose and to consider the role of the providers of contraceptive services both as brokers of information between users and as agents who control or at least influence the choice of reproductive technologies. Using the experiences of Mexico and Brazil, he illustrates ways in which contraceptive regimes that evolved in one set of circumstances can persist long after they no longer male sense. Potter emphasizes that in many cases professionals such as doctors and other health care workers are responsible for distributing information and methods of birth control to a population. These professionals often have their own preferences for certain methods that they then transfer to the rest of the population. Prescribing common methods also works to protect the doctors from malpractice suits. Family planning programs must therefore convert not only the population at large, but those who distribute contraception itself. In the 1970s the Mexican government made a concerted effort to promote family planning in the rural areas of the country. To motivate the doctors, nurses, community health workers, and parteras, to recruit new acceptors of hormonal methods, the IUD, and female sterilization, the administrators assigned monthly targets for new acceptors, where the highest priority was assigned to the IUD and female sterilization. According to most doctors, people's fear of the new methods was the greatest obstacle rather than a lack of motivation to control fertility. Administration of the program was centralized and the family planning workers attended many conferences together and had many visits from program supervisors, leading most workers to provide fairly uniform answers to questions about contraception. They believed that IUD and sterilization were suitable postpartum methods and agreed on the number of children that women should have and the ideal spacing between births. This fostered an interventionist style approach, in which women who had given birth were convinced to undergo sterilization or receive an IUD while still in the hospital. Changes in government led to a decentralization of family planning initiatives and a changing focus toward greater autonomy and a wider array of family planning services. By 1995, fertility had also decline by nearly 2 children per woman and contraceptive prevalence among married women was 53%. The high rate of IUD and sterilization has become a concern, because they are generally limited to women at higher parities. Access to both methods is also a problem, because they generally occur after delivery in a hospital, but many women do not deliver in hospitals. Despite these concerns, the practices of doctors have not changed. Many doctors are not aware of the changes and those that are aware continue to view contraception in an interventionist manner. Therefore, despite the effectiveness and availability of other methods, sterilization and IUDs continue to be the most common methods. In Brazil, the pill and female sterilization are the most common methods of birth control. Under the military government after 1964 Brazil experienced a transformation of medicine and public health policy toward specialized hospital-based curative care, most of which was covered by the social security system. Pills began to be manufactured in Brazil in the 1960s and became enormously popular. However, Brazilian women saw the pill as unsatisfactory for long-term use. Sterilization was virtually illegal and was not covered by social security. However, cesarean sections were covered by social security and in fact the reimbursement to physicians was higher than that for a vaginal delivery. Therefore, doctors would perform a cesarean section and at the same time a tubal ligation. This was a mutually reinforcing occurrence because having a cesarean section weakened the uterus, making later pregnancies more difficult and dangerous. It also led to a substantial increase in the number of unnecessary cesarean deliveries, with the consequent increase in maternal morbidity. Between 1980 and the mid-1990s, the gradual advent of democratic elections for municipal, state, and federal government ended military rule. Beginning in the late-1970s the reimbursement schedule for deliveries was changed so that reimbursement was the same for cesarean and vaginal deliveries. In August 1997, the Brazilian government passed legislation legalizing and regulating sterilization in public hospitals. Public hospitals were under pressure from the government to cut costs by reducing the number of unnecessary surgical interventions. This has reduced the number of cesarean sections performed in public hospitals. However, private hospitals continue to perform a large number of cesarean/sterilization procedures. The period in the 1960s and 70s has apparently fostered a "culture" of sterilization and cesarean deliveries. The medical community itself avers that Brazilian doctors are more skilled in performing cesarean deliveries than American doctors and have pioneered the "bikini cut" that leaves lower and smaller scars. Medical schools and associations have also created a permissive environment for the use of cesareans.