REPRODUCTIVE HEALTH, UNMET NEEDS AND POVERTY ISSUES OF ACCESS AND QUALITY OF SERVICES REPRODUCTIVE HEALTH, UNMET NEEDS AND POVERTY ISSUES OF ACCESS AND QUALITY OF SERVICES Edited by Susana LERNER and Éric VILQUIN Committee for International Cooperation in National Research in Demography Paris 2005 Chapters in this volume originate from papers presented at an interregional seminar held in Bangkok, 25-30 November, 2002, in collaboration with the College of Population Studies (CPS), Chulalongkorn University The seminar was organized by Susana Lerner who also acted as scientific editor for the present volume with the assistance of CICRED series editor Eric Vilquin The seminar and this publication have been supported by the United Nations Population Fund (UNFPA) Additional English editing and translation by James Walker Cover by Nicole Berthoux (INED) Cover photo: Lourdes Almeida About the photo: the photograph was taken in rural Oaxaca (Mexico) in 1992 in the house of the Velasco-García peasant family, five hours after the birth of the baby being fed by the mother The delivery took place on the same cot with the assistance of the grand-mother also shown on the picture First published in 2005 by CICRED Copyright © 2005 by CICRED CICRED Committee for International Cooperation in National Research in Demography 133, Bd Davout, 75980 Paris Cedex 20 - France Tel: 33 56 06 20 19 Fax: 33 56 06 21 65 E-mail: cicred@cicred.org Web site: www.cicred.org ISBN : 2-910053-22-9 CONTENTS Introduction Critical issues surrounding the relationship between unmet reproductive health needs and poverty Susana LERNER Part I Conceptual and methodological issues ― Performance of alternative approaches for identifying the relatively poor and linkages to reproductive health 39 Attila HANCIOGLU ― Vulnerability towards HIV An exploratory survey of couples in Thailand using the life-event history approach 87 Sophie LE CŒUR, Wassana IM-EM and Éva LELIEVRE Part II Challenges in reproductive health needs ― Rethinking the meaning and scope of women’s “unmet needs”: Theoretical and methodological considerations and uncertainties on empirical evidence in rural Mexico 113 Rosa María CAMARENA and Susana LERNER vi ― Unmet need for contraception among married men in urban Nigeria 201 O F ODUMOSU, A O AJALA, E N NELSON-TWAKOR and S K ALONGE Part III The determinants of reproductive and sexual behavior among adolescents and youth ― Poverty, social vulnerability, and adolescent pregnancy in Mexico: A qualitative analysis 227 Claudio STERN ― Social inequalities and risky sexual behaviours among youth in the Ivorian urban milieu 281 Amoakon ANOH, Édouard TALNAN et N’Guessan KOFFI Part IV Access to and quality of health services ― Why women continue to die from childbirth in Dhaka, Bangladesh 311 Bruce K CALDWELL ― Is it possible to turn the tide for maternal health? Investing in safe motherhood An operational research project in Maputo, Mozambique 343 Johanne SUNDBY, Emmanuel RWAMUSHAIJA and Momade BAY USTA ― Service factors affecting access and choice of contraceptive services in Myanmar 367 THEIN THEIN HTAY and Michelle GARDNER 10 ― Induced abortion in Vietnam: Facts and solutions HOANG Kim Dzung and NGUYEN Quoc Anh 399 vii 11 ― Variations in the utilization of reproductive health 425 services and its determinants: An empirical study in India S SIVA RAJU Part V Policy and ideological implications 12 ― Politics and reproductive health: A dangerous connection 449 Carlos E ARAMBURU 13 ― Gender equity and health policy reform in Latin America: Issues of fairness in access to health care 473 Elsa GOMEZ GOMEZ 14 ― An anti-poverty program and reproductive health needs in Mexico’s indigenous population: Contrasting evaluations 517 Soledad GONZALEZ MONTES 15 ― Reproductive rights of women and men in light of the new legislation on voluntary sterilization in Brazil 549 Elza BERQUÓ and Suzana CAVENAGHI List of other contributions to the seminar 587 576 E BERQUO ― S CAVENAGHI For example, there are no significant differences between whites and blacks on time elapsed between application and surgery This is true for all age groups, educational levels, marital status, per capita income, religion, and number of live births Comparing the three strata of interviewees, there are statistically significant differences in the waiting time for sterilization (Table A in appendix II), although the difference is due to the very distinct behavior of pregnant women in contrast to the others (Graph 1) We can observe that pregnant women have better chances of obtaining sterilization during the entire period of observation Men show higher probabilities of obtaining sterilization than non-pregnant women, although the time elapsed between application and performance of the surgery presents no major (statistically significant) variations over the sixmonth period when comparing the curve for these two groups Graph Probability of obtaining voluntary sterilization at public health facilities (SUS) according to user category (data gathered from a follow-up after approximately six months) 0,60 0,50 Probability 0,40 0,30 0,20 0,10 0,00 30 60 90 120 150 Days elapsed from request Men Women Pregnant Women 180 210 REPRODUCTIVE RIGHTS OF WOMEN AND MEN… 577 There is a probability for all users to obtain sterilization, even during the first month after requesting, but it is greater for pregnant women, whereas during the second month, no non-pregnant women obtained sterilization, although some men and several pregnant women were successful This may illustrate two different aspects of the legislation: one is that the law has not been strictly complied with for all users, some obtaining sterilization very shortly after requesting; secondly it seems apparent that the law does not apply as strictly to pregnant women as it does to men, and to men less strictly than to non-pregnant women Graph Probability of obtaining voluntary sterilization at public health facilities (SUS) during a follow-up of approximately six months, according to type of health facility 0,60 0,50 Probability 0,40 0,30 0,20 0,10 0,00 30 60 90 120 150 180 210 Days elapsed from request Outpatient Outpatient in Hospital Different types of health services showed considerable and significant differences in the waiting period for sterilization (at 99% level of confidence by the Wilcoxon Test and by the Log-Rank Test: Appendix II Table B) Graph shows that users who applied for sterilization at a hospital-related outpatient service had to wait much less time for their 578 E BERQUO ― S CAVENAGHI surgery than those who went to an outpatient clinic not located near a hospital Both types of outpatient clinics sterilized some users before the 60-day waiting period, but this occurred much more frequently at hospital-related outpatient services As was mentioned at the beginning of this paper, the public health system in some cities is still not organized in the reproductive area It is therefore more likely that waiting periods of less than 60 days between application and sterilization occur in such places Another important difference between these two types of service is that, besides waiting much less time than those who go to independent outpatient clinics, individuals who seek sterilization at hospitalrelated outpatient services also have much better chances of success This may result in a great disadvantage to persons living in municipalities where no hospitals are available, meaning the majority of the municipalities in the country Graph Probability of pregnant women obtaining voluntary sterilization at public health facilities (SUS) during a follow-up of approximately six months, according to type of health facility 0,60 0,50 Probability 0,40 0,30 0,20 0,10 0,00 30 60 90 120 150 Days elapsed from request Outpatient Outpatient in Hospital 180 210 REPRODUCTIVE RIGHTS OF WOMEN AND MEN… 579 Finally, a very important difference can be seen in the lengths of waiting period to obtain female and male sterilizations in the two types of health services (Graphs 3, and 5) if we observe each interview strata separately The model for sterilization among non-pregnant women shows a statistically significant difference between the two types of service (at 98% level of confidence by the Wilcoxon Test and 94% by the Log-Rank Test: Appendix II, Table D, Graph 4), whereas male sterilization and sterilization for pregnant women show no such broad differences On one hand, this may be because vasectomy is a simpler medical procedure and need not necessarily be performed in a hospital On the other hand, these results may indicate that distortions in the system still persist where sterilizations are still performed during c-sections, sometimes being an unnecessary surgery Graph Probability of non-pregnant women obtaining voluntary sterilization at public health facilities (SUS) during follow-up of approximately six months, according to type of health facility 0,60 Probability 0,50 0,40 0,30 0,20 0,10 0,00 30 60 90 120 150 Days elapsed from request Outpatient Outpatient in Hospital 180 210 580 E BERQUO ― S CAVENAGHI Graph Probability of men obtaining voluntary sterilization at public health facilities (SUS) during follow-up of approximately six months, by type of health facility 0,60 Probabilit y 0,50 0,40 0,30 0,20 0,10 0,00 30 60 90 120 150 180 210 Days elapsed from request Outpatient Outpatient in Hospital This result indicates once again that there are important genderrelated factors regarding voluntary sterilization that must be taken into account when organizing a health system, if better quality and access are to be provided to users In view of the considerable numbers of respondents who were not using any method at all, when they applied for sterilization, and continue not using while they are waiting for sterilization, it is important to consider how counseling is functioning during the process of getting voluntary sterilization The long waiting period and the low proportion of non-pregnant women who are successful in obtaining sterilization indicates the high risk of undesired pregnancies (as was the case of five women during this study) The almost daily expectation that applicants will be called in for surgery may be a cause for many of them to constantly postpone the option for some other method, thus making them even more vulnerable to pregnancy than the general population REPRODUCTIVE RIGHTS OF WOMEN AND MEN… 581 Final remarks As is clear from the situation described above, prior to Law No 9263, female sterilization appeared as the most common means of contraception, a fact that rated Brazil among the world’s highest users of this method Due to legal restrictions, most of such sterilizations took place on the occasion of a Caesarean section, a fact that consequently contributed to an astonishing growth of Caesarean sections themselves In order to have a tubal ligation performed by the public health system, women were required either to undergo an unnecessary Caesarean section or to have the procedure recorded under another code, such as salpingectomy Since both vasectomy and salpingectomy may be indicated for reasons other than sterilization, there is insufficient information available to indicate what proportion of these cases were used as a means to conceal reality or to get around the legislation in effect The terms of the law resulted from a long and detailed debate between women’s movements and public health organs, especially the Brazilian Health Ministry As a result, the Health Ministry eventually began regulating this procedure and reducing abuses, based on a legitimate perspective of respect for women’s and men’s reproductive rights Like any law, its capillary course down through the public health system to the population in general takes time, and the experience in its implementation may lead to alterations that will bring it more closely in line with the population’s reproductive needs Nonetheless, up to the time of the survey, it was still possible to discern a continuation of the practice of female sterilization during csections at some research sites, clearly showing that this longestablished practice carried out for many years is preventing the correct application of the new legislation on family planning, especially regarding the practice of female sterilization, as the results from the followup with pregnant women have shown Additionally, most of the other criteria provided by the new legislation, especially concerning age, number of children, and counseling, are not being fully complied with for any of the three groups (men, non-pregnant women, and pregnant women) who apply for voluntary sterilization from the public health system 582 E BERQUO ― S CAVENAGHI The well-known data in Brazil concerning the prevalence of tubal ligation and vasectomy are eloquent regarding the role of women, especially those in stable unions, in regulating fertility and having final control over reproduction The most recent data available (PNDS-96) show that only 2.4% of the married men (or those in stable unions) were vasectomized, while 40.3% of the women were sterilized Additionally, the data show that female sterilization was more widely known by the men (87.7%) than vasectomy itself (72.3%) Although less frequent, and illegal as a means for sterilization before 1997, vasectomy was already available as a procedure paid for by SUS since 1992 The simple fact of the existence of the code before 1998 indicates the inconsistency of the health system, which paid for male but not female sterilization before legalization The present study, whose preliminary results are analyzed here, allows one to note that some gender asymmetry still exists The following facts are evidence of this assertion: When the decision for sterilization is made, men’s requests have better chances of being successful, unless the woman is pregnant; Failure by the public health system to strictly comply with the legal minimum 60-day waiting period between application and surgery, as provided in the law, occurs more often for men than for nonpregnant women; More men than women who gave up waiting for sterilization stated that their motive was the fact that their partner or spouse had been sterilized during the period of the study; Among all individuals who were sterilized, more women than men showed concern with safe sex, regarding the prevention of SDT/ AIDS; Controlling for a distortion in the system, where women undergo Caesarean sections in order to obtain sterilization, the fact that a vasectomy can be an outpatient medical procedure performed at health centers results in a shorter waiting period between request and surgery for men than for non-pregnant women, whose tubal ligation must be performed in a hospital Federal Decree No 144, of November 1997, normalized the practice of voluntary female and male sterilization, making it legitimate REPRODUCTIVE RIGHTS OF WOMEN AND MEN… 583 among reproductive rights However, this study clearly shows that both the conservative reaction of health professionals and the typical complex bureaucracy of the Public Health System as a whole are hindering the exercise of women’s and men’s reproductive rights Acknowledgements We gratefully acknowledge the Ford Foundation that has entirely funded this research We are also especially thankful to the researchers and organizations that have coordinated the fieldwork: Osmaildes Lacerda Pedreira of the Brazilian Association of Nurses of Tocantins (ABEn-TO), Maria Betânea Ávila from the nongovernmental organization “SOS Corpo - Gênero e Cidadania” in Recife-PE, Mônica Baramaia of the non-governmental organization “Mulher e Saúde - Centro de Referência de Educaỗóo em Saỳde da Mulher (MUSA) in Belo Horizonte-MG, Olinda Carmo Luiz of the non-governmental organization “Comissão de Cidadania e Reproduỗóo - CCR in Sóo Paulo-SP, Võnia Muniz Nequer Soares of the Brazilian Association of Nurses of Paraná (ABEn-PR) and from the Brazilian Association of Obstetrics and Obstetrical Nurses of Paraná (ABENFO-PR), and Wilza Rocha Pereira from the Brazilian Association of Nurses of Mato Grosso (ABEnMT) References BARROS, F C., J P VAUGHAN, C G VICTORIA and S R A HUTTLY (1991), “Epidemic of Caesarean section in Brazil”, The Lancet, vol 338, p 167-169 BERQUÓ, E (1993), “Brasil, um caso exemplar (anticoncepỗóo e partos cirỳrgicos) espera de uma aỗóo exemplar, Estudos Feministas, vol 1, p 366-381 BRASIL (1997a), Lei ordinária no 9263, de 12 de janeiro de 1996 Regula o parỏgrafo artigo 226 da constituiỗóo federal, que trata planejamento familiar, estabelece penalidades e dá outras providências, Brasília, Diário Oficial da União, August 20, 1997, p 17989, col BRASIL (1997b), Ministério da Saúde/Secretaria de Assistência Sẳde, Decree n 144, November 20, 1997, Brasília, Diário Oficial da União, November 24, 1997, n 227, section I, p 27409 BRASIL (1999), Ministério da Saúde/Secretaria de Assistência Sẳde, Decree n 048, February 11, 1999, Brasília, Diário Oficial da União CAETANO, A J (2000), Sterilization for Votes in the Brazilian Northeast: The Case of Pernambuco, Unpublished Ph D thesis, University of Texas at Austin Código Brasileiro de Deontologia Mộdica (1965), Resoluỗóo CFM N 1.154 de 13/04/84, Diỏrio Oficial da União, January 11, 1965 584 E BERQUO S CAVENAGHI Cúdigo Brasileiro de Deontologia Mộdica (1988), Resoluỗóo CFM N 1.246/88, 08/01/ 1988, Diário Oficial da União, January 26, 1988 Código Penal Brasileiro (1940), Capítulo II, das Lesões Corporais, Artigo 129 DATASUS (1992-2001), Assistência saúde: procedimentos hospitalares por local de internaỗóo (available at http://www.datasus.gov.br, access on March 2000) FANDES, A., and J G CECATTI (1991), A operaỗóo cesárea no Brasil: Incidência, tendências, causas, conseqüências e propostas de aỗóo, Cadernos de Saỳde Pỳblica, vol 7, no 2, p 150-173 FAÚNDES, A., and J G CECATTI (1993), “Which policy for Caesarean sections in Brazil? An analysis of trends and consequences”, Health Policy and Planning, vol 8, p 33-42 HARDY, E., L BAHAMONDES, M J OSIS, R G COSTA and A FAÚNDES (1996), “Risk factors for tubal sterilization Regret, detectable before surgery”, Contraception, vol 54, p 159-162 HOPKINS, K L (1998), Under the Knife: Caesarean Section and Female Sterilization in Brazil, Unpublished Ph D thesis, University of Texas at Austin PNDS (1997), Pesquisa Nacional sobre Demografia e Saúde, BEMFAM (Bem-Estar Familiar no Brasil) and Macro International Inc., Rio de Janeiro SAS INSTITUTE Inc (1999-2000), Statistical Analysis System: The SAS System for Windows, Release 8.01 SOUZA, M R (2001), Uma contribuiỗóo ao debate sobre partos cesáreos: Estudo prospectivo no município de São Paulo, Unpublished Ph D thesis, State University of Campinas VIEIRA, E M., and N J FORD (1996), “Regret after female sterilization among lowincome women in São Paulo, Brazil”, Family Planning Perspectives, vol 22, no 1, p 32-37 REPRODUCTIVE RIGHTS OF WOMEN AND MEN… 585 Appendix I Vetoed parts of the Law No 9263 released on August of 1997 THE PRESIDENT OF THE REPUBLIC I make known that the Federal Congress decrees and I promulgate; Pursuant to Paragraph of Art 66 of the Federal Constitution, the following vetoed parts of Law No 9263, of January 12, 1996: ……………………………………………………… Art 10 ― Voluntary sterilization is allowed only in the following situations: I - Men and women with full civil capacity at of least twenty-five years of age or having at least two living children, following observation of at least sixty days between the manifestation of will and the surgical act, during which period the interested person shall be provided with access to a fertility regulation service, including multidisciplinary group counseling which shall seek to discourage unduly early sterilization; II - Present or future risk to life or health, stated in a written report and signed by two doctors Paragraph - Sterilization may only be performed upon presentation of a signed and authenticated document indicating manifestation of will, after information has been provided regarding the risks of the surgery, possible side effects, difficulty of reversion, and the existing reversible contraception options Paragraph - Surgical sterilization may not be performed during periods of childbirth or abortion, except in cases of proven need, due to previous successive Caesarean sections Paragraph - The manifestation of will referred to in Paragraph will be invalid if expressed during alterations in the capacity for discernment due to consumption of psychoactive substances, altered emotional states, or temporary or permanent mental incapacity Paragraph - Surgical sterilization as a contraceptive method may only be performed through tubal ligation, vasectomy or some other scientifically accepted method Hysterectomy or ooforectomy may not be performed Paragraph - In the case of married couples, sterilization may only be performed with the spouse’s express consent Paragraph - Surgical sterilization of totally disabled persons may only be performed upon judicial authorization, regulated pursuant to law Art 11 – The Central Office of the Unified Health System must be notified of all surgical sterilizations 586 E BERQUO ― S CAVENAGHI Art 12 – There may be no individual or collective induction or instigation to the practice of surgical sterilization Art 13 – There may be no demand for a certificate of sterilization or a pregnancy test, for any purpose Art 14 – It is the duty of the Authorities of the Unified Health System to maintain its level of competence and attributions, and to register, inspect, and control the institutions and services that perform activities and research in the area of family planning Sole Paragraph - Surgical sterilization may only be performed at those institutions that offer the means for reversible contraceptive methods Appendix II Test of equality over strata according to selected variables Test Log rank Wilcoxon -2Log (LR) Log Rank Wilcoxon -2Log (LR) Log rank Wilcoxon -2Log (LR) Log Rank Wilcoxon -2Log (LR) Log rank Wilcoxon -2Log (LR) Chi square DF Pr >Chi square A) By type of interviewees 127,928 0.0017 165,056 0.0003 115,716 0.0031 B) By type of health service 57,072 0.0169 85,430 0.0035 55,318 0.0187 C) Pregnant women by type of health service 13,436 0.2464 18,342 0.1756 12,220 0.269 D) Non-pregnant women by type of health service 3.4131 0.0647 5.8992 0.0151 3.1192 0.0774 E) Men by type of health service 0.8824 0.3476 1.3445 0.2462 0.8938 0.3445 List of other contributions to the seminar Élise Chantal AHOVEY (INSAE, Direction des Études Démographiques, Cotonou, Bénin) – Besoins non satisfaits en planification familiale au sein du couple : déterminants démographiques et cadre de vie au Bénin Irina BADURASHVILI (Georgian Center of Population Research, Tbilisi, Georgia) – Reproductive and sexual health status of the Georgian population Anne BAKILANA (School of Economics, University of Cape Town, Cape Town, South Africa) – Methodological challenges of using male questionnaires from Demographic and Health Surveys Maria de Fatima FERNANDO ZACARIAS (National Institute of Statistics, Maputo, Mozambique) – Reproductive health and sexual behaviour of adolescents and young people in Mozambique Carmen Elisa FLOREZ (Universidad de los Andes, Bogotá, Colombia) and Teresa TONO (Centro de Gestión Hospitalaria, Bogotá, Colombia) – Inequities in health status and use of health services in Colombia: 1990-2000 R S GOYAL (Indian Institute of Health Management Research, Jaipur, India) – Meeting unmet information needs on sexual health and safe sex through dialogue Al-Haj HAMED (Social and Human Development Consultative Group, Sudan) – Fundamentalism and poverty: Implications on reproductive health HOANG Ba Thinh (Center for Gender, Family and Environment in Development, Vietnam) – Problèmes de santé génésique des populations vivant sur des embarcations au Viêt-nam 588 Roger INGHAM (Centre for Sexual Health, London, UK) – Dynamic contextual analysis: An approach to mapping and improving understanding of issues relating to young people’s sexual and reproductive health in poorer country settings Chengye JI (Institute of Child and Adolescent Health, Peking University Health Sciences Center, Beijing, China) – Reproductive health education for floating adolescents: Unmet needs of poverty and corresponding strategies, measures and social supports Abdellatif LAFARAKH (CERED, Rabat, Morocco) – Préférences, comportements et besoins non satisfaits en matière de planification familiale Elsa LÓPEZ and Liliana FINDLING (Instituto de Investigaciones Gino Germani, Facultad de Ciencias Sociales, Universidad de Buenos Aires, Buenos Aires, Argentina) – Women, reproductive health and prevention: Individual practices and public actions Arup MAHARATNA (Gokhale Institute of Politics and Economics, Pune, India) – On seasonal migration and family planning acceptance: A tale of tribal and low cast groups in rural West Bengal, India Nancy MOSS (Center for AIDS Prevention Studies, University of California, USA) and Jason SMITH (Family Health International, Research Triangle Park, USA) – Beyond numbers: Giving the poor and marginalized a voice in reproductive health services - a benefit for all Ali MTIRAOUI (Department of Community Medicine, Faculty of Medicine, Sousse, Tunisia) and Nébila GUEDDANA (ONFP, Board of the Family and Population, Tunis, Tunisia) – Promotion de la santé de la reproduction en milieu rural et dans les zones d’ombre Kourtoum NACRO (UNFPA, New York, USA) – Population, reproductive health, gender and poverty reduction: A conceptual framework Amara SOONTHORNDHADA (Institute for Population and Social Research, Mahidol University, Bangkok, Thailand) – Unmet needs related to risk perception among young commercial sex workers Irene M TAZI-PREVE (Austrian Academy of Science, Vienna Institute of Demography, Vienna, Austria, and Federal Institute of Population Research, Wiesbaden, Germany) – Abortion in Europe Factors influencing women and their behaviour patterns in case of unintended pregnancies 589 Malinee WONGSITH (College of Population Studies, University of Chulalongkorn, Bangkok, Thailand) – Reproductive health behavior and quality of care among Thai women Zelda C ZABLAN (Population Institute, University of the Philippines, Quezon City, Philippines) – Improving the quality of care in FP/RH services in the context of an integrated FP/MCH program .. .REPRODUCTIVE HEALTH, UNMET NEEDS AND POVERTY ISSUES OF ACCESS AND QUALITY OF SERVICES REPRODUCTIVE HEALTH, UNMET NEEDS AND POVERTY ISSUES OF ACCESS AND QUALITY OF SERVICES... between poverty and reproductive health, by focussing on and identifying the barriers that constrain and prevent vulnerable groups from fully meeting their reproductive and sexual needs, in particular... LELIEVRE Part II Challenges in reproductive health needs ― Rethinking the meaning and scope of women’s ? ?unmet needs? ??: Theoretical and methodological considerations and uncertainties on empirical