Sterilisation is the most desired method of contraception worldwide. In 1996, the Brazilian Congress approved a family planning law that legitimised female and male sterilisation, but forbade sterilisation during childbirth. As a result of this law, procedures currently occur in a clandestine nature upon payment. Despite the law, sterilisations continue to be performed during caesarean sections. The permanence of the method is an important consideration; therefore, information about other methods must be made available. Tubal sterilisation must not be the only choice. We argue that review of this restriction will not contribute to the increase in caesarean sections but will allow for greater sterilisation choice for men and women.
- Availability of Contraceptives to Minors
- Behaviour Modification
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Tubal sterilisation, officially a legal contraceptive method in Brazil since 1997, is widely used in many countries. Worldwide, more people use sterilisation than any other method of contraception; therefore it is the most desired method of contraception and is proven effective and safe.1
Family planning in Brazil became a legitimate right guaranteed by the Brazilian constitution in 1988. The legislation included established guidelines highlighting a couple's freedom to choose and the State's responsibility to provide educational and scientific resources for the exercise of this right and restricted the link between family planning and population control policies. Law no. 9,263, which regulates family planning, represents the standardisation of surgical sterilisation.2
For many years, sterilisation has been practiced in Brazil in presumed clandestine settings. This context of illegality contributed to the occurrence of various distortions in the practice of sterilisation, such as the performance of caesarean sections, coverage of additional charges and very young women with few children having tubal sterilisation.3
According to the National Survey in Demography and Health (1996), tubal sterilisation was identified as the most commonly used contraceptive method: 40.1% of women 15–49 years of age were sterilised. Sterilisation was practiced mainly through the public sector (70.9%), even without legal support, and the most common age was 25–34 years (64.5%). A total of 21% of women were sterilised before 25 years of age. These indexes placed Brazil as the country with the highest prevalence of female sterilisation and the greatest use of contraception in the third world.4 The contraception pattern, with the high prevalence of this method in Brazil, reflected the lack of guaranteed access to alternative contraceptive methods.
By the late 1970s, Brazil was going through a time of political democratic opening. Governmental decisions about women's health in the 1980s took place in an environment of democratic political transition, increased feminist movement influence, and the health sector linked to public health and preventive medicine.5
With the end of the ‘Economic Miracle’ in the 1980s came a marked impairment in public health investments. The population gave clear signs that the much-discussed demographic explosion would not happen.6
In 1996, the Brazilian Congress approved a family planning law that legitimised female and male sterilisation as a reproductive right, thereby legalising and regulating its practice.7 The law (no. 9,263) arises in the context in which the access to information and health services was the aim, representing a citizenship transformation project. Family planning was perceived as an individual choice rather than a birth control strategy.
Surgical sterilisation is covered by Article 10.
Article 10: Voluntary sterilization is permitted in the following situations:
I—In men and women with full civil capacity and over twenty-five years of age, or at least two living children, who have complied with the minimum period of sixty days from the request and the surgery, during which time the person concerned will be afforded access to fertility regulation services, including counseling by a multidisciplinary team, to discourage early sterilization.8
II—Risk to life or health of the woman or the fetus future, witnessed in report writing and signed by two doctors.8
The large restriction of this law is in paragraph 2:
§ 2 Surgical sterilization is forbidden in women during periods of childbirth or abortion, except in cases of proven need, by successive previous cesareans.8
According to the National Survey on Demography and Health 1996 (before the law no. 9,263), 73.9% of sterilisations were performed during labour.4
Arguments against restricting tubal sterilisation
National policies related to sterilisation differ in Latin America. Many countries have specific sterilisation regulations that are usually related to age or number of children, while other countries combine parity and age requirements. In Argentina, Guyana and Bolivia, the legal situation is unclear. Peru is known for its liberal legislation. Many countries such as Brazil, Chile and Ecuador require spousal consent for voluntary sterilisation.9 To our knowledge, no other country has a specific limiting sterilisation during childbirth.
Brazilian law provided only two criteria for performing tubal sterilisation during pregnancy: risk to the life or health of the mother or fetus and the completion of two successive caesareans. The apparent rationale of the law is to avoid an increase in the number of caesarean sections.
The first argument against this restriction is the fact that it is not effective. Tubal sterilisation is still performed during caesarean sections in Brazil. The difficulties imposed by the law do not mean that fewer women will choose sterilisation during pregnancy because most sterilised women choose to undergo the procedure during delivery and then pay for it separately.
Fernandes et al10 interviewed 335 sterilised women and noted that of the intrapartum procedures performed, 76% occurred during caesarean delivery. This fact plays an important link with female sterilisation performed during delivery in Brazil, where the public hospitalisation sector has been largely used; even so, there is the payment procedure. Although the sample comprised women who attended public hospitals and had characteristically low education levels, few reported economic factors justified the sterilisation choice. Satisfaction with the number of children was cited most often.
The second argument is that it is not necessary to perform a caesarean section to perform sterilisation procedure because the current techniques allow the dissociation between sterilisation and caesarean sections. If the aim is to avoid increasing caesarean sections, sterilisation by other techniques need not be restricted.
The third argument is that many caesareans are already performed in Brazil and changing the law to allow tubal sterilisation during childbirth will not further increase the number of caesareans being performed. Brazil is already known as ‘the world champion of caesareans’.11 Women in Brazil are choosing to undergo sterilisation during caesarean sections and, in most cases, pay for it separately.
According to Fernandes et al,10 the consequence of prohibiting postpartum tubal sterilisation may be increases in the number of caesareans that involve the performance of sterilisations that are not recorded in patients’ medical records.
The fourth argument is that outside that period, people interested in the procedure fail to access it. Because this access is not provided, the choice is not respected and couples seek alternative ways to sterilisation. Despite the law, tubal sterilisation although legal is not really available. According to Berquó et al12 in an unsupported health system, women take advantage of any opportunity where they are already using it. Childbirth and abortion procedures are conditions in which women are already enrolled for health services. By not allowing surgical sterilisation during these periods, the law creates an obstacle to rather than an expansion of access.
There are several difficulties to meeting the demand for surgical sterilisation in Brazil, including a lack of infrastructure and problems to enable the delivery of services to the people of reference.3 The law cannot extend the right of Brazilian women regarding the definitive methods.
Describing the perceptions of public health services managers and professionals concerning the provision of voluntary surgical sterilisation in the Campinas metropolitan area, Osis et al13 observed that people criticised that the impediment was established by the family planning law to perform sterilisation during delivery when a woman does not have multiple prior caesareans. In the interviewees’ opinion, this stipulation penalises women who have only vaginal deliveries. Moreover, this situation sometimes resulted in another pregnancy in women waiting to be able to undergo tubal sterilisation.13
The last argument is the issue of regret. Although sterilisation is intended to be permanent, expression of regret and requests for reversal are not uncommon, and this is an issue that causes concern. Regret is difficult to measure because feelings can change over time.7
Expanding the availability of tubal sterilisation would possibly result in more regret. Many problems involve choices between uncertain alternatives. Every day we are faced with decisions, some which have the potential to change our lives. Health services have the task of enabling people to make such choices. As such, counselling is essential. Information about alternatives must be given and tubal sterilisation cannot be the only choice.
Because autonomy and dignity are recognised as constitutional principles (in Articles 1 and 5) and the two are achieved through laws, the family planning law should be revised.2 Article 13 of the Brazilian Civil Code restricts corporal autonomy, allowing only those acts that do not cause decreased physical integrity.14 The fact that voluntary sterilisation is permitted by the Brazilian Constitution indicates that this procedure is not considered a constraint to this integrity and that pregnancy does not change this interpretation.
Pregnant women should be able to choose sterilisation in the same way as non-pregnant women. This does not mean an increase in caesarean sections rates; rather, it means increased access. There is no justification for denying individuals fertility control methods, nor is there justification not to honour women's reproductive choices.
Forbidding sterilisation during the delivery period appears to create an access barrier, thus making the law only an intention but not a true right. Revision of this restriction will arguably not contribute to increase caesarean rates but will increase the choice available to couples.
Contributors LCS played a role in linking the law with the historical context and bibliographical research. JLAB played an important role in the research of laws.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed