The Strange Tale of Female Sterilization in Brazil

Tubal ligation, a form of female sterilization, has long been one of Brazil's most popular forms of birth control--despite the fact that it was illegal until 1996. Known as laqueadura tubária in Portuguese, or "tying the tubes," the procedure was often done in conjunction with a cesarean section, allowing doctors to covertly provide the operation after a legal one. Perhaps as a consequence, Brazil now has one of the highest rates of C-sections in the world, even after sterilizations were legalized. But the law didn't necessarily make sterilization access easier. The law requires spousal consent, which can limit access for single women or those whose husbands refuse to allow the surgery. The law also forbids sterilization right after a woman gives birth. One study found that private doctors have tended to ignore this rule, but public doctors sometimes adhere to it--which can limit access to this form of birth control for poorer women.

Passed in 1996, Brazil's family planning law legalized both male and female sterilization, which was permitted for any "man or woman with full citizen’s rights and older than 25 years of age, or who has at least two living children, such that s/he observe at minimum a 60-day period between the request and surgery, in which the person must have access to fertility regulation services, including counseling by a
multidisciplinary team, in order to discourage premature sterilization."

But the law also states that a patient must seek consent from his or her spouse in order to have surgery. In practice, this sometimes means women can be denied sterilization surgery if they are unmarried or dont have permission from their husbands. Men, meanwhile, are unlikely to be asked for permission from their spouses to undergo a vasectomy. A bill is under consideration in Congress to remove the consent requirement from the law. "In my opinion, the body of another person is viewed in the family planning law as if it was a good, like a car for sale. It's a distortion. Sexual and reproductive rights belong to each person," the bill's author, Congressman Paulo Rubem Santiago, said in June.

Until 1996, female sterilization was illegal, outlawed by article 16 of decree 20931 of 1931 and by article 129, paragraph 2.III of the Brazilian Penal Code of 1940. Punishment ranged from two to eight years in prison for doctors who carried out the surgery. Despite being banned, the practice was widespread throughout the country, even in public hospitals. By the early 1990s, female sterilization was the most common form of birth control in Brazil, due in part to limited access to other types of contraceptives. Less affluent women also often lacked family planning knowledge and access to such information. In 1996, 40 percent of Brazilian women (married or in unions) aged 15 to 49 had sterilization surgery; of those women, 57 percent had the procedure before the age of 30 and 34 percent had only one or two children. In poorer parts of the country, sterilization rates were higher. In 1994, an estimated 76 percent of women of reproductive age in Maranhão had undergone the surgery, along with 72 percent in Goiás and 60 percent in Pernambuco.

Because tubal ligation was illegal, doctors often performed the procedure following cesarean section surgeries. A 1996 survey found that 59 percent of tubal ligations took place in conjunction with C-sections--many of which were performed only to conduct the sterilization. A 1991 estimate put it even higher, at 75 percent of all tubal ligations performed with C-sections. By performing the two surgeries together, the doctors were able to perform the banned surgery following a legal one, and also charged double. Meanwhile, patients footed the bill for the sterilization. C-sections are still popular in Brazil--today, around 50 percent of all pregnancies are delivered using a cesarean, and 82 percent of women with private insurance get C-sections. Some speculate that Brazil's history of sterilizations performed with C-sections is the reason the country has one of the highest rates of cesareans in the world.

Tubal ligation is controversial in part because of its political uses. Despite being illegal, some state governments promoted the practice in the 1990s, offering the surgery for free. In 1991, Congress launched an investigation of "mass sterilizations," also looking to see if black women were sterilized at higher rates. (It found there wasn't discrimination, but a need to regulate the practice.) Local politicians throughout Brazilian sometimes offer to pay for sterilizations in exchange for votes. "We have a culture of sterilization in Brazil. It's nationwide. A lot of politicians are elected because of their sterilization promises," said Jurema Werneck, executive director of women's health organization Criola told the Washington Post in 2004. In the past, some employers even required women to provide proof they had been sterilized in order to get a job, as they did not want to offer maternity leave.

With the passage of the law in 1996, the number of tubal ligations remained high. A 2001 survey found that nearly 1 in 2 Brazilian women had been sterilized. However, the law outlawed women from having postpartum sterilization surgery in an attempt to reduce unnecessary C-sections. One study in 2003, however, found that private doctors were ignoring this part of the law and still performing sterilizations with C-sections. Public hospital doctors, meanwhile, were less likely to give postpartum tubal ligations. In other words, poorer patients--the ones less likely to have access to other forms of birth control--had less access to sterilizaton.

Photo: Governo da Bahia