Contraceptive Method Use
Determinants of Demand and
Economic Impact in Brazil
Josephine Borghi
London School of Hygiene & Tropical Medicine
Overview
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Contraceptive demand – global perspective
Contraceptive demand in Brazil
Economics of contraceptive demand
Research aim and objectives
Setting
Methods
Contraceptive demand and global
priorities
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ICPD, 1994: universal access to sexual and
reproductive health by 2015
120 m couples unmet need
80 m unwanted pregnancies
19 m unsafe abortions – 30% of maternal
deaths
Percent coverage
Contraceptive Coverage –
Regional Patterns
100
90
80
70
60
50
40
30
20
10
0
Traditional method
Other Modern method
Condom
Pill
Female sterilization
Europe
North
America
Africa
Asia
Latin
America &
Carribean
Regions
Source: UN (2005) World Contraceptive Use - 2005
Annual Incidence of Abortion per
100 Live Births WHO (2000 data)
Contraceptive Use - Brazil
•High level of contraceptive prevalence (77%)
Female sterilization
Pill
24%
40%
6%
5%
Condom
Other Modern method
21%
4%
Source: Last DHS (1996)
Traditional method
None
Female Sterilization in Brazil
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Rationale
 Method security
 Convenience
 Limited access to alternative methods
 Limited provider knowledge of alternatives
 Avoid costs of childbearing / contraceptives
Illegal pre-1996 unless for health reasons
Sterilization and c-section
 60-80% carried out during c-section (Berquo, 1993)
Cost
 61% had to pay for the service (Vieria, 1994)
Regret
 Average age 28 years
 Limited counselling
Abortion in Brazil
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Legality
Frequency
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2 abortions per year per 100 women of RA
Health system impact
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1.7% of hospital admissions due to unsafe
abortion
Economics of contraceptive
demand: what is known?
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Qualitative assessment of barriers to access
Analysis of contraceptive demand based on
observed behaviour – Africa and Asia
User knowledge and use patterns (KAP)
The costs of providing family planning services
Knowledge Gaps
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Preferences between temporary and
permanent methods
Impact of product characteristics and supply
context on demand
Limitations of revealed preferences
Provider incentives
User costs
Macro impact
Research Question
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What are:
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The determinants of contraceptive preferences product characteristics and supply side factors;
and
The economic impact of current patterns of
contraceptive use in Brazil and impact of possible
changes?
Key Questions
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How do individuals make choices about
contraceptive methods?
What motivates providers to deliver
contraceptives, and how do they stand to
benefit?
How do current patterns of contraceptive use
impact the economy of the household, the
health system and the country as a whole?
Setting - Bahia
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4th most populous state
62% mixed race
23% illiteracy (12% national
average)
45 per 1000 IMR (35 per
100 national average)
41% below poverty line
Northeast region 62%
contraceptive prevalence
Study Sites - Background
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Salvador
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Pau de Lima
 48,641 inhabitants
 45% earn less than $90
per month
 Fiocruz cohort study
Barra district
Monte Santo
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Illiteracy 40%
Largely rural
IMR 61 per 1000
Study Methods - Overview
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Literature Review
Discrete choice survey
Household cost survey
Provider survey
Macro-economic model
Literature Review
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Demand, preferences, access to
contraceptives in low and middle income
countries
Economic or non-health effects of
contraceptive use
Discrete Choice Survey
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Aims
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Measure preferences for contraceptives
Measure key attributes of value
Methods
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Focus groups and piloting
Stratified sample 1500 women (un-sterilized) (urban
and rural; high and low income)
Sub sample of 150 husbands
Scenarios
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Contraceptive choices
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Possible characteristics
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Condom, IUD, pill, sterilization, abortion; current method
Price, duration of protection, distance to access, place of
delivery, efficacy, mode of administration, time of
administration, risks; provider knowledge
Possible levels
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Mode of administration
 Manual; operative;
Duration of protection
 Per sex act; per trimester; permanent.
Place of delivery
 Hospital; health centre; drug store
Time of administration
 Before conception; after conception
Household Costs of Abortion
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Aims
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Estimate the household costs of abortion and
treatment of complications
Have these displaced other expenditures?
Methods
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Purposive sample of 150 women after treatment
from post abortion (surgical or medical)
complications, urban, rural
Identified from hospital records (public and private)
Household Costs of
Sterilization
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Aims
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Estimate the household costs of tubal ligation
Have these costs displaced other expenditures?
Relationship, if any, to c-section?
Methods
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Purposive sample of 150 women, urban, rural
Hospital records
Provider Survey
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Aims
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Estimate costs of treating abortion complications
Estimate costs of tubal ligation
Assess provider incentives for offering different
contraceptives
Methods
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Survey of 2 public and 2 private hospitals in
Salvador and Monte Santo (recurrent costs)
Purposive sample of health care providers from
obstetrics wards
Macro-economic model
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CGE model
Simple, closed economy, static competitive
equilibrium
Selected sectors of Brazilian economy
Data sources
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CEBRAP 2007 DHS
SUS info on incidence of abortion complications in
hospitals
IGS input-output data – 2000
Household & provider survey data
Macro-economic effects
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Unsafe abortion
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Tubal ligation
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Labour supply, productivity
Consumption effects (households and providers)
Costs to health system
Financial benefits to health workers
Fertility; HIV –AIDS, STI impact
C-section rate
Financial benefits to health workers
Consumption effects
Temporary methods
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Lower levels of fertility
Increased revenue of pharmaceutical companies
Risks
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Unsure what proportion of abortions are
medical (could be high, meaning low no.
of hospitalized cases for complications)
Sterilization rate may have fallen
Maybe limited to no user costs of
abortion or tubal ligatio
Sensitivity – obtaining accurate
information
Sample selection issues
Finding respondents (timing)