Contraceptive Method Use
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Transcript of Contraceptive Method Use
Contraceptive Method Use
Determinants of Demand and Economic Impact in Brazil
Josephine Borghi
London School of Hygiene & Tropical Medicine
Overview
Contraceptive demand – global perspective Contraceptive demand in Brazil Economics of contraceptive demand Research aim and objectives Setting Methods
Contraceptive demand and global priorities
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
Contraceptive Coverage – Regional Patterns
0102030405060708090
100
Europe NorthAmerica
Africa Asia LatinAmerica &Carribean
Regions
Pe
rce
nt
co
ve
rag
e
Traditional method
Other Modern method
Condom
Pill
Female sterilization
Source: UN (2005) World Contraceptive Use - 2005
Annual Incidence of Abortion per 100 Live Births WHO (2000 data)
Contraceptive Use - Brazil
Source: Last DHS (1996)
Female sterilization
Pill
Condom
Other Modern method
Traditional method
None
40%
24%
21%
6%
5%
4%
•High level of contraceptive prevalence (77%)
Female Sterilization in Brazil 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
Legality Frequency
2 abortions per year per 100 women of RA Health system impact
1.7% of hospital admissions due to unsafe abortion
Economics of contraceptive demand: what is known?
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
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
What are: 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 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
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
Salvador Pau de Lima
48,641 inhabitants 45% earn less than $90
per month Fiocruz cohort study
Barra district Monte Santo
Illiteracy 40% Largely rural IMR 61 per 1000
Study Methods - Overview
Literature Review Discrete choice survey Household cost survey Provider survey Macro-economic model
Literature Review
Demand, preferences, access to contraceptives in low and middle income countries
Economic or non-health effects of contraceptive use
Discrete Choice Survey Aims
Measure preferences for contraceptives Measure key attributes of value
Methods Focus groups and piloting Stratified sample 1500 women (un-sterilized) (urban
and rural; high and low income) Sub sample of 150 husbands
Scenarios Contraceptive choices
Condom, IUD, pill, sterilization, abortion; current method Possible characteristics
Price, duration of protection, distance to access, place of delivery, efficacy, mode of administration, time of administration, risks; provider knowledge
Possible levels 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 Aims
Estimate the household costs of abortion and treatment of complications
Have these displaced other expenditures? Methods
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 Aims
Estimate the household costs of tubal ligation Have these costs displaced other expenditures? Relationship, if any, to c-section?
Methods Purposive sample of 150 women, urban, rural Hospital records
Provider Survey Aims
Estimate costs of treating abortion complications Estimate costs of tubal ligation Assess provider incentives for offering different
contraceptives Methods
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
CGE model Simple, closed economy, static competitive
equilibrium Selected sectors of Brazilian economy Data sources
CEBRAP 2007 DHS SUS info on incidence of abortion complications in
hospitals IGS input-output data – 2000 Household & provider survey data
Macro-economic effects Unsafe abortion
Labour supply, productivity Consumption effects (households and providers) Costs to health system Financial benefits to health workers
Tubal ligation Fertility; HIV –AIDS, STI impact C-section rate Financial benefits to health workers Consumption effects
Temporary methods Lower levels of fertility Increased revenue of pharmaceutical companies
Risks 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)