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)