Contraceptive Method Use

1. Contraceptive Method Use Determinants of Demand and Economic Impact in Brazil Josephine Borghi London School of Hygiene & Tropical Medicine

2. Overview • Contraceptive demand – global perspective • Contraceptive demand in Brazil • Economics of contraceptive demand • Research aim and objectives • Setting • Methods

3. 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

4. Contraceptive Coverage – Regional Patterns Source: UN (2005) World Contraceptive Use - 2005

5. Annual Incidence of Abortion per 100 Live Births WHO (2000 data)

6. Contraceptive Use - Brazil • High level of contraceptive prevalence (77%) Source: Last DHS (1996)

7. 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

8. 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

9. 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

10. 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

11. 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?

12. 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?

13. 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 Setting - Bahia

14. 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 Sites - Background

15. Study Methods - Overview • Literature Review • Discrete choice survey • Household cost survey • Provider survey • Macro-economic model

16. Literature Review • Demand, preferences, access to contraceptives in low and middle income countries • Economic or non-health effects of contraceptive use

17. 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

18. 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

19. 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)

20. 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

21. 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

22. 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

23. 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

24. 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)