What is right with Brazil? (And what is wrong too?

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By Carmen Barroso, Regional Director,
International Planned Parenthood Federation/Western Hemisphere Region

Brazil seems to have squared the circle of slowing population growth without coercive
policies to compel women to have fewer children. Its rate of growth, which was
nearly 2.5% in the 1970s, is now less than one percent, making sustainability
somewhat easier to achieve. Currently, the Brazilian fertility rate is 1.9, which is
comparable to that of many developed countries and below the replacement level
that guarantees a stable population size. Many other countries now have lower rates
but none have experienced such a fast decline, especially in a country where
women’s right to decide the number of children they want was by and large
respected. Pills and female sterilization were the major contraceptive methods that
made the Brazilian “miracle” possible. However, it would be a mistake to think – as
some donors still do- that access to contraception was enough by itself, or that
“demand creation” programs had to convince women that smaller families were
better.
Many factors contributed to the Brazilian demographic transition. As in other
countries, analysts point out that urbanization led many Brazilian couples to
reconsider the desire for large families in the face of the much higher cost of raising
children in urban areas. At the same time, city life has created new aspirations for
education, engendered demand for new consumer goods and isolated families from
extended family members who traditionally shared responsibility for child care.
Similarly, child rearing in urban environments is more time-intensive given the need
for constant supervision to protect children from threats ranging from traffic
accidents to violence.
Brazilian women’s empowerment was also a major factor that contributed to smaller
family size. Between 1976 and 1998, the female labor force grew by 175%, and
continues to climb today, with the salaries of female workers increasing more rapidly
than those of male workers. Women now earn 74% of what men do, which of course,
is still far from parity, but represents great progress in relation to the past. Women
have also benefitted from the rapid expansion of the public school system from
abysmally low levels in the 1960s, when men averaged 1.9 years of schooling and
women 1.7. Since the 1990s, women have surpassed men and how average 7.7 years
of schooling compared to 7.4 for men.

Unlike in other Catholic countries, the influence of the Vatican’s messages against
contraception over individual women’s conscience was never very strong in Brazil,
and today, is almost non-existent. Opposing contraception was not high in the agenda
of the Brazilian Catholic church. It is true that the bishops were opposed to the
government’s attempts at more liberal social policies. But many low ranking priests in
the poor neighborhoods following liberation theology were more focused on social
issues and either ignored or supported their parishioners’ choice of a smaller family.

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Polls of married Catholic women in Brazil show that 70% of them have used
contraception and 88% approve of its use.

A broad array of public social policies also contributed to women’s empowerment and
the creation of social conditions that led to the desire of smaller families. Particularly
interesting were the indirect effects of the public policies and investments that paved
the way for powerful TV networks to become a dominant feature of Brazilian society.
Brazilian-made dramas and soaps— known as telenovelas— have been very popular
since the sixties: Brazilian demographers used to joke that couples did not have time
for sex because they were glued to the screen all evening. But the fact is that
telenovelas featured strong women who made autonomous decisions about their lives,
had more egalitarian relationships, enjoyed the pleasures of consumer society, did
not have their identity defined by motherhood, and had very few children. Millions of
viewers had their daily dose of dreams with these empowered women.

In analyzing the factors that led to female empowerment in Brazil, some analysts give
the soaps a greater weight than they deserve. The images on TV reflected changes
that were already underway in the society at large, changes that also contributed to
the resurgence of a women’s movement. In the sixties, family laws were changing,
divorce became legal, a growing proportion of households were headed by women,
middle-class women were breaking professional barriers, and grassroots women were
actively participating in the emerging social movements in cities and in rural areas.
Women were also resisting the military government; Brazilian President Dilma Roussef
became the most prominent of them all.

So, the first lesson to draw from the Brazilian experience is that the provision of
contraception— while evidently necessary to decrease fertility— is not enough.
Demand is equally important and it is created mainly by women’s empowerment, not
by efforts to convince women that smaller families are better.

A second lesson is that respect for human rights is not only compatible, but actually
supportive of a successful demographic transition. Brazil never established
demographic targets, which too often can lead to overzealous health providers
stamping on the rights of their clients, nor did it offer incentives for women to agree
to be sterilized, a common practice in Asia that has led to disastrous consequences.

There was, however, considerable debate in Brazil about the right of women to
decide freely and without coercion about the number of children they want. The
military that ruled Brazil from the mid-sixties to the mid-eighties never managed to
reach a unified position regarding population growth. Some generals were openly pro-
natalist and wanted rapid growth in order to occupy the Amazon and avoid foreign
invasion. (Ironically, the left opposition to the military was not immune to these
arguments.) Others lamented the “quality of the human material” they encountered
among the uneducated and unfit recruits, and prescribed smaller families so parents
could better invest in the physical and mental condition of their offspring.

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As a result of this divergence, the military government never had a population policy.
Regulation of fertility was left to the market forces and to the non-governmental
organizations (NGOs). Given the limited resources of the reproductive health field at
the time, the rights of women who had an unmet need for contraception were not
entirely fulfilled, but the rights of those who wanted to preserve their fertility were
protected from massive abuse. The pill became widely available without prescription
for those who could afford it, or free-of-charge through NGOs that catered to the
poor. Financed through international sources during a period of strong nationalist
sentiment, these NGOs were accused of having population control objectives and
were subjected to intense scrutiny: a group of Missionaries in the Amazon for
example, was accused of sterilization without consent, an accusation that resulted in
a Parliamentary Inquiry.

While these charges were never confirmed, they were an indication of the strong
opposition to population control shared by civil society groups and the media. In this
sense, the presence of these “watchdogs” had the salutary effect of preventing a
state sponsored policy condoning abuses of human rights. This does not mean that
violations never happened; they did, even among middle class women who paid dearly
for their private doctors. They were, however, more the result of poor service
quality and the fact that the very idea that patients had rights was still not
widespread among providers and even the women themselves.

With the growing empowerment of women generating a desire for fewer children ,
and access to contraception largely limited to women who could afford to pay, poor
women started resorting to desperate measures to avoid or interrupt a pregnancy.
Local political candidates offered free sterilization in exchange for votes, and the
number of complications from unsafe abortion reaching the government hospitals was
in the hundreds of thousands.

In this context, the Brazilian government took the first step to protect reproductive
rights. In 1983, more than ten years before the International Conference in
Population and Development in Cairo, Brazil instituted the Policy of Comprehensive
Women’s Health (PAISM), which recognized the right to access contraception and the
duty of the government to guarantee it. As Brazil transitioned back to democracy
after more than two decades of military rule, the country adopted a new constitution
in 1988 that—thanks to the intense mobilization of the women’s movement—enshrined
the right to family planning. Brazil’s new constitution also created a unified public
health system (SUS) that extended coverage of primary health care, and gradually
started to include sexual and reproductive health care.

In the 1990’s the Brazilian experience inspired the Cairo conference to adopt a new
reproductive health paradigm. The conference outcome—the Cairo Programme of
Action— in turn, strengthened the resolve of the Brazilian government. In 1997, the
government passed new norms for the implementation of family planning services,
and technical guidance for the provision of legal abortion services for victims of
sexual violence in 1999. This trend of extension of rights continued until today. In

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2005 a National Policy of Sexual Rights and Reproductive Rights was adopted, and
technical guidance on the humane treatment of abortion was issued. Three national
conferences on policies for women were convened by the Ministry of Women’s Affairs
in 2004, 2007 and 2011. All of them demanded legalization of abortion.

Today, the human rights agenda in Brazil remains a work in progress. Enormous socio-
economic inequality persists despite the success of the governmental policies aimed
at diminishing the huge gaps between the rich and the poor, gaps that are reflected
in the country’s reproductive health outcomes. While more than half of the Brazilian
population is black, whites still enjoy higher socio-economic, educational and health
standards. For instance, the gap in schooling between white and black women, while
diminishing in recent years, is still 1.6 years. A recent study shows that 47% of black
women are not using contraception, compared to 40% of white women. Maternal
mortality rates are 67 (per 100,000 births) for black women, while the rate for white
women is 40.

Geographic disparities are also found between the rest of the country and Northeast,
which is developing rapidly but is still—by far—the poorest region. In Brazil, 16.2
million people—or one in 10—live in extreme poverty (on around US $1.30 per person
per day). Brazil’s rural North and Northeast regions have the highest percentage of
people living in extreme poverty: in the Northeast region, per capita income is less
than half that of the more developed Southern region. Similarly, maternal mortality
rates and adolescent birth rates are higher in these regions than the rest of the
country.
These inequalities result in large numbers of women with unmet need for
contraception becoming invisible within national averages. As a result, international
donors now ignore Brazil as they do with the rest of Latin America and the Caribbean,
where similar inequalities within countries and between ethnic groups are huge.

Another area of the human rights agenda where Brazil gets a failing grade is abortion.
Since 1940, Brazilian law allows abortion to save the life of the woman and in cases of
rape. For many decades, the law was ignored and practically all abortions were done
clandestinely, most of the time under unsafe conditions. Latin America—has the
highest rates of unsafe abortion in the world and Brazil is no exception. Restrictive
laws did not deter large numbers of women from ending their pregnancies, making
abortion one of the main causes of maternal mortality until today.

Strong mobilization from civil society led to the creation in 1989 of the first legal
abortion services in a public hospital, but progress has been very slow. Today, there
are only 64 such service delivery points in the whole country.

Today, the law remains very restrictive; the only small progress was the recent
decision of the Supreme Court to permit abortion in cases of anencephaly. At the
same time, unsafe abortion complications continue to bring thousands of women to
public hospitals, making post abortion curettage the second most frequent surgical

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procedure in the country, and adding a huge burden to the health system. The total
number of these surgeries is declining, but still remained high at 192,763 in 2011.
The decline is attributed to the widespread use of Misoprostol, which is clandestinely
purchased in the informal market. Due to the restrictions imposed on its sale and to
the prohibition of dissemination of information about its use, young, black,
Northeastern and poor women are the ones who have least access to it and are most
exposed to using wrong dosages and consequent risks. Hopefully, this will change
soon, given the Ministry of Health’s recent announcement to adopt the successful
harm reduction strategy that has been implemented in Uruguay.

The third lesson from the Brazilian experience is the need for comprehensive
sexuality education to complement youth-friendly health services. Adolescent fertility
is quite high in Brazil, and unlike the trend among older women, it has not declined
rapidly in the last decades. In fact, as was the case in several Latin American
countries, the proportion of Brazilian adolescents who become mothers had even
increased up until around 2005.

Widespread changes in behavior of both adults and adolescents have not been
accompanied by societal acceptance of the rights of young women to exercise their
sexuality in autonomous ways. Young women begin sexual activity, already
shortchanged by the lack of recognition of their right to information and services that
can help them to make informed decisions and protect themselves from infections
and undesired pregnancies. At the same time, gender inequality also makes young
women and girls vulnerable to coercive and forced sex and outright violence.

High fertility rates among adolescents have been a concern during recent decades in
Latin America, as they have remained static while the rates have fallen in other parts
of the world. In Brazil, the most notable increases occurred among the poorest,
least-educated young women living in urban areas. In 2000, 20% of all children were
born to mothers between ages 15 to 19.

Adolescent motherhood tends to be a sentence of lifetime poverty for adolescents

and their children, in what experts call the intergenerational transmission of poverty.
Adolescents who become mothers have difficulty staying in school and getting decent
work. Early motherhood also is major component of population growth, being linked
to what demographers call population momentum: an effect that is independent of
fertility rates per se.

In spite of guidelines issued by the Ministry of Health dating back to 1998, most
schools do not have good programs of sexuality education. A 2005 census of
elementary and secondary private and public schools found that only 60% of them
addressed AIDS and only 52% with adolescent pregnancy. The broader theme of sexual
and reproductive rights was even more neglected: only 45% covered it. The Ministries
of Education and Health were bold enough to encourage distribution of condoms in
schools but only 9% of schools actually followed the recommendation.

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Finally, the last lesson from the Brazilian experience is the importance of civil society
in creating political will, providing services the government cannot offer, and for
holding governments accountable for the commitments they make. Strong public
health advocates and a vibrant feminist movement joined forces in Brazil on critical
moments in the past and continue to be vigilant today1.

A key factor that helped the Brazilian women’s agenda gain such wide support was
the pragmatism of the feminist movement. They built alliances with political parties
of the left and the center, even as none of them fully embraced a “radical” agenda of
gender equality. Also, they focused on incremental gains in spite of the fact that
those gains only bore a pale resemblance of their more far-reaching ideals. They
participated actively in the struggle to end the dictatorship and were rewarded by a
more democratic regime which was very open to the engagement of civil society.
Unlike in other countries, the leadership of the Women’s Rights Council, created by
the government in the early eighties soon after the end of the military dictatorship,
came from the women’s movement, was accountable to it and tried to support
women’s organizations to the degree possible. Another example of the opening of the
democratic government to the participation of civil society in general and feminists in
particular was that in the eighties—well before Cairo—the government created a
Commission on Reproductive Health and Rights with wide representation of different
ministries and professional associations, and it was presided by feminist scholars and
activists

International funders offered vital support to critical NGOs, including some women’s
organizations. Local NGOs put reproductive health and rights in the agenda of public
policies and debates. Some provided services and demonstrated the existence of the
demand for modern methods of contraception among all sectors of the population,
including the feasibility of catering to that demand despite religious opposition. With
the return of democracy, many engaged with the public system, providing both know
how and technical support for educational activities, as well as a critical look at the
possible effects of state policies. Sociedad Civil Bem-Estar Familiar no Brasil, or
BEMFAM, for example, has worked with the government and private sector for nearly
50 years to increase access to vital health services—including contraception, care
during pregnancy and comprehensive sexuality education—among poor, marginalized,
and youth populations.
NGOs provided key contributions both for the formulation of policies and for
substantiating the presence of Brazil in international fora. Brazil has frequently
played a leadership role in this arena, including the International Conference on
Population and Development in Cairo; Human Rights Council sessions regarding sexual
rights; The United Nations Committee on the Elimination of Discrimination against

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Feminism re- emerged in Brazil in the 1970s, under suspicion of being an imperialistic
import from the North, but it remained deeply connected to the demands of women who
were active in grassroots social movements. For instance, they campaigned for day care
services, a vital need for poor women who work outside their homes. Gradually the face of
feminism became as diverse as the country itself, including in the rural areas.

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Women (CEDAW), where the Brazilian government has committed to (but not yet
complied with) issuing reparations following the death of a poor young black mother
who died due to inadequate services offered during pre-term childbirth; and more
recently, at the United Nations Commission on Population and Development, where
the sexual rights of adolescents were recognized.

Civil society organizations collaborate with the government in various ways, but they
are also able to maintain an independent stance thanks to their diversified sources of
support. Due to their autonomy, they can bring a critical voice, including when well-
intentioned policies are ill designed. This was recently the case when the
Administration issued an Executive Order designed to decrease maternal mortality
that included references to the rights of the unborn child and required pregnant
women to sign a registry in order to receive benefits. Subjected to intense criticisms
from a wide variety of sources, the order was left to quietly expire.

Support for these organizations is now critical for the maintenance of gains made and
the advancement of the sexual and reproductive health and rights agenda. The
religious opposition is now more diverse, stronger and better organized. Legal experts
working to reform the penal code are proposing an expansion of the causes for which
abortion would be permitted, but evangelical representatives in the Congress are
expected to be the main obstacles to change. Actually, they have presented
numerous proposed bills that would make the law even more restrictive. Beyond
abortion, the quality of services in the health system is still far from ideal. The needs
of adolescents remain unmet, and social and economic inequalities are still huge.
Brazil is certainly a source of inspiration to other countries, but there is much still to
be done.