Medicalization Reproductive Agency, Desire

Medical Anthropology, 25:221263, 2006 Copyright # Taylor & Francis Group, LLC ISSN: 0145-9740 print/1545-5882 online DOI:
10.1080/01459740600840263
Medicalization, Reproductive Agency, and the Desire for Surgical Sterilization among Low-Income Women in Urban Brazil
Gina Hunter de Bessa
This article draws on data from ethnographic fieldwork in an urban housing project to examine the social context and meanings of surgical sterilization for low-income women in Brazil. Low-income women resort to sterilization because they distrust or are unsatisfied with alternative methods and because it helps them to fulfill the requirements of modern, responsible motherhood. Although sterilization is an option among few alternatives, and one that has subjected women to greater medical management and intervention, I argue that sterilization also represents poor womens active struggle to improve their lives and to resist the burdens placed on them by unequal gender relations. This article contributes to a growing anthropological literature that demonstrates how reproduction has become a central site where social values are constituted and contested, and it details womens diverse responses to the process of medicalization. Key Words: agency; Brazil; female surgical sterilization; reproduction
Over the past 50 years womens reproductive bodies have increasingly come under the clinical gaze (Foucault 1973). In this process of medicalization, aspects of reproduction once thought to be primarily political, personal, or social in nature have come to be
GINA HUNTER DE BESSA is an assistant professor of anthropology in the Department of Sociology and Anthropology at Illinois State University. Her research focuses on how poor women navigate discourses of development and modernity, the impact of ethnophysiology on contraceptive use, and childbirth and motherhood in Brazil. Correspondence should be sent to: Gina Hunter de Bessa, Department of Sociology and Anthropology, Campus Box 4660, Illinois State University, Normal, IL, 61790-4660. E-mail: glbessa@ilstu.edu
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seen as medical problemsproblems that are thought to be best solved by physicians through medical practice and management. Medical explanations and treatments have ascended at the expense of alternative understandings and arrangements. Although biomedicine offers numerous life-saving and lifeenhancing possibilities, feminists have persuasively argued that the medicalization of reproduction frequently entails serious negative consequences for womens health and human rights. Technological developments and an ethos of intervention have often led to the excessive or inappropriate use of medical procedures, unnecessarily exposing women to physical and psychological health risks. Feminists have also alerted us to the real and potential uses of reproductive technologies as instruments for social control, to the ways medicine extends patriarchal control over womens bodies, and to womens loss of autonomy and self-determination as scientific expertise eclipses other forms of knowledge.1 Although the feminist critique of medicalization sometimes conceptualizes biomedical authority as a form of oppressive, top-down power, sociologists and anthropologists have argued that medicalization is better understood as an interactive process. Women are not simply passive victims of medical ascendance, as Catherine Kohler Reissman (1983) has argued, and may actively participate in the medicalization of reproduction if it seems to serve their own interests. Margaret Lock and Patricia Kaufert (1998:2) also propose that womens responses to the process of medicalization may range from selective resistance to selective compliance, although women may also be indifferent. However . . . ambivalence coupled with pragmatism may be the dominant mode of response to medicalization by women. Careful attention, therefore, must be paid not only to how women understand their reproductive options and interests but also to their complex responses to medical interventions. Women are neither passive recipients of power nor entirely autonomous. In this article I examine the medicalization of reproduction in Brazil, where more than half of all contracepting women have been surgically sterilized (Remez 1997).2 In contrast to other developing countries where rates of sterilization are high, sterilization prevalence in Brazil cannot be directly attributed to any explicit government population policy or family planning initiative; rather, the Brazilian case illustrates what may happen when widespread and increasing demand for fertility control is not met by adequate
The Desire for Sterilization in Brazil
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family planning services (Martine 1996; Potter 1999). Over much of the last four decades, fertility control methods have been generally available for wealthier women through private health clinics (Barroso 1984). Low-income women, in contrast, have been left with dangerous, clandestine abortion and the often unsupervised use of only a few contraceptive methods that are available through pharmacies, private family planning organizations, and=or individual physicians. Since the 1970s Brazilian women have relied almost exclusively on only two contraceptive methods: the pill and surgical sterilization. In 1996, the year for which the most recent national data are available, 76.7 percent of married women of reproductive age used some form of contraception; but surgical sterilization (40.1 percent) and the birth control pill (20.7 percent) accounted for the majority of contraceptive use (BEMFAM=DHS 1996).3 Ironically, sterilization was legally restricted until 19974 and was permitted only in certain medically justified cases, such as when a future pregnancy posed a risk to a womans health. Voluntary sterilization was, therefore, covered neither through the public health care system, which serves the majority of the population, nor through private health insurance.5 Doctors, however, were often willing to perform tubal ligations, and they circumvented legal restrictions by performing them in conjunction with other abdominal surgeries (most commonly a cesarean section delivery) so that the hospital costs of the surgery and anesthesia would be covered (Barros et al. 1991; Faundes and Cecatti 1993). Seventy-one percent of tubal ligations have been performed conterminously with c-sections (excluding the northeast region, where a different pattern emerged) (Potter 1999). This arrangement for subverting legal restrictions and covering the costs of sterilization resulted in several negative consequences, including a large number of unnecessary c-sections, the absence of counseling and informed consent, unequal access to sterilization, and a perverse market for clandestine sterilization in which physicians sometimes receive side payments and politicians arrange sterilization in exchange for votes (Caetano 2000; Caetano and Potter 2004).6 Within this medicalization of reproduction, sterilization and cesarean section have become mutually reinforcing procedures (Berqu 1993). With expansion of hospital-based care beginning o in the 1960s, rates of surgical childbirth soared. Cesarean deliveries became both a consumer good for women who could afford private
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health services and a remunerative and convenient practice among obstetricians. Until the late 1970s physicians were compensated at higher rates for cesarean than for vaginal births. Even though reimbursement rates have since been revised, planned cesarean deliveries continue to offer the convenience of scheduling. Brazil has registered some of the highest rates of cesarean births in the world25 percent to 30 percent of births in public hospitals and 70 percent in private hospitals (Potter et al. 2001). Surgical deliveries contribute to the incidence of sterilization due to repeat cesareans (the recommendation being that once a woman has had a c-section all future pregnancies will also end in cesarean due to the risk of uterine rupture) in conjunction with the routine practice of sterilization after three consecutive cesarean deliveries (Faundes and Cecatti 1993; Barros et al. 1991). A third c-section, in other words, provides a medical justification for performing a tubal ligation. High rates of surgical sterilization and cesarean section present obvious negative consequences for womens health and reproductive rights. Unnecessary c-sections contribute to maternal and infant morbidity and mortality (De Muylder 1993), while the extensive reliance on sterilization represents both the excessive costs women bear for fertility control and the fragility of womens repro ductive rights (Correa and Avila 1989; Berqu 1982; Giffen 1994).7 o The routine and parallel use of sterilization and c-section represents aspects of a reproductive culture (Mello e Souza 1996) within which surgical interventions into womens bodies have become normalized, even though, for much of the population, basic health services are inadequate. In many ways, high rates of sterilization seem to be the result of womens conscious choices and determination to gain access to a service that the state long failed to provide. While women have taken extraordinary measures to reduce their fertility, sterilization appears to be an option among few alternativesand one that has subjected women to greater medical management and intervention. Several scholars have argued that womens decisions to undergo sterilization, in Brazil as elsewhere, are a response to the states lack of investment in reproductive health care, a pervasive (although sometimes implicit) ideology of population control, and a series of social determinants (such as womens position in the workforce and patriarchal gender relations) that women have little power to change (Barroso 1984; Lopez 1997; Petchesky 1981). Taken
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together, it is argued, these factors have created a context within which sterilization is not exactly a choice (Correa 1994:26). Feminists have shown that the ideology of choice in family planning obfuscates the larger social and institutional forces that structure and constrain the choices individuals can make (Petchesky 1981; Lopez 1997). I agree with Sonia Correa and Rosiland Petchesky when they write that rights, understood as private liberties or choices, are meaningless, especially for the poorest and most disenfranchised, without enabling conditions through which they can be realized. These conditions constitute social rights and involve social welfare, personal security and political freedom (Correa and Petchesky 1994:107, emphasis in original). Reproductive freedom therefore entails not only the ability to choose from a series of sage, effective, convenient and affordable methods of birth control developed for men and women but also a context of equitable social, political and economic conditions that allows women to decide whether or not to have children, how and when (Lopez 1997:160). The prevalence of female surgical sterilization in Brazil provides an especially interesting case for examining medicalization and reproductive agency and has been a source of contentious debate among feminists, social scientists, and others in Brazil. Scholars have wondered whether the demand for sterilization signifies an attempt at greater autonomy or whether it is a last resort taken by desperate women: Could it be that women have become aware of gender domination and initiated a process of deconstruction of the power relations in which they are inserted? If so, does a tubal ligation imply greater autonomy and the construction of more equitable gender relations? . . . Or is the option of sterilization the inevitable result to a lack of accessible alternatives that she perceives to be trustworthy? (Osis et al. 1999:523, my translation). In this article I use data from ethnographic interviews with lowincome women in urban Belo Horizonte, Brazil, to examine how these low-income Brazilian women understand their reproductive options, what factors influence their reproductive and contraceptive practice, and their own interpretations of their decisions to undergo sterilization. By focusing on individual womens narratives I do not deny any of the historical and structural factors that have framed womens reproductive lives, nor do I assume that women freely choose sterilization; rather, I understand that a womans reproductive and sexual options depend on the
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intersection of many factors in her life, including social class, work environment, prevailing social representations of the body, and gender relations. Thus womens contraceptive practices are not based on a rational assessment of costs and benefits so much as they are embedded in a series of ongoing, shifting decisions and negotiations with partners and institutions (Carter 1995). By addressing how certain working-class women conceive of their reproductive options and experiences, I illustrate the social forces in the home and the community that compel women to make certain choices, and I examine the subjective significance of sterilization for gender relations and womens gender identity. In particular, I argue, alongside Citeli et al. (1998) and Dalsgaard (2004), that the meaning of sterilization extends beyond fertility control and represents womens attempt to gain a measure of control and to construct a better life. The views of poor and marginalized women are often absent in discussions of reproductive health policy and programs (Sen, Germaine, and Chen 1994; Sadana and Snow 1999). Yet, if we are to understand how current medical arrangements serve or detract from those needs, womens own perceptions and assessments of their reproductive needs are critical to our analyses (Dixon-Mueller 1993; Fathalla 1994; Snow et al. 1997). Cross-cultural research has shown that the meaning and organization of reproduction itself is highly culturally variable, requiring us to attend to the ways reproductive health needs are defined in local contexts and to the crosscultural commensurability of notions like reproductive rights and empowerment (Petchesky 1998). Detailed, ethnographic examinations are essential for understanding how medicalization affects differently positioned women and how biomedical technologies may be embraced, altered, or opposed by people in diverse settings. Anthropologists have shown that reproduction and contraception are key arenas for the articulation of identity in many societies and that the meaning of contraceptive methods, like the meaning of all technologies, can only be understood within certain political, social, economic, and cultural contexts (Russell and Thompson 2000). For instance, family planners and demographers frequently refer to abstinence as a traditional contraceptive method (as opposed to modern methods like the intrauterine device or the pill), yet Beti women in Cameroon rely principally on periodic abstinence not only because they believe it to be effective, but also because it enables them to enact a disciplined, honorable and
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modern identity of self-control (Johnson-Hanks 2002:230231). Heather Paxson (2002) shows how family planners attempts to steer Greek women away from abortion and toward the rational use of so-called modern contraceptives fails to account for the local notions of sex and love and the everyday gender inequalities faced by middle-class women. Furthermore, people employ or resist contraceptive methods for a variety of reasons, some of which (e.g., their medicinal effect) have little to do with a desire to limit childbearing (Bledsoe, Fatoumatta, and Hill 1998; Davids 2000). The meaning of biomedical technologies cannot be assumed outside of local uses and contexts. In the present urban Brazilian case, I show how having many children has come to carry the stigma associated with poverty, rural life, and backwardness. I argue that womens desire for sterilization represents their attempt at social mobility (if not for themselves, then for their children) and is a mark of responsible motherhood. Sterilization is also seen as the the only [contraceptive] method that really works and, therefore, is a way of taking care of oneself. However, womens attempts to be good mothers and modern women are often fraught with conflict, especially in relation to their husbands, who, they say, have not kept up with the times.
DATA AND METHODS Data for this article come from ethnographic fieldwork I conducted between 1996 and 1998 and again, for two months, in 2002. My field site was a working-class housing settlement (conjunto habitacional) called Taquaril8 located on the urban periphery of Belo Horizonte, a metropolitan area of over three million people in the southeast region of Brazil. My analysis centers on in-depth, ethnographic interviews with 20 women residents who were sterilized or seeking sterilization; informal interviews with a larger number of women from the community; and participant-observation, which allowed me to examine womens quotidian struggles with both biological and social reproductive responsibilities as well as to investigate the social context of reproductive decision making. I also volunteered with a grassroots womens health organization that worked in Taquaril; conducted an informal, semi-structured survey on reproductive health issues with women from 15 households on
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the principle streets (becos) on which I worked; and conducted interviews with community leaders, local health care professionals, and physicians at the principal area hospitals. Finally, my analysis is informed by in-depth interviews that I conducted with 40 women from across the city as part of a larger study of childbirth and con traception (Perpetuo and Wajnman 1998). The women I interviewed in Taquaril reflect the diversity of the community. They ranged in age from 18 to 50 and had completed between two and eight years of formal education. Only two of the women interviewed were full-time housewives; the rest held jobs outside the home (mostly as domestic and service workers). Although one woman has been a community leader for many years, none of the other women was regularly active in political or social movements. The average household income in 1998 was about R$260 per month (two minimum wages,9 or about US$215), significantly below what it actually cost to support a family. Sixteen of the 20 women were married or cohabitating, two were single, and two were widowed. All but the youngest women had witnessed dramatic social changes between their mothers and grandmothers lives in contrast to their own. Some of these women came to Belo Horizonte from rural areas in the 1980s and participated in the squatters movement that founded the community. Other residents were raised in the city and moved into Taquaril from other poor neighborhoods. I high light, in particular, the story of Arac, one especially articulate woman whose narrative provides a commentary on the tensions produced by the rapid social changes that have transformed Brazilian society over the last several decades. Before turning to a discussion to these womens perceptions of motherhood, contraception, and sterilization, their reproductive trajectories must be placed within the context of Brazils demographic transition and the development of contraceptive services.
DEMOGRAPHIC TRANSITION, THE DEVELOPMENT OF CONTRACEPTIVE SERVICES, AND THE RISE OF STERILIZATION Although levels of fertility have been declining since the 1960s throughout Latin America, Brazil is noted for the rapid pace of decline, especially in the absence of a population policy or program (Martine 1996).10 Fertility rates fell faster in Brazil than they did in
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countries such as India and Mexico, where explicit populationreduction policies and programs were implemented during the same time period. In 1960 the average number of children per woman in Brazil was 6.3, but early in that decade fertility rates began to fall rapidly. By 1980 the total fertility rate had declined to 4.5 children per woman, and rates continued falling from 3.5 in 1984 to 2.5 in 1991 (Berqu 1993:367) to near replacement levels o in 2000 (Goldani 2002:358). Fertility decline occurred earliest in urban areas and in the wealthier and more industrialized south and southeast regions of the country, and, over subsequent decades, it gradually spread even to the most impoverished rural areas of the north and northeast. The most proximate determinant of this decline has been the dissemination of highly effective contraceptive methods. Yet, significant regional, socioeconomic, and rural-urban differentials in fertility rates persist, and contraceptive patterns follow marked regional distinctions.11 Socioeconomically disadvantaged women continue to have relatively higher levels of unwanted fertility and are more likely than are women of higher income and education levels to resort to surgical sterilization (Perpetuo and Wajnman 1998). Rates of sterilization are highest in the north and center-west regions of the country and lowest in the south, where the pill is prevalent (BEMFAM=DHS 1996).12 The acceleration of fertility decline in the 1960s coincided with the coming to power of a repressive military regime (196488) and widespread social change. The period was marked by rapid industrialization, miraculous economic growth followed by economic crisis, and increasing social exclusion, especially in rapidly expanding, precarious urban favelas, or shantytowns. Demographers note that no single or simple factor explains Brazils rapid demographic transition, and they point to a wide range of social, political, and economic factors over the past half century that indirectly shaped Brazilians motivation and ability to reduce family size (Martine 1996; Goldani 2001). One influential analysis (Faria 1989) cites the unanticipated and unintended effects of government policiesspecifically, the expansion of social security and health care networks, the promotion of consumer credit policies, and heavy investment in mass communication networks (especially television)which, in combination, indirectly affected values and attitudes regarding family size and sexual behavior and increased the demand for the regulation of marital fertility. The expansion of health and social security
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coverage to a larger portion of the population shifted familial responsibilities and expectations, eliminating elder parents dependence on their childrens support. Health policies implemented by the regime increased the number of medical personnel, encouraged curative over preventative medicine, and promoted private-sector health services. These policies not only expanded access to services and information but also reinforced medical authority and legitimacy, paving the way for the medicalization of social life.13 The extension of consumer credit for the first time to lower-income social sectors changed consumer aspirations and expectations. This, in combination with massive investments in telecommunications, resulted in a dramatic increase in the number of televisions and of television programming. In 1960 fewer than 10 percent of urban households had a television; in 1991 78 percent of these households had one (Faria and Potter 1999). Television programming may have affected fertility behavior through providing increased information about sexuality and contraception as well as through encouraging consumerism, small family size, and changing gender roles (Faria 1989). Other factors that influenced reproductive intentions included the massive entry of women into the paid labor force, increasing levels of education for both men and women, and the rapid, large-scale urbanization of the Brazilian population in the 1960s and 1970s (Martine 1996). Despite widespread demand for fertility control, few means were available. Although at the 1974 Bucharest Conference the Brazilian government declared, for the first time, that couples were free to determine the size of their families and to have access to family planning information and methods, it took few initiatives in this direction until over a decade later (Martine 1996). Martine argues that abortion, although illegal,14 was probably responsible for much of the early fertility decline. Surgical sterilization was first adopted by middle- and upper-class Brazilian women in the 1950s and only gradually became more widely accessible (Correa 1994). Oral contraceptives, increasingly available after the mid-1960s, could be purchased through pharmacies and were distributed through family planning agencies (Merrick and Berqu 1983). Private family o planning organizations (with international funding through USAID, the International Planned Parenthood Federation, the Population Council, and other agencies) were permitted to operate in Brazil as early as 1965 (Corral 1996). BEMFAM, the Society for the Welfare of the Family, was the largest of such organizations and worked primarily in the impoverished northeast region.
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The governments laissez faire policy and the foreign funding for family planning organizations were interpreted by many Brazilians as a back-door population policy and as imperialist intervention in national affairs (Sobrinho 1993). Womens health advocates criticized the work of BEMFAM and other organizations for offering a highly restricted range of methods (namely, the pill and surgical sterilization), providing poor-quality care, and imposing a top down approach to family planning (Avila and Correa 1999). Some argue that the long-term effect of this has been widespread distrust of reversible methods (Correa and Avila 1989) and that lack of medical supervision, along with side effects of the pill, likely contributed to an increasing demand for surgical sterilization in the years before contraceptives became widely available in the public services (Correa and Avila 1989; Martine 1996). The role of social actors (such as the Roman Catholic Church, the womens movement, the population establishment, and public health-sector professionals) on fertility decline and the rise of sterilization has been hotly debated in Brazil, with some claiming that their influence was largely unanticipated and unintended (Martine 1996) and with others arguing that physicians, with the support of the state, played key roles in influencing the reproductive behavior of the Brazilian population (Goldani 2001; Caetano and Potter 2004). While early interpretations of widespread sterilization accused the population establishment of abusively and indiscriminately sterilizing disadvantaged and=or minority women (Barroso 1984; Berqu 1982; GELEDES 1991), subo sequent studies failed to find evidence of direct coercion (Berqu o 1994). Furthermore, research on the socioeconomic correlates of sterilization in the 1980s revealed a widespread demand for sterilization and a positive correlation with a womans income level (Alencar and Andrade 1993). However, the complicity between women and physicians regarding sterilization is often problematic. Caetano and Potter (2004) show, for example, the role of individual physicians and politicians in facilitating access to sterilization in the northeast, where politicians routinely provide goods and services, including sterilization, to the poor in exchange for votes. They also recorded evidence that, in addition to medical indications (e.g., repeat cesareans) for sterilization, physicians made decisions regarding whether to perform these operations on the basis of social indicationsa lot of children, low income, a bad marriage (86). In some cases, rather than simply facilitating,
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physicians directly participated in womens reproductive decisions (Caetano 2000). High rates of sterilization became a key issue for the Brazilian womens movement in the 1980s, which, along with other segments of civil society, mobilized against the authoritarian regime. Feminists brought into public debate the ways in which the states maternal and infant health programs reduced womens health to reproductive functions. They also called attention to the states neglect of family planning, the Malthusian directives underlying much of the international population control movement and national family planning organizations, and the role of the medical class in promoting sterili zation (Avila and Correa 1999). To counteract these trends, in 1983 leading members of the womens movement, in conjunction with health professionals, successfully launched the Comprehensive Womens Health Assistance Plan (PAISM), which guaranteed access to a full range of contraceptive methods offered within the context of comprehensive and integrated reproductive health care (Costa 1999). With re-democratization and a new federal constitution in 1988, health care was defined as a right of all citizens and as the responsibility of the state within the Unified Health Care System (SUS). However, economic crisis and structural adjustment policies led to the deterioration of public services and contributed to the persistent underfunding of SUS (although health services benefited from new funding sources after 1995). Within the Ministry of Health, PAISM faced problems of financing as well as conservative political opposition and was only very slowly implemented. The Municipal Health Secretariat of Belo Horizonte, for example, did not incorporate PAISM into the citys public health services until 1993, and then did so only partially (Fonseca and Perpetuo 1994). So, although family planning methods were guaranteed by law, services and supplies were frequently insufficient and women were required to wait in long lines and schedule multiple appointments in order to secure birth control (Maia and Chamcham 2002). Despite constitutional guarantees, the (limited reach of) PAISM, and pressure to reduce hospital costs, neither sterilization nor cesarean rates diminished from the mid-1980s to the mid-1990s. Female surgical sterilization rose among married women from 27 percent to 40 percent from 1986 to 1996 (BEMFAM=DHS 1996:4).15 Potter (1999) makes the compelling argument that, by this point in time, Brazils contraceptive pattern had already become locked-in through path dependence and positive reinforcement
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for both physicians and women. Brazilian obstetricians had become specialized in both cesarean section deliveries and sterilization, and their practice was widely accepted within the medical community. For women, both cesareans and sterilization had become normalized, and there was strong social influence to continue to use sterilizationa tried and true method (Berqu 1993; Potter o 1999). Potter argues that this culture of sterilization sustains entrenched patterns of cesarean section and sterilization despite changes in the institutional and legal context that gave rise to them in the first place. In an effort to curb high rates of sterilization and unnecessary cesarean deliveries, sterilization was legalized in 1997. Law 9.263=96 permits voluntary sterilization for women and men who are 25 years of age or who have at least two living children. The legislation also stipulates a 70-day waiting period and counseling.16 While the new law guarantees the right to sterilization, women still encounter obstacles gaining access to sterilization, including physicians misinterpretation of the law, excessive wait time between date of request and date of service, lack of service facilities, and failure to secure spousal consent (Berqu and Cavenaghi 2002; Luiz o and Citeli 2000). Moreover, incentives for performing unnecessary cesarean deliveries and surreptitious tubal ligations persist because the new regulations outlaw postpartum sterilizationsan aspect of the legislation meant to decouple the procedures (Potter et al. 2003). Most recently, in March 2005, the Brazilian government launched a family planning program for 200507 as part of its National Policy on Sexual and Reproductive Rights, which aims to expand the supply of reversible contraceptive services, increase access to voluntary surgical sterilization, and offer assisted reproduction services within SUS. It is hoped that these measures will go some way toward meeting service demand and reversing the increasing surgicalization of reproduction. Given the context within which women have undergone sterilization, one might expect to find large numbers of women who are dissatisfied or who regret the procedure. Yet this is not the case: women have reported that they are largely satisfied with the procedure and would recommend it to friends (Berqu 1993). Osis et al. (1999) o found that effectiveness and lack of side effects are the principle characteristics that Brazilian women look for in a contraceptive method and that sterilized women are significantly more satisfied with their contraceptive method than are non-sterilized women.
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Indeed, levels of regret17 percent in one study (Vieira and Ford 1996b)are low considering the widespread use of the procedure. There is some agreement that women turn to sterilization because they have less success using other methods. Perpetuo and Wajnmans (1998) analysis of the socioeconomic correlates of sterilization shows that womens education level is inversely correlated with sterilizationpresumably because women with greater education levels have more information about alternative contraceptive methods and greater possibilities for using these correctly. Lower- and lower-middle-class women are much less successful than are their more privileged counterparts when it comes to using reversible contraceptive methods effectively, and they are more likely to undergo sterilization after exceeding their desired number of children (Perpetuo and Wajnman 1998:328). The authors conclude that women in lower economic strata have been doubly penalized due to restricted access to sterilization and due to the less favorable conditions (i.e., after having had more than their desired number of children) under which they were sterilized. Comparing demographic factors between similar cohorts of sterilized and non-sterilized women aged 30 to 49 in the state of Sao Paulo, Osis et al. (2003:1402) also found that sterilized women were more likely than were non-sterilized women to initiate childbearing early in life and to lack knowledge of how to plan and control their fertility. Numerous interpretations of womens demand for sterilization have highlighted their lack of power, and even their victimization, at the hands of the state and the medical class. Sterilization has been described as a survival strategy of low-income women (in combination with paid labor) and as a last resort against the abandonment they have faced regarding their reproductive life (Giffin 1994). It has also been described as a refusal of motherhood by poor women facing severe economic constraints and the solitary burden of childcare (Correa 1989:3536). Suzane Serruya (1992, 1996), who interviewed women in the City of Belem in the north of Brazil, found that sterilization had come to be seen as a privilegea route to social mobility, improved sex lives, and freedom from worry about reversible contraception. She argues that poor women invest sterilization with positive significance because they (erroneously) associate it with privilege, the chance for social mobility, and sexual liberation. In the process of medicalization, she argues, women have lost dominion, knowledge, and authority
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over their bodies and therefore are willing accept the greater control afforded by greater medical intervention (Serruya 1996:172). Serruya characterizes sterilization as voluntary mutilation and as womens desired domination by biomedicine (ibid.). Her interpretation leaves little room for serious consideration of womens agency or their own assessment of their needs. More generous interpretations, on the other hand, recognize that sterilization represents womens initiative and struggle for selfdetermination, even though the procedure has become so normalized as to be an almost natural lifecycle event (Citeli et al. 1996). Citeli et al.s research17 entailed interviews and focus groups with women who came from three different regions and who were primarily social activists. They included members of a rural workers union in the northeastern state of Pernambuco, members of a domestic workers union in the City of Rio de Janeiro, and health movement activists in the City of Sao Paulo. Although they found significant differences among these groups of women, in all cases sterilization represented not only freedom from future pregnancies but also freedom from the toll on their health that biological reproduction entails (Citeli et al. 1998). Dalsgaards (2004) ethnographic study centered on non-activist, working-class women in the northeastern city of Recife. From a phenomenological perspective, she argues that women in a poor, violent neighborhood of Recife seek out sterilization because it gives them a sense of control over their own lives. These women face imposing constraints: frightening violence in the neighborhood that makes raising children a fearsome task, the physical discomfort and suffering from birth control pills, and humiliation at the hands of medical staff during delivery. These, she argues, are all clear motivations impelling women toward sterilization. However, Dalsgaard also argues that sterilization is an attempt to be seen as valuable and respectable mothers in the eyes of othersespecially those of friends, neighbors, and authorities (i.e., doctors). Taquaril is, in general, considerably poorer than is the neighborhood where Dalsgaard studied. Drug and gang violence erupted in Taquaril on occasion, and mothers feared their teenage sons would be lured into these social milieus; however, violence and fear was far from generalized and most people described the neighborhood as calm. Yet women in Taquaril, too, saw sterilization as a way to better their lives and were more assertive than were the women described by Dalsgaard with regard to utilizing sterilization as a
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form of resistance. I take Dalsgaards (2004:173) assertion that womens relations to children, husbands, mothers and friends (often neighbour women) carried particular weightsocially, materially as well as affectivelyfor the women and show how the women of Taquaril, too, attempted to be responsible and to negotiate reproduction and sterilization in relation to husbands, neighbors, relatives, and others. Some women in Taquaril also explicitly framed their struggle for sterilization as a means of resisting their husbands.
THE BABY FACTORY: DISCOURSES OF REPRODUCTION AND POVERTY Women in Taquaril reflected on the changes in family size that had occurred between their own generation and previous generations, and they saw this as an outgrowth of urban life, of the difficulties of raising children in the city and trying to give them a better life than they had had. The experience of motherhood is shaped by the specific material conditions of womens lives, but this does not mean that these women were isolated from middle-class values and trends: they had ample exposure to these through the media and, especially, their own personal experience as domestic workers in middle-class families. The women in Taquaril espoused a relatively new model of the modern family but, for a variety of reasons related to their class position, had difficulty achieving it. They have taken up the discourses found in the media, among health care professions, and among the middle classes: families are something that should be planned and fertility can be controlled. These notions were not experienced just as generalized goals. Particular relatives, neighbors, and employers often played important roles in scrutinizing a womans reproductive behavior. Eugenia, for example, migrated to Belo Horizonte from rural Bahia when she was only a young girl. Her parents sent her to live with her older sister, Margarete, who was already married and living in the city. When I interviewed her, Eugenia was in her forties, and it was clear that Margarete had been her principle form of social support and friendship for much of her life. Margarete only had one child, but Eugenia had four. When, one day, Margarete complained to another sibling that Eugenias house was over-run with kids, the offence ran so deep that Eugenia disowned her, refusing to
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speak to her or to see her. And, at the time of the interview, it had been seven years since they had exchanged words. When I asked how many children women thought was ideal, the answer was invariably one or two, or um casal (a boy and a girl). This was in explicit contrast with the family size of their parents and grandparents generation. In the past, women explained, people had as many children as God sends. Nowadays this is not desirable. Despite references to planned families, none of the women thought she had been able to achieve a planned family. All of the women I interviewed in Taquaril had more children than their stated ideal, were ambivalent about their fertility, and=or said that they had become pregnant too young or had not had enough time between pregnancies. They were ashamed to have had one child right after another. When I first came to Taquaril to study womens reproductive experiences, Ftima, the mother of two a daughters, said that I had chosen the right place. She exclaimed disparagingly, The [urban] periphery is a baby factorythe only factory in Brazil that doesnt go on strike! Associations between poverty and (supposedly excessive) fertility are represented in the media and in the everyday comments of middle-class and working-class people alike. An article from Belo Horizontes principal newspaper, Estado de Minas, was subtitled Rates of national demographic growth have declined but, in poor areas reproduction goes full steam [reproduca esta a todo o vapor] (Maakaroun 2001). The article begins with the stories of two women, a 23-year-old with six children and a 52-year-old who had had 15 pregnancies. The focus of the article, however, is a study that shows that families in the metropolitan region of Belo Horizonte who earn up to one-quarter of the minimum salary have an average of 3.1 childrenhardly the rampant fertility implied by the title and vignettes. Low-income women judge their own excessive fertility and that of their neighbors in contrast to the small, planned families of the middle classes. Arac noted that the middle class only has one or two [children], and here we have so many. Her neighbor, Wilma, the mother of three children, agreed, commenting sarcastically: If you are asking how many children we should have, its none! The implication, of course, is that if the wealthier families can afford only one or two children, the residents of Taquaril cannot afford any. The prevalence of an economic rationality demonstrates the extent to which reproductive discourses and practices have become
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a central site for measuring social progress and a marker of self and other (Kanaaneh 2002)in this case, rural versus urban, working class versus middle class, ignorant versus cultured. A nurses assistant at the local health centera woman who is a resident of Taquaril and who is responsible for conducting family planning information sessionsthought that knowledge about contraceptive methods was improving. She attributed this to the fact that residents were gaining culture because they were now living in the city:
With each day that passes women [in Taquaril] are better informed [about family planning]. Its something that the 15-year-old girl knows about more than her mother because she has had this advantage, urbanization has this advantage, despite all the problems [of the neighborhood]. The little bit of culture that the poor have, they got it in the city, because in the country they didnt know anything!
Not everyone in Taquaril agreed that small families are best. Lea, the 40-year-old mother of four boys, was, contrary to her desires, sterilized because of the serious heart problems she experienced during her last pregnancy. Despite the troubles they get into you have to worry about the drugs and the stuff they can get into on the streetId still like to have more children. They are the joy of the house. Children are valued for their affection and company and for the care they may someday provide their parents, but Leas comments were spoken self-consciously against the backdrop of a more dominant view. Most residents of Taquaril were very sensitive to the fact that large families are associated with backwardness, rural life, and poverty, and family planning was understood as a route to achieve the modern family and social mobility.
ITS HARD TO RAISE A FAMILY THESE DAYS: MOTHERHOOD AND THE MODERN FAMILY These days virginity upon marriage is a cultural ideal rather than a reflection of womens actual behavior, yet women in Taquaril found it difficult to use contraception at sexual initiation due to the sexual double standard of passive (innocent) femininity and active masculinity (see also Parker 1991). Planning ahead to use contraception placed a womans proper femininity into question. Few women, in fact, used contraception before they were
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in a committed relationship, and even then usually only after the birth of their first child. Although an engagement sometimes indicated public recognition of a young couples sexual relationship, often engagements and marriages came on the heels of a pregnancy (Kaufman 1998). Most marriages in Taquaril are common-law marriages rather than official unions registered on paper. A couple is considered married if they reside together or if the man provides some support for the household. For both a man and a woman, marriage implies responsibility and the fulfillment of complementary roles. Traditionally, the function of marriage is procreation, and children still represent and solidify nuptial unions. Ideally, parenthood is the work of both father and mother: both should accept responsibility (assumir responsibilidade) for raising children. Traditionally, the fathers role has been to provision the household: a good husband=father leaves nothing for want (deixa nada faltar). Given high unemployment rates, however, many men find it difficult to fulfill their roles as family provider, and it is often a womans income that supports the family. New ideals of companionate marriage have also affected womens perceptions of mens role in the household (Rebhun 1999), and women longed for dialogue and affection. Motherhood remains central to the gender identity of workingclass women (Neuhouser 1998), but womens participation in paid work and community organizations means that womens identities are not exclusively limited to the domestic sphere (see also Diniz, Souza, and Portella 1998). Despite some recent shifts in gender relations, reproductive and domestic tasks are still almost exclusively assigned to women. In the womens narratives biological reproduction was always related to social reproduction, the work of childrearing, household chores, and family relationships. As soon as daughters are old enough, they are expected to assume household tasks. Most women work outside the home at least part-time and rely on help from their teen-age daughters. Whereas employment for men is hard to find, women, even young girls, can find as work in domestic service.18 When I asked women why they had decided to undergo sterilization, they said that they needed the ligadura19 because they could o not afford to have more children (na tenho condico es), and they specified that they were not referring to basic necessities such as food. Women identified the primary problem as raising children
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properly and providing them with schooling. Sometimes they echoed a popular sayingWhere one eats, ten eatmeaning that food could be stretched whereas other material objects and education could not.
[My husband] thought it [the tubal ligation] was good . . . he thought it was good because he didnt want any more kids. Because he thinks that kids are a lot of work, you know. And it is really difficult to raise kids these days. Not because they wont have anything to eat, or anything to wear . . . but to raise them. Its very difficult to raise a family these days. (Josefina, 33, seamstress, three children, sterilized at age 30) Life here in Taquaril is very difficult, I think that its due to the conditions that people have to live in that there are so many children just running loose here . . . If you put a child into the world, then you have to take full responsibility for raising the child. Because its not so difficult to give a kid some rice and beans, whats difficult is to teach him how to behave out there [in life]. (Lena, 38, crafts vendor, four children, sterilized at 26)
Although not all households had a secure food supply, many women, like Arac, insisted that the problem was not feeding children but getting them to school:
Life is so hard! To educate a kid these days, Oh My! [Nossa!]. Because . . . to eat, they will eat. But school? Nobody manages to help us educate our children. I have a son in the 5th grade and I know how much each pad of paper costs. The money my husband makes is enough for food, but not enough for school supplies, and I never ask him for it. So thats why I think that people should use birth control if at all possible [as pessoas tendo condico es de evitar, tem que evitar]. (Arac, 32, domestic worker, four children, sterilized at age 29)
In addition to traditional signs of a good mother, such as keeping a child well-fed and clean, there are now new requirements for good motherhood. Women said they now needed information and something to pass on to [their children]. Arac thought that the biggest problem with becoming a mother at age 17, as she had done, was that she had nothing to give them at that age. Yet Arac thought that she had become an excellent mother:
Because I gave up every opportunity in life that I had to be a mother, to take care of my kids, everything that they need, that is within my reach, I try to do. I talk to them a lot. I explain how life is out there, and that maybe they are going to have a reality different than what Im living today . . . I told [my daughter] that when I was her age I couldnt study, I
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had to work in order to get by, and my daughter is 13 and she goes to school and studies. So I think Im a marvelous mother. I keep them in school; I buy what they need. If they need me to fight with them, I fight. If they need affection, I give it. I think that being a mother is this.
A key feature, then, of good motherhood was not only limiting ones family size but also providing children with schooling and other needs. These statements reflect the discourse of family planners, circulated widely in Brazil as elsewhere, which holds that women should limit fertility in order to be better mothers to the children they already have. The focus on education also reflects the states recent interest in promoting basic education through a federal government program (Bolsa-escola) that pays a stipend to parents whose children regularly attend school. In this way, the discourse of schooling as a means to social mobility has been bolstered by real, material benefits. The need to provide children with material goods had also become a justification for a housewife to seek wage work (even if her husband disapproved). Mothers wanted to provide nice clothing, book bags, tennis shoes; but these goods were out of reach of many people in Taquaril. A working woman usually paid all of the expenses related to her childrens schooling and clothing, even if her husband was employed. With no publicly funded daycare available, women were constantly pulled between the necessities of working and caring for children. Those who did this poorly were seen as letting their kids out loose into the street. If a woman worked, she had to be able either to afford daycare or to find someone to look after her children. Although this brought the extra burdens of the double day paid work held positive significance for many women, who said they were glad that they had learned to work and had some control over their own money. For women in Taquaril, fertility control and employment are more than survival strategies (Giffin 1994): they are an investment and a route to a better future. Fertility control is also central to responsible parenthood. Women who had children one right after another, who could not provide adequate school supplies and clothes for their children, or whose households were left in disarray were often labeled disordered (famlia desestruturada). Many women, however, complained that men do not share their concerns, that men have not kept up with the increasing importance of the
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quality of life a parent must offer children as measured in terms of material goods and opportunities of schooling and employment. As one woman stated, When a woman really loves a man and a man really loves a woman, they dont fill the house with kids. This conflict is a point to which I return to below. Womens reproductive intentions are framed by the shifting meanings of motherhood and gender relations. Limiting family size is not a negation of motherhood; rather, it is a route to becoming a better mother. Motherhood is central to the identities of working-class women in Taquaril, but it has taken on new demands, such as providing goods and information. Still, this does not explain why the women turned to sterilization rather than to some other method of birth control. In response to this query, women spoke of their distrust of other methods, of their own negative experiences, and of a series of obstacles to reversible contraceptive use (e.g., difficulty of access, male opposition, and side effects).
YOU CAN ONLY BE SURE WHEN YOU SEE YOUVE BEEN CUT: WOMENS PERCEPTIONS OF CONTRACEPTION When not attributed to its lack of availability, womens failure to use reversible contraception is almost always interpreted as their ignorance of their own bodies and their lack of information regarding how these methods of birth control work (Correa 1989; Perpetuo and Wajman 1998; Osis 2003). My discussions with women in Taquaril about contraceptives methods added a large degree of complexity to these arguments. When I arrived in the community several birth control methods had been theoretically available to women in Taquaril for three years, and they understood that, in order to receive birth control through the community health centers, they had to attend a family planning information session and have a gynecological exam. All of the women I interviewed had been through family planning seminars or had consulted a health professional about birth control. Most had experience with the pill, the IUD, and some traditional methods (withdrawal and the calendar [tabela] method). There was widespread belief in Taquaril that the birth control pill and other methods were ineffective. Even women who had used the pill successfully over many years questioned its reliability. Delia, who had used the
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pill for eight years, told me, I thought it was secure, I felt secure; but I cant say this around todays young people. You see what is happeningeveryone gets pregnant taking the pill [todo mundo engravida dio]. Mariana, who was only 20 years old and who had tomando reme two children, hoped to undergo sterilization because she believed it was the only effective birth control method available: This business about avoiding pregnancy with the pill, I dont know, I dont trust it much, no. This business about the pill, the IUD, I dont trust them. Only sterilization gives you concrete proof that you cant get pregnant, because you can see that youve been cut. Many women reported that they got pregnant while taking the pill. As Luza, a 38-year-old with three children told me, I used Nordete, and I used it for two years. I took it correctly, but one fine day I started to feel nauseous and I was pregnant, while taking the pill. While a few conceded that they may have forgotten to take the pill, others insisted that their bodies had simply gotten used to the pill or that they had used a pill that was too weak. Many women also quit taking the pill because of its side effects and the feeling they had that it was not good for ones health. Given inadequate services at public health centers, women often found it more convenient to purchase oral contraceptives (without a prescription) from the pharmacy. It would not be surprising, then, that many women lacked adequate instruction on pill usage, took an incorrect dosage, and=or took the pills despite contra-indications. All of these factors increase the health risks of oral contraceptives, complicate womens use of the pill, and decrease the pills efficacy (Rosenberg et al. 1995). And many women felt that other methods did not offer viable, effective alternatives either. Some women disapproved of the IUD because they considered it an abortifacient. Some told stories of babies born with an IUD embedded in their bodies, and some thought that IUDs could get lost inside a womans body.
I was really afraid of that IUD. People always say that a baby can be born with [the IUD] stuck in it, and that you cant have sex in just any way. My husband is very respectful, but even he was afraid of the IUD . . . afterwards you have a child full of problems. (Eugenia, 40, housewife, four children, sterilized at 32) My cousin used the IUD but when she went to the doctor, he said it had gotten lost [tinha sumido] . . . I really dont trust it. (Fabiana, 20, one child, not sterilized)
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None of the women I met in Taquaril had ever used a diaphragm, although some had heard of it. Health workers rarely recommended it because they believed that lower-income women would find it shameful and unacceptable due to a traditional resistance to the manual manipulation it required. Some older women I interviewed did find the idea unpleasant, but younger women said that they had been discouraged from trying the diaphragm. One young womans employer, a nurse, dissuaded her from trying the diaphragm because that will get you another child for sure . . . Use the IUD before you use [the diaphragm] because with that thing you have to put it in and take it out, put it in and take it out. While national surveys report widespread knowledge of contraceptive methods, womens ability to name several methods should not be conflated with the kind or quality of knowledge that they possess (Osis et al. 1999). Vieira (1999), too, found that womens attitudes toward contraceptive methods and abortion indicate that the option of sterilization is related to prior use of contraceptive methods, particularly contraceptive failure and adverse effects (746). Womens failure to use methods effectively should not be reduced to a lack of information; rather, anthropological studies have found that, in many societies, prevailing notions of how the body works diverge significantly from the biomedical model and that this lay model of the body complicates womens use of contraceptive methods (see, for example, Nichter and Nichter 1987). In Brazil, working-class representations of reproduction envision conception as the comingling of menstrual blood and semen (Leal 1996, 1998; Victora 1996). Thus women believed they were most likely to get pregnant on the days directly surrounding their menstrual periods. Many women told me that a traditional method of avoiding pregnancy was to refrain from intercourse for three days before to three days after ones menstrual period:
Gina: Did you use any other method [before the ligadura] , Conceicao: Only what my mother taught me, ne that you avoid having sex three days before and three days after the menstruation. But for me it didnt work ne? . . . since I got pregnant so many times. (Conceicao, 38, two children [nine pregnancies], sterilized at age 36)
Menstrual blood both cleans and prepares the womb for conception, and it is also the very substance of a fetus. Accordingly, many contraceptive methods fail to make sense (Leal 1996).
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For example, one stops taking the pill exactly during the days considered most propitious to fertilization. Traditional methods of contraception (abstinence, withdrawal), in contrast, function by either preventing the intimate interaction of bodily fluids or by interrupting a pregnancy in progress. Herbal infusions were not abortifacients, but they would bring down the menses. The pill also frequently diminishes the quantity of a womans menstrual flow, which women perceived as blocked or retained menstrual blood. When women complained of the negative side effects of the pill (such as headache, nausea, fatigue, and nerves), they explained that this was due to the excess of menstrual blood that had failed to descend (Bessa 2006). These factors led women to periodically rest from the harmful effects of the pill. Side effects, such as changes in menstrual flow, may be considered trivial from a biomedical standpoint, but they are highly unsatisfactory to women. The unacceptability of, and lack of success associated with, using reversible contraceptive methods meant that women had more children than they desired and had little success spacing their pregnancies. Without recourse to legal abortion, and often after the harrowing experience of clandestine abortion, sterilization was the best option that many women could choose, although it often came after the ineffectiveness of the pill or exhaustion from its unwanted side effects. Having decided to seek sterilization, however, a woman had no assurance that she could do so. And the first obstacle for many women in Taquaril was often their husbands.
COMPLICITY AND CONSENT: THE POLITICS OF REPRODUCTIVE CONTROL Before sterilization was regulated and widely offered in the public health system, one of the biggest issues for women was how to gain access to the procedure. One of my interviewees, in fact, came to me wanting to know whether I was the lady talking to people about sterilization. She thought I might know of a doctor who could help her out (i.e., perform a tubal ligation) because she was crazy about undergoing sterilization [doida pra ligar]. Many women actively sought out sterilization at the local health center and regional hospitals. Arac shared her story of marital strife and a several-year-long pilgrimage in search of a doctor who would give her a tubal ligation.
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Arac grew up in Belo Horizonte as one of nine children. As a young girl she periodically escaped an abusive stepfather by living on the streets and returning home every few days to see her mother. She rarely attended school, and at ten years old she went to live with a better-off family and worked as a bab, taking care of their a small child. At sixteen she met and began to date (namorar) Jose, a doorman (porteiro) who was four years older than she. When she became pregnant Jose found a place for them to rent and they began to live together. When Jose soon lost his job, Arac began working as a cleaning lady (diarista) to support herself, her husband, and her young son. Although she supported the family, Jose fought to maintain his authority within the marriage. He told her that she was a minor and that he was her guardian. Jose was a jealous husband: he questioned her whereabouts and demanded her obedi ence. Arac was miserable in her marriage but could not leave it. She now had child and, therefore, would not be hired as a live-in domestic (see also Diniz et al. 1998), nor could she return to her mothers house and thus risk abuse at the hands of her stepfather. Arac learned about contraception during her first pregnancy. Friends told her that women who are breastfeeding do not get pregnant, so she did not worry about finding a way to avoid (evitar) get ting pregnant while breastfeeding her son. Within a year, Arac was pregnant again. When her second child, a daughter, was born, Arac decided that life was too difficult. Scared by her pregnancies, which came one right after the other, she decided she did not want to have any more children. Her mother had died and her closest siblings were brothers, so her neighbors were her most important source of information. She learned from them about sterilization and about a hospital in the city that might perform the operation but was warned that her husband would have to give his written consent. Even though she had not used any other contraceptive method, she was already considering sterilization. Jose was adamantly opposed but told her he would agree to it if they had another child.
Well then I wanted to get sterilized [ligar], but Jose wouldnt agree to it. He said that if we had one more child, then he would sign the papers, and I believed him. So, I got pregnant right away and this was our planned child but then [afterwards] he didnt want to sign the papers! He lied to me and I believed him.
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After the birth of her third child, despite her husbands disap proval, Arac sought out family planning services and began looking for a doctor who would perform a tubal ligation.
Everywhere I went the answer was the same. I went to a polyclinic and the medical committee and the doctor told me that he could only perform the sterilization if I had a serious health problem. He said that I was very young and could have another ten kids yet!
Due to her young age, doctors recommended other birth control methods, and Arac began taking a contraceptive pill:
But then I started to have problems like varicose veins [veia arrebentada] and dio] so I stopped taking it. stomach-aches when I took the pill [com o reme After three months, I was pregnant. Today I see this talk about condoms [camisinha] but I didnt see this then. Condoms were expensive. I went to many [family planning] seminars and they didnt have free condoms, and an IUD wasnt cheap.
When I asked whether she had learned about other methods, such as the diaphragm, she said yes but that she found it ludicrous: A husband doesnt let you know ahead of time that you are going o to have sex (O marido na avisa que vai ter relaca As Aracs story o). shows, gender relations directly influence the kind of methods women can choose. Married women said that they were expected to be sexually available to their husbands. In fact, both men and women expect men to have less control over their sex drive, and to have a greater need for sex, than do women. Of course not all men were resistant to contraception. Some, especially younger, men were described as cooperative and respectful regarding birth control. Bete, 17, a newly married woman with one child, said that her husband reminded her every night to take her birth control pill. But for many women, contraceptive methods that require a partners cooperation or planning are impractical. Desperate and pregnant for the fifth time, Arac decided to have an abortion. With the help of a friend she contacted a woman in a nearby neighborhood who performed the abortion by introducing a probe (sonda) into her uterus. She aborted the fetus but continued to hemorrhage, suffered severe pains, and eventually went to the hospital, where, fortunately, she recovered. Traumatized by her experience, Arac no longer feared Joses opposition. After securing his consent, she then struggled to save money for the fee the physician charged her, even though a tubal
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ligation should have been covered by the citys 1992 sterilization provisions. She underwent sterilization in 1993:
I confronted him; I talked and explained that I was not willing to have more children because we already had a lot of children and we could not provide for them. But he said that he wasnt signing any papers. And then I went to the hospital and I told the doctor that my husband wouldnt sign, and he said, Well then I cant do the sterilization. So then I talked with him [Jose] again and told him that I had made up my mind to not have more children at any price. Its between the ligadura or abortions! I insist that you sign this, because if I get pregnant again, Ill have an abortion. And he got really mad and we didnt talk about it anymore. But then I went to his workplace with the paper and told him to sign, and he said he wouldnt, and so I said, Fine, but you will be left at home to care for your kids alone. And when I said this I had my packed bag over my arm. I pressured him. So then he signed them and threw the papers on the ground. I thought, What am I going to do if he doesnt sign these papers? . . . Many women die because of abortion. I almost died. I suffered so much, it was a horrible pain and I didnt want to go through that again. . . . Then I had to come up with the money. It was a damned struggle to get that months wages. I had to borrow money from friends and everything. But then I finally got the ligadura and I was already 29 years old. If I hadnt done it, Im sure Id have another baby by now.
The fact that women turn to sterilization because other methods fail or entail unbearable side effects does not eliminated the fact that sterilization, at least for some women, contains elements of resist ance (Lopez 1998) to patriarchal gender relations. As Arac put it:
I imagined that Id have four children. When I joked around, I always said I was going to have four: two boys and two girls. I thought it sounded cute. But after I had my second child, I saw that life was too complicated and I didnt want any more children. We didnt own our house; we paid rent. [Jose] never worried about school, he thought that we could have ten kidsor however many God decided to send ushe never thought about using birth control [evitar de jeito nenhum]! But I went over his orders, and I got sterilized.
Given the division of labor in the household it is not surprising that women were more eager than were men to limit their family size. Brazilian law grants couples the right to determine their fertility. Yet, because men and women do not equally share the burdens and costs of childrearing, they often disagree about fertility, contraception, and sterilization.
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Sterilization is not without risks and side effects, which revolve primarily around the the perceived effects of tubal ligation on womens sexuality. It was commonly believed that the ligadura either left women especially hot (sexually interested) or cold (sexually uninterested), although this idea was contested:
The ligadura was the only option for me. At least I dont feel anything. I o didnt become frigid [na esfriei]. A woman is cold if shes going to be cold, and shes hot if shes going to be hot. One thing has nothing to do with the o other [A mulher e fria se tiver que ser fria e e quente se tiver que ser; na tem nada haver uma coisa com a outra]. (Arac)
Men rejected female sterilization because it was thought to interfere with womens sexuality. Leas husband told me that his neighbor had had a tubal ligation and then started chasing after every man on the street. After Lea was sterilized for medical reasons, she said, Hes never talked about [their neighbor] again. He doesnt want to think about it. Arac also explained that her husband resisted her own desire to be sterilized because then she could go with any man:
Arac: My husband said that a woman who sterilizes [mulher que liga] can go with any man because she wont get pregnant. But when I got pregnant, he said that baby wasnt his either . . . The only thing that changed [after she was sterilized] is that he became even more jealous, he assaulted me with words even more. I had to go to the doctor . . . and then he asked how my husband reacted to the ligadura and I told him. And [the doctor] said that its because the macho man thinks that when a woman is not sterilized, if she has an affair, shell get pregnant and hell know. After [the surgery], if she has an affair, she cant get pregnant. My husband wore himself out saying this to me! Gina: But you were on the pill before that, right? Arac: Yes. I think that when a woman gets pregnant, the man gets crazy to see if the baby looks like him!
Female sterilization represents a conflict: it affords women more control over their bodies because it is the most effective contraceptive method but it threatens male control over female sexuality. For men, especially, sterilization represents a breakdown of the important division between procreative sex within marriage and extramarital sex (on the street) outside the home or with prostitutes. When, through sterilization, a mans wife definitively ends the
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possibility of procreation, she comes symbolically closer to being the loose woman on the street for whom sex and reproduction are not linked. Within this context it is the authority associated with a physicians recommendation of sterilization, or a physicians willingness to perform a tubal ligation, that allows some women to challenge patriarchal authority (Citeli, Souza, and Portella 1998). To the extent, however, that physicians and the new law require a husbands consent, they become yet another gatekeeper with whom women must negotiate for control of their fertility. Not surprisingly, women knew the justifications used by the medical professional to evaluate their request for sterilization, and they used these in their favor. The pre-1992 restriction of sterilization to medically justified cases, for example, could be manipulated. Ceclia underwent sterilization at age 26, immediately following the cesarean birth of her fourth child. Although her other births had been normal, her fourth was planned as a cesarean so that she could have her tubes tied.
I had to invent health problems in order to be able to ligar through the [Military Police Health Plan]. At that time [before it was legal], they wouldnt ligar a young woman. But I had some health problems, and the doctor invented some other ones so that she could do the sterilization. I told her, If you dont want to give me the sterilization, and I have more children, then you can take responsibility for them. Ill bring them to your house! (Ceclia, 33, domestic worker, four children)
Tania, another resident of Taquaril, enlisted the help of her middleclass employer to locate a physician who would perform a sterilization. Although at first the physicians secretary protested that Tania was too young (26 years old) for sterilization, Tania said, I explained my situation . . . my living conditions . . . and I think she took pity on me. This physician later agreed to help other women whom Tania knew and who, like her, already ha[d] many children and [did]t have [the right] conditions [in which] to raise them. Other physicians also took it upon themselves to offer sterilization services. Early in my fieldwork one obstetrician and several women in Taquaril related the story of how, several years earlier, a gynecologist working at the one of the local health centers routinely offered and performed sterilizations for residents in the community. His practice was denounced by a journalist who claimed
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that he was sterilizing women in order to gain popular support for his wifes candidacy for a city council position, and his license was eventually suspended. Women in the community were furious when this service abruptly ended. Eugenia, who was sterilized by the infamous physician, defended him:
Eugenia: Many women ligaram [through Dr. Thomas] until that mess broke out. [They said] he was sterilizing women who hardly had any kids and without their husbands authorization, so husbands showed up there wanting to kill him. But he was just doing his duty [fazendo a obrigaca dele]. It was the women who went o there without authorization from their husbands and asked for the ligadura! He did it there at Hospial P. where he [also] worked. He said to me after I had the operation that he was at my service if I needed anything else. Gina: Did many women go there to get sterilized? E: There were a lot, when that doctor was here, he sterilized a lot of women . . . The women were happy for what he did for us; I was very satisfied. Gina: And there was . . . a journalist and the press . . . Eugenia: Yes, the press went there and some women were mad because they hadnt had a chance to take advantage of it. Because, the women here suffer so much . . . they were upset; many didnt have the operation because their husbands didnt want them to.
Although women have managed to gain a privilege that the state has denied to them, many of them had to undergo sterilization without appropriate counseling. Some women do not fully understand the irreversibility of the procedure, as is shown by the common belief that there are two distinct techniques of sterilization: cutting the tubes, which is permanent, and tying the tubes, which may be undone (see also Vieira and Ford 1996b). However, for many women, the greatest health risk of clandestine sterilizations is posed by the link to c-sections. Cesareans have become the price to pay for access to tubal ligations; and, like the price of everything else, it is subject to inflation. As one woman explained, Now it takes four cesareans in order to get a tubal ligation [agora o sa quarto pra ligar]. Some have suggested that womens demand for c-sections drives the high rates of surgical deliveries (Faundes and Cecatti 1993) Women may value c-sections because they are seen as less painful than vaginal childbirth and come with greater medical attention than other forms of childbirth (Serruya 1996; Dalsgaard 2004).
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However, large-scale studies by Hopkins (2000) and Perpetuo et al. (1998) reveal that the vast majority of women (over 70 percent) prefer vaginal childbirth because recovery is faster and less painful than is the case with c-sections. Women consider vaginal birth to be normal and believe that it is what is best for both infant and mother. Women in Taquaril did not prefer cesarean deliveries but, rather, wanted to have normal deliveries so that they could recover more quickly. Marianas children were both delivered by cesarean o section because the doctor told her she had dystocia (na tinha passagem), but she had hoped for a vaginal birth:
Mariana: Because . . . the girls here who already have children, they say that the pain [of child birth] is just during the birth and then you dont feel anything else. You feel some pain, because of the stitches and all [from the episiotomy]. But not like with the cesarean. With the cesarean at the time, you dont feel anything. But youll feel the result later. Even today, my stitches hurt. Its been 20 days and even today I have to walk slowly and those things. I have to be so careful. I cant lift anything heavy because I might open up again. So there are many reasons.
Even though a vaginal birth would be painful, Mariana reasoned that recovery and a return to normal activity would be faster than it would with a cesarean childbirth. Despite her young age, Mariana said she really wanted to undergo sterilization, in part, because she did not want to go through another cesarean. When she asked a nurse about sterilization, she was told that she was too young: [The nurse said] you are too young . . . you have your whole life ahead of you. But I said to her, Yeah, but I dont want to be cut open all the time. But she said, you have to use some other contraception [ir evitando], because the doctors are not going to give you a sterilization. Doctors occupy a position of relative power in relation to their birthing clients and have significantly more control over what happens in the delivery room (Hopkins 2000). In contrast to women, doctors benefit from the convenience and shorter delivery time that cesarean sections afford. REPRODUCTIVE RIGHTS AND THE MEDICALIZATION OF REPRODUCTION Reproduction in Brazil is thoroughly medicalized. Clearly, women are subject to new forms of disciplinary power and the sterilizing
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nature of modern society, in which men and women are discouraged from procreation (Minella 1997). An awareness of the constraints women face calls attention to the need for both expanded contraceptive services and the creation of enabling conditions within the family, gender relations, and society at large (Correa and Petchesky 1994). Analyses of the culture of sterilization explain why some women might have become committed to a limited set of contraceptive options (Potter 1999) and suggest that expanding contraceptive availability may not be sufficient to reduce the numbers of sterilized women. Conceptualizing medicalization as imposition, however, misses womens active role in attempting to gain access to sterilization prior to the 1997 law and their sense of entitlement to fertility control. In an attempt to understand womens motivations for opting for sterilization, Brazilian feminists have found themselves caught in the dilemma of how to critique the kinds and range of choices available to women without denigrating the decisions women do make for themselves, even under severe social and economic con straints (Correa and Petchesky 1994:111). In contrast to interpretations that see sterilization as indicative of womens inability to challenge traditional sexual relationships and=or their passivity in the face of increasing biomedical control, I argue that sterilization is a complex response to rapid changes in womens lives and is indicative of their active negotiation with modernity. The lives of most middle-aged women in Taquaril are dramatically different than were those of their mothers and grandmothers. Women desire small families and strive to provide their children with a better life. They see sterilization as one route to social mobility and to better health. Their decision to be sterilized is conflicted and constrained, but it is an expression of their active agency. For some women sterilization is also a way of resisting unequal gender relations. Arac clearly expressed this when she said: I went over his orders, and I got sterilized. Accounts of the process of medicalization that leave little room for womens pragmatic assessment of their reproductive needs contribute to the production of stereotypes that portray poor women as passive, submissive, and fatalistic. It may be that women have used medical technologies strategically as a form of resistance in their individual lives only to become the objects of other forms of power (Abu-Lughod 1990). But the notion of control over ones body and ones fertility is itself an invention of modern society and modern
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medicine, along with the tools to exercise that control. Neither biomedicine nor womens responses to biomedical interventions can be seen as singular or uniform. A variety of social, institutional, and historical factors have contributed to the culture of sterilization and the culture of c-sections in Brazil, and womens responses to these surgical interventions are not identical. We must make a distinction between, on the one hand, those procedures that women adopt because they somehow serve womens own perceived needs and, on the other, medical interventions that women tolerate because they have little power to resist them. In the Brazilian case, unnecessary cesarean sections present the greater violation of womens bodily integrity, autonomy, and rights. In many settings around the world sterilization has been the tool of population control interests and family planning programmers. In some cases women have actively adopted sterilization because their interests overlap with those of the state programs (Whittaker 1998) or because it reconfigures familial power relations (Saavala 1999). Womens responses to medicalization are specific, depend on the perceived impact of the intervention on their daily lives, and must be examined anew in each context (Lock and Kaufert 1998). The research supports the conclusion that more attention should be paid not only to the kinds and quantity of methods to which women have access but also to the kind and quality of information women have about them. Expanding contraceptive choices is too often envisioned as a question of augmenting con traceptive services (Daz et al. 1999). A consideration of the ethnophysiology of the working classes challenges the idea that simply making more methods available is sufficient. Health services must also take into account womens understanding of their reproductive system and address the side effects that they find uncomfortable and unhealthy. It may also be that the social representations of contraceptive methods should be addressed so that methods other than sterilization will be seen as credible (Osis et al. 1999). Finally, womens contraceptive behavior and their ability to exercise sexual and reproductive rights cannot be understood apart from other spheres of social and economic life. Reproductive choices are structured in the home and in the community. Expanding family planning within health services will have only a limited impact if women lack the power to negotiate their sexual and reproductive lives within their personal relationships. Efforts to enhance
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womens reproductive rights and health will have to reach far beyond those of the reproductive health services. ACKNOWLEDGMENTS The research for this project was supported by a Fulbright Fellowship, a grant from the Graduate College of the University of Illinois at Urbana-Champaign, and a New Faculty Research Grant from the College of Arts and Sciences at Illinois State University. I thank the women of Taquaril, who so generously shared their days with me. I sincerely appreciate the assistance of my collaborators at CEDEPLAR: Centro de Desenvolvimento e Planejamento Regional, especially Ignez Oliva Perpetuo and Maria do Carmo Fonseca, and of my colleagues at MUSA: Mulher e Saude, especially Cremilda Almeida and Monica Bara Maia. Special thanks also to Maria Tapias and four anonymous reviewers from Medical Anthropology for their thoughtful critiques of this article. NOTES
1. Just a few examples from this vast literature include Corea (1985); Ehrenreich and English (1979); Gordon (1977); and Tanaka and Alvarenga (1999). 2. Female sterilization refers generally to various medical methods for preventing the eggs passage through the fallopian tubes. In Brazil the most common procedure is tubal ligation, during which the fallopian tubes are severed and sometimes bound. 3. Other modern methods, such as the IUD (1.1 percent), injections (1.2 percent), and condoms (4.4 percent), contributed little to the contraceptive mix; traditional methods, such as periodic abstinence (3 percent) and withdrawal (3.1 percent) only slightly more so; and rates of vasectomy (2.6 percent) were insignificant compared to rates of female sterilization (BEMFAM=DHS 1996). 4. Sterilization was effectively illegal due to a clause in the Medical Ethics Code. 5. Universal health care in Brazil is provided in public facilities that are reimbursed de through a government health insurance system, the Sistema Unica de Sau (SUS). A second group of facilities, called conveniados, are private but have contracts with the state system. These two groups serve the majority of the population, and in-text references to public services refer to both. A third group accepts private health insurance only. 6. Caetanos research in the northeast of Brazil documents the fact that politicians and physicians arrange and pay for sterilization. Sterilization has become one among several political goods that politicians exchange for votes. This has led to a greater number of interval cesarean sections in the northeast as opposed to other regions. 7. The high rate of sterilization carries additional health risks related to HIV and other sexually transmitted infections since women who have been sterilized are not likely to use condoms (Barbosa and Villela 1995).
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8. The Taquaril housing settlement is composed of some 40,000 residents in 14 neighborhood sectors. It is large enough not to warrant the use of a pseudonym. All the names of women interviewed, however, are fictitious. 9. The minimum salary is a federally established monthly wage. In 1998 the minimum wage was R$130, which corresponded to approximately US$107. Income is usually referred to in terms of the number of minimum wages one receives. 10. The Brazilian government maintained explicitly pronatalist positions at least until the 1970s due to the perceived need to occupy its vast territories, particularly in the Amazon region, and to provide abundant labor force for industrialization. These strategic interests converged with a conservative maternalism and with the Roman Catholic Churchs staunch opposition to contraception. 11. In 1996 the total fertility rate (TRF) for the northeast region was 3.1 compared to 2.5 for Brazil as a whole, and the TFR for rural women was 3.5 compared to 2.3 for urban women (BEMFAM=DHS 1996). By 1999 the TFR in Brazilian metropolitan areas ranged from a low of 1.8 in Belo Horizonte to 2.2. in Curitiba (in the south) compared to 2.4 for Brazil (Goldani 2001:2). Women with higher levels of income and education also have lower average fertility (1.9) than do women with lower levels (2.3) (Perpetuo and Wajnman 1998:328). 12. Regional differences in fertility rates and contraceptive patterns are attributed to dramatic socioeconomic differences, the differential impact of immigration patterns (Goldani 2001), and local cultural patterns (e.g., Caetano [2000] on the northeast). See Potter (1999) and Goldani (2001) for excellent discussions of fertility decline in Brazil that address regional distinctions. 13. Goldani (2001) describes a long process of medicalization that affected the reproductive behavior of Brazilian women. She sees medicalization as a complex interaction between medicine, family, and the state and highlights the key role of medical discourse and physicians from the 19th-century hygienist movement through early 20th-century eugenics to the contemporary (196096) modern contraceptive revolution. 14. Abortion is illegal in Brazil except in cases of rape or when the mothers life is at risk; however, it is widely practiced and, until the 1970s, was probably the most significant method for limiting fertility. Some estimates calculate that one-third of all pregnancies end in clandestine abortion. The illegality of abortion is a consequence of the opposition of the Roman Catholic Church. Although the majority of Brazilians are Roman Catholic, the influence of the Church has had greater influence on official government positions on contraception and abortion than it has had on the reproductive behavior of Brazilian women. 15. In addition, the average age at sterilization fell from 31.4 in 1986 to 28.9 in 1996. 16. In the City of Belo Horizonte a 1992 municipal law had already provided for voluntary sterilization. But few facilities offered the service, and those that did required that each case be approved by a medical committee that assessed a womans age and parity (both higher than those established by the 1997 federal law), medical history, spousal consent, and socioeconomic factors. 17. This article is based on the Brazilian component of a large cross-cultural study of reproductive rights and experiences organized by the International Reproductive Rights Research Action Group (IRRRAG). The results of this project are cited in this text under Diniz, Souza, and Portella (1998); Petchesky and Judd (1998); and Citeli et al. (1998)
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18. Few women in Taquaril these days work as live-in domestics, although live-in domestic service was common in previous decades and affected womens reproductive trajectories (see also Pitanguy and Mello e Souza 1997). 19. In addition to esterilizaca (sterilization), women in Taquaril usually referred to the o procedure as a ligadura (ligature) or a ligacao (ligation). They also used the verb form ligar (to ligate). Ligar as trompas corresponds to the English, to tie the tubes.
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Medicalization Reproductive Agency, Desire

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Medical Anthropology, 25:221263, 2006 Copyright # Taylor & Francis Group, LLC ISSN: 0145-9740 print/1545-5882 online DOI:

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

The Desire for Sterilization in Brazil

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