[Surgical contraception on mentally retarded women]. / La esterilizacion quirurgica en mujeres con retardo mental

PIP: Mentally retarded (MR) women present a difficult dilemma in medicine because of the vulnerability of this population to unscrupulous people, and their ability to conceive. Sterilization remains the only contraceptive methods that can prevent pregnancy among these women without the additional complications found in temporary methods. There are 3 categories of people who should be included in any discussion of this type: 1) MR with IQ's of 55=70; who have reached the 4th grade; who can get married and lead a semi-normal life within society. This group should not be considered for sterilization; 2) MR with IQ's of 40-55; these can generally adapt themselves to society; however, it's possible that the process of the "normalization" is too great an effort which could aggravate the burdens of pregnancy and childbearing; sterilization is recommended for this group; 3) MR with IQ's under 40; this group is severely retarded, requiring supervision; they are incapable of taking care of themselves, especially their personal hygiene, and require sterilization. 24-26.4% of children will be retarded when 1 parent is retarded, and 44-47% when both parents are retarded. In cases where sterilization is recommended: 1) it must be determined that the patient cannot demonstrate voluntary informed consent and that coercion was not used; 2) that the patient cannot raise a child; 3) that the patient is at risk of getting pregnant; 4) it must be proven, through a multi-disciplinary committee that there are no other alternatives in the cases; 5) the legal consent of the patient's guardians must be obtained; 6) in cases where there aren't any legal guardians, the institution or legal authority must follow all legal procedures before the Colombian Institute for Family Welfare according to Articles 599 and 600 of the National Health Code. (Author's modified).^ieng

Decree No. 139, Regulations to the Law of Public Health, 4 February 1988.

PIP: This document contains provisions of the 1988 Regulations of Cuba's Public Health Law relating to primary health care, maternal-child health care, sex education, contraceptives, and health care of the elderly. The regulations guarantee maternal-child care in a program which will be revised and updated periodically. All pregnant women will receive medical assistance, and pregnant women at risk will receive specialized care. Institutionalized deliveries are also guaranteed. Attention will be paid to early diagnosis and proper treatment of uterine and breast cancer and to reproductive health care. Children will receive preventive and curative medical assistance. Health education activities will be directed toward the prevention of adolescent pregnancy. Assistance to the elderly will take the form of rehabilitation services, hospital care, housing, domiciliary assistance, and social organizations.^ieng

Public policy and female sterilization in Costa Rica.

For 20 years, female sterilization has been increasing in popularity as a contraceptive method in Costa Rica. However, contraceptive sterilization has never been allowed explicitly under Costa Rican law. In 1976 the Costa Rican National Assembly instituted more stringent guidelines regarding medical sterilizations in order to eliminate contraceptive sterilizations, which had been occurring under relatively loose interpretations of national policy. Data from the 1976 National Fertility Survey and the 1981 Contraceptive Prevalence Survey indicate that the change in policy had only a short-term effect. Period sterilization rates fell substantially after 1976 but rebounded considerably by 1980, and the estimate of the proportion of married women who will ultimately be sterilized was approximately .5 for the periods both before and after 1976.

PIP: There has been a rapid decline in fertility in Costa Rica in the past 2 decades as a result of dramatic increases in the use of contraceptives, female sterilization being one of the most popular. The objection of certain groups to contraceptive sterilization was responsible for a change in procedures designed to eliminate sterilization for contraceptive purposes. However the enforcement of this policy has had little or no long term effect since medical versus contraceptive indications for the procedure cannot be defined precisely, and surgical sterilization for medical reasons is an important part of any modern health program for women. Other examples of government effort to eliminate access to certain forms of contraception or to reverse fertility declines, especially Eastern European countries such as limiting the availability of abortion, have had only very short-lived impact on birth rates. Romania provides the most striking example. In 1966, before stringent regulations in regard to abortion went into effect, the abortion ratio per 1000 live births was 3050; in 1967 it was 333, when abortion was legally limited to women over 45; or women having 4 or more children; or with specific medical indications. But the ratio increased to a level close to 1000 by 1972; abortions were being performed more frequently on the grounds of adverse mental health consequences, which were classified as a medical indication. The general conclusion from the cases cited in this paper is that once low fertility norms are widely accepted in a society that is accustomed to access to the effective contraception needed to fulfill those norms, the ability of a government to restrict access to certain methods of contraception is substantially limited. Studies of family planning in developing countries show that the task of initiating a fertility decline is very difficult as high fertility norms are deeply integrated into social systems and not easy to dislodge. However, once low fertility norms and associated behavior are firmly established, they are equally difficult to dislodge.

Brazilian policy change means new role for BEMFAM.

PIP: Brazil's sudden policy change from a staunch pronatalist country to 1 which would not only recognize the right of couples to plan their families but would endeavor to make this right available to all sectors of society has meant new work for BEMFAM. In the 2nd 5-year development plan the government stated its confidence that a properly informed public would make family decisions that would result in a demographic growth rate consistent with economic and social development. Brazil foresees population growth of 2.7%-2.8% by 1985 with an accelerated decline in subsequent years. For almost a decade BEMFAM has offered the only organized family planning service in Brazil. In Rio Grande do Norte the association has developed a successful program of community-based distribution of contraceptives (mainly orals) which serves 150 municipalities with scarce medical care. Paramedical personnel and existing community services are used. 2 laws which need to be changed are the law which prohibits the dissemination of contraceptive information and the regulation prohibiting the sale of oral contraceptives without a doctor's prescription.^ieng