Frequency and characteristics of induced abortion among married and single women in São Paulo, Brazil Aborto provocado: sua dimensão e características entre mulheres solteiras e casadas da cidade de São Paulo, Brasil

This article presents the results of a study in the city of São Paulo, Brazil, aimed at estimating the frequency of induced abortion among women 15 to 49 years of age. The objective was to characterize the occurrence of induced abortion by comparing the ideal number of children, age, and contraceptive use between married and single women. Based on random sampling, 1,749 interviews were held, including 764 married women, 658 single women, and 327 with other marital status. The analysis included: mean number of abortions per woman by analysis of variance and proportions of abortions and pregnancy, using the chi-square test. The mean abortion rate for married women (45 per thousand) did not differ statistically from that of single women. However, the pregnancy rate was much lower in single women, and when single women became pregnant they used abortion more frequently; while fewer than 2% of pregnancies in married women ended in induced abortions, among single women the abortion rate exceeded 18%. Therefore, the priority in the reproductive health field should be to invest in the supply and dissemination of appropriate contraceptive methods for women’s early sexually active life. Induced Abortion; Contraceptive Agents; Reproductive Health Introduction Abortion is a major public health problem in Brazil 1, especially since it is one of the principal causes of maternal mortality 2, and most of these deaths are avoidable 3,4. Abortion is currently considered a silent pandemic that calls for imperative public health and human rights measures 5. Brazilian legislation only allows abortion when the pregnancy poses a threat to the woman’s life or has resulted from rape, and even in these limited situations, various reports indicate great reluctance by health professionals and difficulty by women in obtaining legal abortion within the public health care system 6,7,8. The restricted legality of induced abortion in Brazil contrasts with the reality of an estimated 750 thousand to one million abortions per year. Some 250 thousand annual cases of hospitalizations in the Unified National Health System (SUS) are known to occur for complications due to abortion 3. The deficient supply of contraceptive methods by the National Health System has been identified as a major factor contributing to clandestine abortion. In 1987, a household survey was carried out in the Vila Madalena neighborhood in the city of São Paulo, Brazil, to measure and characterize the occurrence of abortion, concluding that young, single women used induced abortion the most 9. In 1993, using the same methodolARTIGO ARTICLE Silva RS, Vieira EM 180 Cad. Saúde Pública, Rio de Janeiro, 25(1):179-187, jan, 2009 ogy, a study was held with 1,749 women living in the city of São Paulo, detecting a trend identical to that of the previous study, i.e., that young, single women without children, who use ineffective contraceptive methods (especially condoms and/or the rhythm method), and that report accepting an abortion under any circumstances are the ones that report the highest induced abortion rates when they become pregnant. In Vila Madalena, a high-income neighborhood with an extremely low fertility rate, both the mean number of abortions per thousand women and the proportion of abortions per pregnancy were double those observed for the city of São Paulo as a whole. There is thus strong evidence that in a transition from a given fertility rate to a substantially lower rate, i.e., in the process of declining fertility, the use of induced abortion increases sharply. Additionally, as expected, contraceptive use was more frequent in Vila Madalena than in the city of São Paulo as a whole, consistent with the increasing demand for tubal ligation, which has been the most prevalent contraceptive method for some time in Brazil 10,11. According to Vieira et al. 11, in Brazil as a whole and in the State of São Paulo, women tend to use oral contraceptives until 30 years of age, after which the tubal ligation rate increases. Therefore, induced abortion tends increasingly to be an option for young women during their initial sexually active years and/or outside of a stable marital union. Both studies also showed (through multivariate analysis) that being in favor of induced abortion weighs heavily as a factor for choosing abortion. The next most important factor is marital status: being married is a highly protective factor – more precisely, married women use abortion substantially less often. Even among women who claim harboring restrictions to abortion, single women use it more often. In other words, in spite of their restrictions, that is, even not being totally in favor of the practice, single women (i.e., not living in a stable marital union) are impelled to turn to abortion when they become pregnant. In 2000, the Vila Madalena neighborhood was revisited, this time through an indirect (selfcompleted) survey. Although the interviewees’ median family income had increased since 1987 and the fertility rate had dropped even further, the profile of women using induced abortion remained the same 12. Thus, given the decisive role of marital status for understanding the dynamics of abortion, regardless of place or calendar year, we felt it was important to conduct this analysis considering marital status (married versus single), taking data for the city of São Paulo collected in 1993 as the baseline for subsequent studies using the same instrument and methodology.