At long last we have some official information regarding that troublesome statistic often used by persons implying a genocidal plot in Puerto Rico: "35% fo all Puerto Rican women have been sterilized." According to a letter received by Mrs. Mary Morain, AVS board member, from Dr. Maria Teresa Berio, president of Puerto Rico's Commission for the Improvement of Women's Rights: Sterilization is a favorite method of the Puerto Rican women for family planning. It began in 1943 and its rate among women of reproductive age increased until 1968 when, according to a study done by Dr. Jose Velasquez Calzada, professor of demography of the University of Puerto Rico, School of Public Health, it reached 35%. The government had never officially offered these services through its family planning progra. In february 1974, when the leadership of the program was reorganized and the socioeconomic composition of that 35% was analyzed, it was found that the majority, almost 66% of the women, were of the upper class and the upper middle class, denying the concept that only the poor are sterilized and at the same time indicating an injustice in regard to the accessibility of these services. Only women of means or those who could pay were being sterilized, and those with lower incomes had no access to these services although they wanted and needed them as much as those who could pay. It was in order to correct an injustice in the offering of sterilization services that we decided to offer this operation free of charge to all strata of society. The poor did not have the same access as the rich to these serviecs. The Puerto Rican Family Planning Program is strictly voluntary. In no way are people convinced or coerced to use these services. The people of Puerto Rico have enthusiastically endorsed the family planning program. In a study carried out in 1974 by the Department of Health, 83% of the population believes that sterilization should be offered by the program and should be free of charge.
The degree to which voluntary sterilization (VS) is accepted as a form of fertility control throughout the world was assessed by examining the prevalence and legal status of VS in all countries for which information was available and by examining current religious and traditional attitudes toward VS. Information on VS prevalence for 73 countries indicates that in 28 countries, 10% of all eligible couples rely on VS. In a number of countries, including Korea, New Zealand, Panama, US, and Puerto Rico, 25% or more of all currently married women of reproductive age rely on VS. VS prevalence rates tend to be higher in Asian countries than in African, Latin American, and Middle Eastern countries. In a number of countries, the average age and family size of VS acceptors is declining. Information on the legal status of VS for 124 countries indicates that 22 countries have laws which permit or encourage VS. These countries contain 13.4% of the world's population. In 54 countries, representing 60% of the world's population, there are no laws restricting VS, and VS is generally assumed to be legal. In 29 countries, representing 14% of world's population, the legal status of VS is unclear. In the remaining 29 countries, sterilization is forbidden except for medical or eugenic reasons. The degree to which these laws actually restrict VS varies from country to country. For example in Indonesia VS is illegal but widely practiced. Although some religious teachings discourage sterilization, the impact of religion on VS varies considerably from country to country. In the Catholic countries of Panama, Dominican Republic, and Philippines the prevalence of VS is high, and in the Catholic countries of Argentina, Bolivia, and Uruguay the prevalence of VS is low. VS prevalence is generally low in Muslim countries, but high in the Muslim countries of Tunisia, Indonesia, and Bangladesh. VS prevalence is high in the Buddhist country of Thailand but low in the Buddhist country of Burma. Cultural traits such as machismo and son preference tend to be associated with negative attitudes toward sterilization; yet, VS prevalence is high in China and Panama despite the presence of a strong preference for sons in the former country and of machismo attitudes in the latter country. Acceptance of VS as a form of birth control appears to be increasing throughout the world. This trend will probably become stronger as improvements are made in VS technologies and Vs delivery systems.
On overview is provided of a 9-month outreach program in family planning (FP) for poor Spanish-speaking families in Maricopa County, Arizona. Arizona does not provide any public FP services. A network of bilingual outreach workers provided educational sessions to individuals, to groups in homes and schools, during neighborhood meetings, and at work places. The tasks involved presenting information, advocating FP, transporting people to medical appointments, and guidance through the health care system. More than 600 people received FP information during this period. 77 asked for FP referrals, and 89 requested referrals for sterilization. Literature in Spanish and English was field-tested. The costs of voluntary sterilization were underwritten by a small fund from the Arizona FP Council (AFPC) and by donations from private providers and clinics. The outreach effort was successful because of consistent follow-up until services were rendered. This persistence was necessary in order for many clients to navigate the English-speaking system and satisfy their needs. The need for FP services was documented. Lists were generated of persons waiting for sterilization. A recent development was the availability of public funds for those qualifying for state assistance in order to obtain voluntary sterilizations. An independent evaluator commended the program for breaking down barriers which confront low income, Hispanic, minorities and recommended that it be adopted to other special populations needing FP services.
The Association of Voluntary Sterilization (AVS) conducted a survey in 1981 of freestanding clinics and outpatient hospital facilities to determine the cost of sterilization. Of the 888,000 sterilizations performed in the US in 1981, approximately 5% (31,000 female sterilizations and 15,000 vasectomies) were done in freestanding clinics or outpatient hospital facilities. This is a small proportion of the total, but among this small universe of providers costs were generally much lower than those for in-hospital procedures or for services from private practitioners. Some providers reported using a sliding scale of fees based on an individual's annual income. Such costs are not analyzed here because the data provide no information on the most frequently used points on sliding scales. Only costs in facilities that had a fixed fee for services are presented. The data reflect charges for male and female sterilizations in all 4 regions of the US. 252 facilities were surveyed. 77 reported providing female sterilization only, 115 offered vasectomy only, and 60 provided both male and female sterilization services. Of the 137 facilities serving women, 41 reported fixed fees, 23 used a sliding scale of fees, and 73 did not respond to the question on cost. Of the 175 providers of vasectomy, 55 reported fixed fees, 47 used a sliding scale, and 73 failed to respond to the question. Among 41 providers in clinics and outpatient hospital facilities, the average cost of a female sterilization was $492, far below the $1180 recently estimated for the private sector. The median cost, $450, was less than the mean. 63 responses fell within $100 of the median, i.e., between $350-$550. The lowest charges were in the South. By geographic region, median charges were $500 in the Northeast, $450 in the North Central region, $377 in the South, and $419 in the West. Among the 55 providers of vasectomy (42 freestanding clinics and 13 outpatient facilities), the average cost of vasectomy was $201, lower than the recent estimate of $241 among private practitioners. The median was less at $195. Vasectomy fees were more uniform than those for female sterilization. The 4 regions differed little. In sum, outpatient sterilization procedures, particularly for women, represent great savings, in some cases more than 50%. Given that the cost for vasectomy is much lower than for female sterilization, it is still possible to realize savings of as much as 17% in outpatient facilities.
