On June 21, 1994, in Sao Paulo, a meeting took place of reproductive health professionals: service providers, university professors, representatives of nongovernmental organizations, secretaries of health of states and municipalities. They issued a manifesto on reproductive health in Brazil. In view of the preparations for the 3rd International Conference on Population and Development to take place in Cairo in September, 1994, it is hoped that these points will be incorporated into the official platform and in government action plans. Reproductive health is a basic human right. The growth of population decreased in Brazil in the 1980s, yet assistance in the area of reproductive health is still insufficient and unsatisfactory. The population decrease did not result in the improvement of health care and family planning. Maternal morbidity and mortality rates are still high in Brazil, especially in the north-northeastern regions, where it is 10 times higher than the national rate. There are 5 maternal deaths per 100,000 live births in Canada, 8 in the US, and 140 in Brazil. 90% of these deaths could be avoided by routine reproductive health measures. Important causes of infant mortality in Brazil are malnutrition and infectious diseases, which could be prevented by lifting the low socioeconomic level and through vaccination and birth spacing. Although fertility has been on the decline, the fertility of 10-19 year old adolescents has increased significantly, leading to high mortality rates for their infants. An estimated 1.4 million abortions occur per year in Brazil with frequent complications because of its illegal, clandestine nature. It is also estimated that 6-8 million women have been sterilized, which is the primary means of family planning because of the lack of other contraceptive options. The combination of cesarean-tubal ligation operations has been institutionalized in health services, which creates major distortions in the delivery of health care. Sexually transmitted diseases are on the rise, and HIV infections are contracted mainly from sexual intercourse and IV drug abuse. Furthermore, it is absolutely necessary for men to participate in family planning education in order to raise the status of women.
The 1988 Brazilian Constitution defined the right of married individuals to family planning (FP). In 1981 ABEPF (the Brazilian Association of Family Planning Entities) was established in order to unite the private entities that were engaged in FP work. ABEPF has been working in a responsible manner without profit since then, and has earned the right to be granted the title of public federal utility. However, it is paradoxically because of its FP work that ABEPF is not given this title. The opponents of FP continue to obstruct the realization of Paragraph 7 of Article 226 of the Constitution. Public federal utility is an extremely important appellation because of the benefits and status conferred. ABEPF is already recognized as a public utility in the state of Rio de Janeiro. Previous attempts to acquire the title were turned down without justification by Dr. Zilda Arns, the director of CNBB. Then, the director of ABEPF and Dr. Zilda Arns met on December 7, 1992, when another application looked more promising. However, it was vetoed again, with Arns claiming that ABEPF might potentially become a proabortion body. In reality, those who refuse to help a broad, safe, and responsible FP program are themselves accountable for the high abortion rate. With its hypothetical arguments about the potential proabortion image of ABEPF, the representative of CNBB in the Ministry of Health arrogates the right to create all kinds of obstacles to preclude ABEPF from getting this title. While this obstruction continues, hundreds or thousands of fake organizations have falsely benefitted from public resources, and those who have created the obstacles have not done anything against this pattern. The issue here is the destiny of FP and the population policy of this country, because the federal authorities do not want a confrontation with the bishops.
A first-page picture of the journal O Estado de S. Paulo on October, 1993, depicts 3 children playing in the ruins of a school building in Bahia. They are dressed in rags, just like the immense majority of children begotten in recent years. They are disgracefully filthy, with dishevelled hair, in the company of a pig content to share its habitat with such animalistic beings. In the inside pages of the same edition are profuse photos of other pigs dressed in suits and ties. This ostentation mocks the people and mainly the 3 children who do not attend school because the money for it has been embezzled from their pockets. Decent journalists, conscious of these piggish humans, endeavor every day to make this country a decent place to live. In the fight for a dignified and decent country, the journal Planejamento Agora, edited by ABEPF, makes an important statement with its slogan that the fight is true when the spirit is unabated. Planejamento Agora stoically battles to make every animal child alive today a human child who is wanted. The work and team of Planejamento Agora are saluted, and they are urged to continue the struggle on behalf of such children.
The choice of the most appropriate contraceptive method, when its use is begun, and the motivation of adolescents to use it, are significant factors in adolescent contraceptive continuation. The contraceptive method must suit the personality of the adolescents, who are insecure in most cases, less stable emotionally, rebellious, and uninformed. This pattern can induce constant changes of partners, and accidental and unpredictable sexual activity. Since adolescence is a period of biological and psychological transformation, the contraceptive must be highly effective, safe, and well-tolerated, so that its side effects should not prejudice the continuation of its use. The behavioral contraceptive methods, coitus interruptus, ovulation, and sympto-thermal methods, are contraindicated for adolescents because of their low effectiveness and the requirement of a great deal of discipline. The condom, diaphragm, and spermicides can prevent sexually transmitted diseases, thus they are optimal for adolescents. Their effectiveness is higher than that of behavioral methods but could be better, and they require a certain discipline, which limits sexual spontaneity. The IUD is contraindicated in adolescents and in women who have never given birth, because of the possibilities of pelvic inflammation resulting in pain and bleeding and expulsion of the IUD. The use of hormonal contraception is recommended only two years after the first menstruation, for fear of interference in the biological development of the adolescent. Recent studies have shown that modern low-dose oral contraceptives (OCs) do not exert harmful effects on the adolescent organism. While paying heed to contraindications, OCs can be indicated for this age group. Hormonal contraceptives are effective, safe, and well-tolerated by the majority of patients. They regulate menstruation, and provide beneficial effects such as the reduction of dysmenorrhea and the protection against pelvic inflammatory diseases, benign diseases of the breast, and even uterine and ovarian cancer.
Sexuality, contraception, and pregnancy are inseparable, yet they are a taboo subject both for the whole country and for adolescents. The ever-earlier awakening of sexuality requires educational mechanisms that assign fundamental importance to the implementation of social, psychological, and cultural protection strategies. The resolution of pregnancy is dependent on income just as maternity is secondary to financial independence. The majority of rich adolescents get an abortion, while poor adolescents carry to term their undesired pregnancies. Adolescence is a phase of confusion with peculiar psychosocial and cultural aspects. In the low-income population the start of formal education is precarious and delayed, an important factor in the discrepancies between well-to-do and poor social classes. Pregnancy and abortion rates vary according to economic conditions, however, their resolution clearly shows ethical, religious, and moral subjectivity. The media, rural exodus, increasing urbanization, and the economic crisis make maternity a less dominant aspect of women's lives. Young people do not obtain the necessary information for safeguarding their fertility because of the lack of specialized services, thus they are uncertain about what the health care system can provide. Much opportunity is lost because professionals are too busy or too disinterested to listen to these alienated youngsters. Preconceived notions, disinformation, and uncertainty coupled with emotional obstacles and noncooperation of the partner result in the use of contraceptives becoming a complex and difficult problem to resolve. It is necessary to alter our perceptions of adolescent sexual development. In Brazil, where more than half of the population is young, it is indispensable to devise collective programs not restricted to conventional medical practices to reach all adolescents.
