In Brazil, even more so than in the United States there has been an upsurge in use of both surgical contraception and delivery. The investigators' aim is to distinguish among and weigh the influences that lead Brazilian doctors to perform, and Brazilian women to demand, sterilizations during a cesarean section delivery. These have to do with: the doctor's convenience and remuneration; women's preferences for surgical delivery and contraception; and the incidence of repeat cesarean sections, which supposedly place women at high risk of rupturing their uterus during a future pregnancy and lead to the choice of an irreversible method. To assess these alternative influences, they will employ a research design that incorporates both the providers and consumers of services, and delves into subjects that are not found in regular surveys of fertility and contraceptive practice such as have been carried out by DHS. The investigators will interview obstetricians regarding their training and the criteria they apply to decisions regarding type of delivery and sterilization; and interview women regarding their experience, knowledge, and preferences. They will also carry out a prospective study in which mothers would be interviewed early in pregnancy and then after their delivery and interview senior medical practitioners regarding the history of surgical contraception and delivery in their medical community. The research will be carried out in four states of Brazil chosen to capture the variation that exists within Brazil in the rate of cesarean sections, the proportion of all contraception accounted for by female sterilization, and the proportion of sterilizations that are performed during cesarean sections. This project will contribute to current debates about the nature of the process of contraceptive adoption during a rapid fertility decline and, for the first time, highlight how such a process can go wrong, leading a society to become locked-in to technologies that are neither safe nor cost-effective.
