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CHAPTER 9 THE PROXIMATE vARIABL2S The factors that directly influence fertility and together determine its level--the so-called proximate variables-- can be grouped as follows, according to Bongsarts (1983): al b) c exposure to regular sexual relations - proportion of married women prevalence of deliberate control of mar ital fertility use and efficiency of contraceptives prevalence of induced abortion ) determinants of natural marital fertility duration of postpartum infecundity f ecundity spontaneous intrauterine mortality prevalence of permanent sterility Ilowever, not all these f actors have the same impact ire determining discrepancies between natural fertility and the total fertility rates observed In a given context. In fact, the proportion of married women, the use and efficiency of contraceptives, the prevalence of induced abortion, and the duration of postpartum infecundity account in general for over 95 percent of those discrep- ancies; the effects of the remaining three factors are difficult to measure in such studies as fertility surveys. Postpartum infecundity depends in turn on the length of sexual abstention following delivery and on the duration of breastfeeding. In Latin America, prolonged abstinence Is not as common a practice as it is in some African and "fan countries. As can be seen in Table 67, in the NIER, a limited number of women declared they abstained. On the other hand, what does still exist among some groups of women of rural origin is Postpartum quarantine. or ~re- 181.

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l 182 - 3 o U] a) Did E~ Q o . - C) V ~: o U - m ~: s~ s" C) 1 s9 O ~ 3 N S~ ~: ~o a~ X o ~: S~ OQ 5: ~C ~: 1 - 1 ul 1 . o, ~ q. o O ~ O ~D o ~ o ~ .-, _ ~ 1 ~ ~ ~ ~ tD : s~ O 5, ~ 1 . . ~ . . . ~ . . O ~ ~ ~ o ~ ~ r~ o o o un Cl, u~ ~ O ~r C) o _ ~J ~ c~ ~ r ~ 1 ~ O u~ ~ ~ O O :1 ~ 1 1 ~ ~: ~ ~ u' ~ ~0 ~ tD ~ ~4 0 c, ~ ~ ~r O ~d ~ ~ _ U] N - _' C P. ~ ~ C C ~ ~ ~2 P. ~4 :, C~ C L. N :' Ld C) ~S 0 C #e CD O ~ Q s~ O ~ O CO ~ C} g' ~C \0 1 0 ~ ~ 1 r' {~ ~ 1 0 1 ~ ~ 1 ~ ~ 1 o ~ o ~ ~ o o A I 1 ' ~ ~ 1 1 ~ ~ ~ 1 1 1 1 1 1 a, U~ O \0 1 un co a~ 1 ~ ~ 4~ Y~ O 1 1 c . 0 U~ u~ 0 O U' _l U 1 1 ~ C~ c-4 1 ~ ~ ~ 1 0 1 1 1 1 O ~ `0 ~ O C~ ~ ~ O ~ O . I 1 1 1 1 o . O O a' 1 ~ ~ ~ ~ a, ~ ~r ~D O 1 . . . . .. . .. ~ O ~ ~ ~ O \0 0 r~ ~ r4 :s -4 ~ . ~ 0 40 _ C) Ea ~ ~ e C ~ o ~ ~ =, ~ . N ~ O `4 ~ 4 C) ~U h4 e o. ~ ~ ~ _ c a ~ ~ ~ ~c 2 a ~ 8 c, ~ P. cn ~ 0 ~ z

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183 elusion, ~ referring to a period when diet, bodily hygiene, and sexual practices are carefully controlled. Given these complications, in this section the duration of post- partum infecundity is measured exclusives y by the duration of breastfeeding . In the terms of the Bongaar ts index, `]escr ibed in Chap- ter 1, the values for the mar r iage rate, Cm in each of the nine NIHR contexts were the following: Cachoeiro de I tapemir im Santa Cruz-Urban Sao Jose dos Campos Sertaoz intro Santa Cruz-Rural Recife Parnaiba-Urban Conceicso do Araguaia Parnsiba-Rural 0.648 0.710 00657 0.842 0.698 00651 0.766 0.777 0.832 The subsections below discuss the NIHR in relation to the other three primary proximate determinants: noncontracep- tion use (Cc), postpartum infecundability (Ci), and abortion (Ca). CON=A=:PTI VE USE Contraceptive Prevalence The NIER registered greatly varying levels of contracep- tive use in the various contexts. Parnaiba-orban and -Rural--an area which, as noted in the Appendix, has been occupied for a long time and now has a practically stag- nant economy--was shown to have the lowest fertility rates consistently, and it ~s this area which reqistered the lowest proportion of contraceptive use. are far from negl~gible, however: ~.~_ _ ~ ~ ~ _ ~ _ . ~, These proportions indeed, of every five w~men ~n rarna1Da-Rural WhO were married at the time of the survey, one was using some contraceptive method. In Conce~cso do Araguaia, this proportion reached a~most 30 percent, wh~le in the other contexts it was over 50 per- cent. If these proportions are compared with those obtained by the Contraceptive Prevalence Surveys (CPS), described in Chapter 1 of this report, there is a high degree of consistency among some of the available results. For the state of Pisui, except for the capital, the CPS showed a contraceptive use rate for 1979 of around 28.8

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L84 percent, very close to the value obtained by the NIHR for Parnaiba-urban ( 27. 7 percent), as shown in column 1 of Table 68. The C]?S rate for Recife in 1980 was 51.5 per- cent using contraceptives, while the NIHR rate was 57. 5 percent. Similarly, in Santa Cruz do Sul-Urban, the CPS showed 63. 0 percent of marr fed women using contraception; this value was very close to that found by Bathes (1976), in 1975 for Rio Grande do Sul (64. 6 percent) . On the other hand r attention should be paid to the fiery high rates found in the NIBR for Sao Jose dos Campos ( 74.9 percent) and Sertaozinho (69~2 percent) D when compared with the data for Sao Paulo found by Nalcamura et al. ('979), in 1978 (63~4 percent for the municipality of Sao Paulo, and 58. 6 percent for the rest of the state) . Even when the NI}IR rates were estimated as an average of age- specific use rates (column 2, Table 68), Sao Jose still had a high rate of 71.9 percent, and the rate for Sertao- z intro remained unaltered. Since there is as yet no reason to suppose that these two contexts constitute special cases in the use of contraceptives as compared with other parts of Sao Paulo state, it is probable that the NIER has overestimated the proportions of contraceptive use. For the purposes of all the -following cat adulations, therefore, the proport ions of contraceptive use for Sao Jose ~ . .d Ser - taozi~o adopted were, respectively, 6304 percent and 5806 percents TABLE 68 Currently Married Women Aged 15-49 Currently Using Contraception, Nine Contexts: Brazil Average of Currently Age-Specific Number of Context Using (percent) Use Rates Cases Sao Jose dos Ca~os 74~9 71.9 415 Santa Cruz-Orban 6300 60.6 219 Santa Cruz-Bural 58.3 54.3 242 Parnaiba-lJrban 27. 7 27.7 220 Parnaiba-Rural 20. 7 19.6 . 207 Sertaozinho 6902 69.3 224 Conceicso do Araguaia 29.6 29.1 214 Cachoeiro do Itapeoirm 69.9 64.5 229 Recife 57.5 52.0 348

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185 The data used as a basis for calculating average age-specific use rates showed that control was differential according to age but existed for all ages. Evidently, when observing this fact by age bracket, caution should be the rule given the extremely small number of women in each bracket. To provide a more comp] ete idea of what may be happening in the urban areas of Brazil, the information on all f ive urban contexts has been combined by age bracket. As was done in Chapter 8, this is a device to increase the size of the samples, for as already stressed at the outset, it is contrary to the very objective of the NIBR to aggregate situations as distinct as these. The relevant f igures are thus the following: Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Mean value Percent Use 48~1 6200 71.6 71.6 64.3 53.1 26.8 56.8 In other words, 48 percent of young couples living in urban areas are already regulating fertility. The m^Yi- mum use rate is in the 25-29 and 30-34 age brackets, with the proportion falling thereafter. Proceeding the same way for the rural contexts, a lower overall mean value of 45.5 percent is obtained. For the different age brackets, the rural use rates are as follows: Age 15-19 20-24 25-29 30~34 35~39 4 0~44 4S-49 Mean value Percent Use . 30e 7 5 0 e 4 S5e 8 5 3 e 4 46e 9 44 e 0 3 7 e 5 5 e 5

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186 Contraceptive Method s Table 6 7 shows the methods used by those women who were resorting to contraception. Such devices as the IUD and d iaphragm were practically absent f rom all nine contexts. There were four main methods: rhythm, coitus interruptus, the pill, and female sterilization. In Santa Cruz-Urban Cachoeiro, and Sao Jose dos Campos, 85. 4 percent, 84. 8 percent and 78. 1 percent of women, respectively, used highly eff icient methods ( the pill or ster ilization, with the highest proportion for the pill)o In Corlce~cao do Araguaia and Parnaiba-Rural ~ 84. 5 percent and 85. 4 percent of women, respectively f were using the pill or tubal sterilization (with a higher proportion for the latter). The remaining f ire contexts showed proportions for use or these two methods ranging from 61 percent to 69 percent; in Recife, female sterilization tonic the place of the pill. In sum, the more traditional methods have already lost ground to more modern and eff icient methods. One interesting fact is the 8.3 percent f igure for use of the condom in Sao Jose dos Campos, whereas this method has practically disappeared in the other contexts; this may reflect the presence of large numbers of Emigrants who had arrived in Sao Jose over the years immediately pre- ceding the survey. Similarly, the high proportion of women using the rhythm method in Santa Cruz-Rural may be explained by the fact that most of the population is of German extraction, and thus inf luenced by the European tradition. The fact that vaginal methods only appeared significantly in Recife is another noteworthy point. Although the NIHR samples were small and the propor- tions of women sterilized at the time of the survey were therefore sub ject to considerable sample f luctuations, the growth of this practice can also clearly be seen in the results of the CPS, as reported in Chapter 1. One note- worthy fact about "he age distribution of married women who were sterilized at the the of the NIER (Table 69) is that in Cachoeiro, Conceicao do Araguaia, and Parnaiba- Rural, 50 percent or more were age 34 or younger, while in Araguaia, L5 percent had not yet reached the age of 2S. What is surprising in all this is the fact that female sterilization is illegal in Brazil. The Medical Code of Ethics, Chapter HI, Con Medical Responsibility, article 52, states:

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187 e U] X C o C) it: ~' it a' 3 N I' U) ~: S~ o o 53 eq ~0 - ; U] o U' C o C) o ~ o U2 - fo P4 o: u q a' C ~ :1 U~ a: o o t) t:: o U o o o s C) - u ~: n - ~ c d: 0 h4 ,~ 48 4 o. a L. C) 4 ~ `: D U! ~ :, o C, 5 0 0 r~ r~ O ~ D ~ ~ _ O ~ ~ ~ \0 . ~ O U~ ~ \0 ~ ~ U' ~1 ~4 ~ 0 ~ ~ r~ ~ ~ ~ ' a 0 ~ a' ~ O1 ~ <" ~ ~ ~ r~ ~ c~4 O C~ ~ ~ ~ O4 0 ~ r~ ~ ~o ~ r~ r~ O ~ ~ O O U' ~ 0 c~ c~ 0 ~n t~ r~ 0 O ~ -4 C~ ~ `0 ~ ~ . . ~ 0 ~ ~ ~ ~ ~ C~ o, ~ - 4 ~ ~ \0 0 0 cr' ~ ~ ~ ~ . . ~ ~ O 0 ~ 01 ~ ~ ~ - 0 .0 C - o O O ~ ~ 4, O 0 O 0 0 I_ . . . . . . O 0 0 \0 ~F 01 ~ 01 ~ ~ ~ ~7 ~ O ~ O C~ C~ o U~ ~ Z

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188 Sterilization Is condemned, but may be practiced in exceptional cases, when there is a precise indica- tion approved by two medical doctors consulted In conference. Aside from the few cases in which a woman's health prob- lems lead to the advisability of sterilization, the marked increase in tubal sterilization among Brazil's female population may be the result of two factors. The f first is a consequence of the misuse of caesareans over recent years, this has been stimulated by the INAMPS (National Health and Welfare Service) through higher remuneration for this kind of operation than for normal delivery. Official data show that from 1971 to 1980 in Brazil, the proportion of caesareans to total deliveries rose from 14.6 percent to 2903 percent. The rates for Sao Paulo over the same period rose from 17.5 percent to 36.0 percent, and similar increases occurred in practically all the Brazilian state. A study performed in Ribeirao Preto, Sao Paulo state, concerning standards of assistance for deliveries showed that in 1972, 1973, and 1974, 18.1 percent, 23.0 percent, and 24.1 percent of hospital deliveries' respectively, were caesareans (Boletin de la Oficina Sanitaria Panamerican, 1978). Recent data on Greater Sao Paulo and Greater Recife permit a comparison between the type of delivery of the latest and penultimate children born to mothers who gave birth over the last 8 months (Berquo, 1981). The results for Greater Recife show that 14 percent of deliveries of the penultimate child were caesareans, while the rate is 27 percent for the latest childo I~ addition, 11 percent of these mothers gave birth by caesarean in both cases. For greater Sao Paulo, 21 percent of deliveries were caesar- eans for the penultimate child and 31 percent for the latest, while 17 percent of these mothers had given birth by caesarean in both cases. It is well known that any woman who has already had two or three caesareans is a sure candidate for sterilization. The policy adopted by INAMPS has thus increased women's chances of being ster- ilized. Nowadays, in fact, doctors receive the same remuneration whether a delivery is normal or caesarean; nevertheless, it seems that the doctors themselves have grown accustomed to caesarean deliveries and thus continue persuading pregnant women to accept them, with a continu- ing effect on sterilization levels. The second factor which may determine the marked increase in tubal sterilization is linked to the non-

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189 off icial family planning programs underway in Brazil. As noted in Chapter 3, physicians in private practive have been mak ing more f requent use of public f ac ilities to per- form sterilizations even though use is not officially promoted. If this were not so, given the legislation mentioned earlier, these results would not be occurring and affecting even. very young women, as seen in the data shown here. Bongsarts' Index of Contraception In calculating the Bongaarts contraception index (Cc = 1 a S x E x U), described in Chapter 1, the values for "U. are already available in the second Cole of Table 68. Values for ~E. in any given context are calculated by adding the products of the values in Table 63 and the weights which correspond to each of the methods in accordance with its Off iciency: Methods Foam/Cream Jelly D iaphragm Rhythm Condom IUD pill Sterilization Abstention Other Contraceptive Ef f iciency 0~87 0~88 0 a82 Oe91 0 a96 0~98 1 e 0 0 1~00 O.90 Values for "E. thus calculated are shown in Table 70. If BUT, ~E., and "S. are replaced in the formula for Cc by their respective values, the results obtained are as shown in Table 71. As can be seen, the degree of control is greatest in Cachoeiro de Itapemir~, followed by Sao Jose and Santa Cruz do Sul-tirban. The lowest values of Cc are for Conceicso do Araguaia and Parnaiba-Urban and -Rural. In other words, these results conf irm the f indings Obtained when Imp was calculated by Coale's method. The relation between the values for Cc and total fertility is also very clear : that is , the lower the value for C<, the lower the total fertility rate.

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190 `;e S" 3 o - ~n a, U S~ o o C - U e~ W 0 :D o V tQ ~ JJ Q`t X C - o ~ C'-) m ~S 2 ~: a~ Q~ 3 o r ~, - ~; ~ E~ ~ N L. Z Ct 1 - a' z c ~ O cn N a 1 c ~ 0 U1 C. 0 C, 0 oo ~ 0 U) ~ 4, - u ~4 - 0 ~ Ld 4, _ 9, 0 1 r-1 ~ O C) ~ O C O O ~ O O ~ D t" "e iS, O _. O O O '= ~ . e 0 0 ~ ~r _ ~ ~ ;~ O O O O ~ O O ~ O 0 ~e ~1 0 1~ 0 Y. _' O e ~ e ~ O 0 ~1 0 ~ O ~1 ~ O \0 _. ~ C~ O CD re f., e e e C~ ~ ~ ~ O O O O 0` u~ 0 ~o a 0 e e ~ O ~ ~ ~ t_ 01 O O ~ U~ ~ O u~ Od S~ tD O ~ ~ O O 0 ~ O ~ `0 ~ O O ~ \0 ~ `0 U' - 0 60 41 4|| O O ~ee ~ O O U~ ~ ~ ~ ~ O1 <" O o `0 t. N O r~ ~ e o o o e e e ~ ~ ~ tO ~ _' O O ~ ~ ~ ~ C - N o ~4 0 CO - a -4 C Ll L ~: ~ C C h4 J o4 a O 4, x~ o' ~ ~ ~o r~ en \0 . ~4 ~ ~ U' -4 ~ 0 0 -4 0 0 0 ~ ~ 0 U' ~ o, ~ 0 0 0 U' ~ 0 . . . . {~ ~ C. O O O C~ "e O re 01 O t~ O ~ O ~ ~ tme O ~ O ~' ~ ~ {q - O ~ O C ~ O C,) c ~ ~ 4~1 O ~ ~ ~ ~ ?4 ~ ~ O _ C 0 O ~C ~ C ~d 4 L4 ~ ~ O. t0 ~ C ~ ~ > L. ~ O _ O ~ ~n ~ ~ u a ~ 7e 0 >.

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191 TABLE 71 Index of Contraception, Nine Contexts: Brazil Context Value of Cc Cachoeiro do Itapemirim Sao Jose dos Campos Santa Cruz-Urban Sertaozinho Santa Cruz-Rural Recife Parnaiba-Urban .312 .316 .360 .381 .450 .457 .710 Conceicso do Araguaia .693 Parnaiba-Rural .791 Postpartum Infecundability Before the 1960s, almost no studies on breastfeeding in Brazil were carried out. Rea (1981) presents a table, reproduced here (Table 72), which gives a good idea of the Brazilian breastfeeding situation. These data show considerable variability depending on the region and liv- ing standard. The author does, however, emphasize that comparison in this case should be approached with caution since the information and/or methodologies involved are mostly heterogeneous. As noted in Chapter 5, the phenomenon of early wean- ing exists in today's Brazil, as it also does in a number of other Latin American countries (Lesthaeghe et al. 1981). On the local level, a recent study conducted by UNICEF/INAM/~-~:uRAP (Berquo et al. 1981) in the metropol- itan areas of Sao Paulo and Recife showed a very low aver- age time for breastfeeding for mothers in both areas. Unbiased estimates of the aver age duration of natural breastfeeding can be made using the calculation technique known as the current status method, based on the propor- tions of children in each age group who were being breast- fed at the time of the interview (Jain and Bongsarts, 1981). The average time for Greater Sao Paula was 3

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192 TABLE 72 Percent of Breastfed Children at 4 Months of Age, by Various Studies: Brazil Location Year Percent Remarics Recife (PE) 1968 5.8 >3 months Sao Paulo (SP) 1971 72.0 immigrants Sao Paulo (SP) 1973 31.6 low-income Ribeirao Preto (SP) 1974 39.3 Salvador (BA) 1974 38. 9 Rio de Janeiro (RJ) 1974 25.0 Pelotas (RS) 1974 160 ~ Icapara (SP) 1975 78 .8 3 months, rural Vale do Ribeira 1975 150 0 3 months, rural Salvador (BA) 1975 45. ~ >3 months Getulis" and Guaiembe (SP) 1975 89. ~ Japanese extraction, 3 months Campinas (SP) 1976 35. 3 Austin (RJ) 1977 54.0 Paullnea (SP1 1977 40. 0 Sorocat~a (SP) 1978 30.0 >3 months Botucatu (SP) 1978/79 50 0 7 3 months, medical post, school Sao Paulo {SP) 1979 41.9 low~incame Sao Mateus (SP) 1980 13.0 working~class district Greater Sao Paulo (SP) 1981 38.0 Greater Recife (PE) 1981 2S. O Source: Bea (1981). months, and for Greater Recife 2.2 months. Even conside~- ing that this study included mothers of children no more than 8 months old at the time of the interview and thus truncated the distribution with regard to higher breast- f ceding times, these values are very low. Between the first and second month, 42 percent of children in Recife and 53 percent in Sao Paulo had already been weaned. The fact that women in Recife breastfeed for less t ime than those in Sao Paulo had already been highlighted by Puffer and Serrano tl973) at The time of the Inter- american Study on Childhood Mortality, conducted between 1968 and 1970. This survey showed that of the children who died in their f irst year, the proportion breastfed for

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193 one month was 26.8 percent and 35.5 percent for the muni cipalities of Recife and Sao Paulo, respectively; the proportion of breastfed children who died at ages 6-11 months or over was 1. 4 percent and 4.1 percent for R-cif e and Sao Paulo, respectively. Although the data presented by Puffer and Serrano refer to children who had already d fed at the time of the study and thus to some extent underestimated the breastfeeding times, they nevertheless indicate the regional differences involved. In 1975, working with 593 families in the Vale do Ribeira (coastal region of Sao Paulo state) having a total of 1,005 children under 5 years, Rea (1981) found 14.6, 7 . 4 , and 5. 8 months to be the mean breastfeeding times, respectively, for mothers born in the Vale region, other regions of Sao Paulo state, or other states . For the NIT contexts, the mean breastfeeding times were as follows :1 Cachoeiro de Itapemirim Conceicao do Araguaia Sertaozinho Parnaiba-Rural Sao Jose dos Campus Santa Cruz-Rural Parnaiba-Urban Santa Cruz-Urban Recife - 8.5 months 805 7.3 months 6.3 months 6.0 months S.5 months 4.8 months 402 months 3.3 months months On the basis of these values, Bongearts' index of post- partum infecundability (Ci) was calculated. In the NIER survey, as usually occurs in surveys of this kind, there are no reliable data on the postpartum amenorrhea period, that is, on ~i.. For this reason, the model put forward by Bongearts (1983) was used, which establishes an expo- nential relation between ~i. and the mean duration of breastfeeding, here represented by B: i ~ 1.753 exp. ( .1396B - O. 001872B21 . If B is replaced by the values found for mean breastfeed- ing times, the values shown in Table 73 are obtained for .~. and Ci. Since Ci is 1 in the complete absence of lactation or of postpartum abstinence and tends toward zero as the duration of postpartum infecundity increases, it can be seen that Cachoeiro and Conceicao do Araguaia showed the highest intervals for postpartum amenorrhea, while Recife showed the lowest.

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194 TABLE 73 Values of Air and Ci, Nine Contexts: Brazil Value of n i. Context in `Months Value of C Cachoeiro do Itapemirim 5.0 0.850 Conceicao do Araguaia 5~0 0.850 5ertaozinho 4 . 4 0. 87 3 Parnaiba-Rural 3 ~ 9 O. 892 Sao Jose dos Campos 3.8 0.897 Santa Cruz-Rural 3e6 0~906 Parnaiba-Urban 3 O 3 0 . 918 Santa Cruz-Orban 3OO 0.928 Recife 2.7 0.942 ABORTION The information on abortion in the No" covers both span taneous and deliberate abortion, for the same reasons as those alleged in the majority of surveys on human repro- duction: the questionable credibility of replies to ques- t ions intended to identify the two separately when the survey itself kiss not been specifically designed to study abortion. With the information available ~ total abortion rates (TAR) were calculated (Table 74). These rates were extremely variable from one context to another. The rate for Santa Cruz-Urban was only 9.2 percent of that for Parnaibaoral. In Santa Cruz-Ur},an and -oral, abortion was practiced little, with Cachoeiro next in frequency. Sao Jose, Sertaozinho, and Recife had much higher and very similar rates. Parnaiba had the highest rate of all, though lower for urban than for rural women. To calculate Ca, the total fertility rates were taken from Table 51 and values for But from Table 62. values For Ca (Table 74) were all very high, and close to 1. Thus, although this practice is underway in Brazil and involves many thousands of women, in overall calculations of fertility control it is of secondary importance.

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195 TABLE 74 Total Abortion Rates (TAR) and Bongaarts' Abortion Rate (Ca), Nine Contexts : Brazil Context TAR Ca Cachoeiro do Itapemirim 0.719 0.963 Santa Cruz-Urban GO 068 0.985 Sao Jose dos Campos 0.462 0.931 Sertaozinho 0 ~ 454 0.942 Santa Cru2-Rural 0.104 0. 987 Recife O O 478 0.947 Parnaiba-Urban 0. 617 0. 9S3 Conceicso do Araguaia 0.263 0.983 Parnaiba-Rural 0.735 0.967