As is typical in demographic transitions, declines in mortality preceded declines in fertility in Brazil, but the process took only a few decades rather than centuries, as it did in developed countries. The death rate started to fall in the 1940s because of the expanding public health system, urbanization, and sanitation. The crude death rate in 1995 was eight per 1,000 population, a notable decrease from the 1960-65 rate of 12.3. The 1995 level, which is similar to that of developed countries, resulted from the age structure being still relatively younger.
Life expectancy at birth, which is a measure of mortality that is not affected by different age structures, began to rise in Brazil in the 1940s. It increased from 42.7 years in 1940 to 52.7 years in 1970 and 67.1 years in 1995. It is projected to reach 68.5 years in 2000 and 75.5 years in 2020. Life expectancy for women is about seven years greater than that for men, but the differential is decreasing.
A decline in mortality has occurred in all regions, but strong regional variations in life expectancy persist. The lowest levels are found in the Northeast (65.4 years in 1995) and the highest in the South (69.4 years in 1995), slightly higher than the Southeast. The North and Center-West regions have levels of life expectancy close to the national average. Within the socioeconomic strata, higher life expectancy is strongly associated with higher family income. Mortality is generally higher in rural than in urban areas, except for the lowest income groups.
In the past, the principal causes of death in Brazil were infectious and contagious diseases, especially diarrhea and intestinal parasites among infants, as well as tuberculosis, measles, and respiratory diseases (for a discussion of infant mortality, see Indicators of Health, this ch.). As these were brought under control in the postwar period, primarily in the more developed regions, degenerative diseases such as cardiovascular disorders and cancer became proportionately more prevalent. Deaths from external causes, including violence and traffic accidents, also gained importance.
In 1996 the crude birthrate was estimated at 21.16 births per 1,000 population, a significant reduction from 42.1 for the 1960-65 period. As in the case of mortality, crude birthrates are affected by the age structure and, therefore, difficult to compare among countries and regions or over time. It is preferable to use the total fertility rate, a standardized measure that corresponds to the average number of children per woman at age forty-nine, the end of her reproductive life, assuming that she has survived and followed the fertility patterns characteristic of each age category.
Brazil's total fertility rate dropped from close to six in the 1940s and 1950s to 3.3 in 1986 to 2.44 in 1994, not much higher than the replacement level of 2.2. Fertility declined in urban and rural areas, in all regions, and among all socioeconomic strata, although the rates continued to vary. In large countries, such a rapid and generalized fertility decline had been observed previously only in China, where official policy placed intense pressure on couples to have only one child. Projections indicate a total fertility rate of 2.0 in the year 2000 and 1.8 in 2020, lower than replacement.
The Brazilian birthrate began to decline noticeably in the 1970s, by which time socioeconomic changes had made large families less affordable than in the traditional social and economic structure in rural areas. In the past, especially in rural areas, children started work early and supported their parents in old age, and the children did not cost much to raise. In the 1990s, they attend school for longer periods and cost more to support.
Meanwhile, new methods of birth control, primarily pills and female sterilization, became widely available in the 1970s. Oral contraceptives are sold over the counter without prescription. Surgical sterilization, which is practiced in Brazil more than any other country, is typically performed during cesarean deliveries. Such deliveries comprised nearly a third of all deliveries in the 1980s. Surgical sterilization is of questionable legality, but is often carried out by doctors who are paid for the cesarean section by the public health system and receive private payment for extra services on the side.
The number of Brazilian couples opting for sterilization as a means of contraception increased by more than 40 percent during the 1986-96 period, based on the Demographic and Health Survey carried out by Bemfam, an NGO. The survey, conducted between March and July 1996, interviewed 12,612 women between fifteen and forty-nine years of age as well as 2,949 men between fifteen and fifty-nine years. The survey found that 40.1 percent of married women or women living with partners had been sterilized, as compared with 26.9 percent in 1986. In 1986 only 0.8 percent of males had had a vasectomy, as compared with 2.6 percent in 1996. The Bemfam survey showed that the average age at which women are sterilized was 28.9 years in 1996, as compared with 31.4 years in 1986.
In the early 1990s, the use of birth-control pills and female sterilization (tubal ligation) continued to contribute to the fertility decline in Brazil. About 65 percent of Brazilian women used contraceptives, which is comparable with levels in developed countries. Of the women who used some method and were in union, 44 percent were sterilized. About 7 percent used rhythm, while other contraceptives or methods were rarer.
Abortion in Brazil is significant. In the early 1990s, some 1.4 million abortions were performed each year, almost all of which were technically illegal. This corresponds to approximately one abortion for every two live births. The only cases in which abortion is not subject to legal sanctions in Brazil are rape and danger to the mother's life, but the law is not enforced effectively. The practice of unsafe, clandestine abortions helps to explain why Brazil has the fifth highest maternal mortality rate in Latin America, estimated at 141 deaths per 1,000 births, in contrast to eight in the United States.
A fertility decline in Brazil occurred in the absence of any official policy in favor of controlling birthrates. The government's stance was one of laissez-faire. Although it did not promote family planning, largely because of the influence of the Roman Catholic Church, the government did little to interfere with the widespread practice of contraception among the population at large. Nor did the population pay much heed to religious dogma. In the case of fertility regulation, social change in Brazil occurred from the bottom up. Women took much of the initiative.
In the 1980s, the Ministry of Health included family planning services as part of an integrated women's health program. However, because of a severe lack of funds, the direct effects of the program were limited. Changing public opinion and the women's movement in Brazil favored changes in official policy, which were slow to come about. The 1988 constitution included the right to plan freely the number of children. A Family Planning Law took effect in 1997 in order to regulate sterilization, making it available in the public health network but forbidding it during deliveries, as well as provide birth-control alternatives through the same network.
Data as of April 1997