HEALTH : Despite Ban, Sterilization Big in Brazil : Tubal ligation is major form of birth control. Bill seeks to stem frequency by making procedure legal.

About twice a month, gynecologist Maria Picarde says yes, but this time when a young woman in her cramped office made the request, the doctor shook her head no.

The woman, 18, wanted to be sterilized.

Sterilization is illegal in Brazil, except in life-threatening circumstances; punishment for the offending physician can be up to two years in prison. But like thousands of other doctors in Brazil, Picarde has done hundreds of such procedures in her 17 years of practice.

“She was just too young,” Picarde said. “You have to consider everything, the big picture--housing, finance, education, age. I had a case of a poor woman, about 37, with four children who was pregnant again. She was married, and they couldn’t afford the children she had, so I said yes. But this (18-year-old) woman, she just didn’t understand the gravity of the decision.”

Unfortunately, officials say, not all physicians are so thoughtful. The combination of physician insensitivity and greed, patient ignorance and the cost of contraceptives has made illegal sterilization the primary form of birth control in Brazil.

Federal officials estimate that in the state of Maranhao, 76% of women of reproductive age have been sterilized, in Goias, 72%, in Pernambuco, 60%.

Brazil’s Congress is considering legislation to reduce sterilization--by making it legal.

Legislation has passed the House of Representatives and is awaiting a vote in the Senate, but it will face stiff opposition from the Roman Catholic Church in a country with the world’s largest Catholic population.

The bill would make sterilization available upon request, imposing a 60-day waiting period during which the woman would be told about contraception.

Congressman Eduardo Jorge Martins Alves Sobrinho, who introduced the legislation, said he and various women’s organizations hope that will spur women to choose non-permanent forms of birth control.

“You would be creating a mechanism to protect the population from . . . mass sterilization,” Sobrinho said.

A month’s worth of contraceptives can cost $6 for pills or $30 for condoms, in a country where half of all workers earn less than $120 a month.

Sterilization is so widely practiced that many recipients, officials admit, don’t realize it is illegal. Some local governments even promote sterilization.

Several towns in Parana, a southern state, offer free tubal ligations for poor women with more than five children. Chagas Alves, a gynecologist and state legislator in the northeastern city of Cascavel, has admitted sterilizing 750 poor women in the past 15 years. And during election years, politicians offer to help women get sterilizations in exchange for votes.

“Everybody knows, but nobody sees,” said one nurse.

To both cover their tracks and increase fees, doctors perform sterilizations during Cesarean childbirths. Brazil has the world’s highest rate of Cesarean deliveries, in part, some speculate, because of sterilizations.

“Doctors claim the Cesarean is necessary because of health risks,” said Rita Bagaini, planning director of the Civil Society of Family Welfare, a private health organization. “Then they can charge (the federal health service) twice the rate of a normal delivery, and the woman pays for the tubal ligation.”

Birth Control Comparison

How Brazilian birth control compares with U.S. methods. Percentages apply to those who practice birth control:

Brazil U.S. Female sterilization 44.4% 27.5% Pill 41.0% 30.7% Vasectomy 0.9% 11.7% Periodic abstinence/withdrawal 6.2% 4.5% Condoms 2.5% 14.6% IUD 1.5% 2.0% Others 3.5% 9.0%

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Cesarean Rate

Percentage of births that are Cesarean: Brazil: 32% Puerto Rico: 29% U.S.: 24% Britain: 10% Japan: 7% Sources: Institute of Brazilian Geography and Statistics, Alan Guttmacher Institute, World Health Organization