Resumen : The gender approach to reproductive health care has many obstacles to overcome in its implementation in Brazil. Brazil officially endorsed the 1974 Declaration of Bucharest and the right of couples to control fertility and the public responsibility to provide the means of exercising that right. Modernization and the domination of social policy by elites has resulted in a decline in state participation in fertility control and a deterioration in public services. The public sphere was privatized during the military regime and thereafter. Private, internationally supported family planning agencies have operated in Brazil since 1965 and have remained almost completely unintegrated into the public sector. Feminist concerns have resulted in the official legitimization of the women's movement and the establishment of a national women's council. However the public recognition and the general indicators of gender modernity (fertility control and participation in the paid labor force) mask the situation of poor women's inappropriate use of contraception and continued poverty. 71% of women in any form of union in 1986 reported use of some form of contraception: 41% oral pills and 44% sterilization. Yet a 1984 national survey found that 25% of births in the preceding 5 years were a result of unwanted pregnancies, and 70% of women with 4 or more children had a smaller ideal family size. The private sector was the main source of supply for oral pills. Less than 50% of users had received a medical consultation before initiating use, and 23% used the pill incorrectly, as reported in 1984 survey. 40% of pill users were smokers and almost 50% had health problems that contraindicated pill use. Abortion complications have risen dramatically during 1978-90. Fertility control in Brazil has meant long-term cumulative effects of incorrect, contraindicated oral pill use, clandestine, unsupervised surgical sterilization, and illegal abortion; the impact of sexually transmitted disease and anemia is not even known due to poor statistical recording. Brazil's Program of Comprehensive Health Care for Women represents ideological gains, but public institutional inadequacy, insufficient national allocation of resources, and a low level of political priority remain obstacles to improvement in women's status.
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