Surgical Sterilization in Brazil’s Public Health System Before and After the 2022 Reform of the Family Planning Law: An Interrupted Time Series Analysis

Introduction: Brazil's Law 14,443/2022, in force since March 2023, lowered the minimum age for voluntary surgical sterilization from 25 to 21 years, removed the requirement for spousal consent, and guaranteed sterilization during delivery under specified conditions.This study assessed changes in female and male sterilization in the Brazilian Unified Health System after the reform.Materials and methods: An ecological interrupted time series study was conducted using monthly counts of tubal ligation and vasectomy from the Brazilian Hospital Information System (January 2015 to December 2025).Rates were calculated per 100,000 women aged 15-49 years and men aged 20-59 years.A negative binomial model with a population offset, a linear trend, and harmonic seasonal terms was fitted to the prepandemic period (January 2015 to February 2020) and projected over March 2023 to December 2025 to estimate the number of procedures expected from pre-pandemic trends; the period from March 2020 to February 2023 was excluded because elective surgery was disrupted by the COVID-19 pandemic and the subsequent recovery and because the publication of the law in September 2022 may have prompted anticipation.Results were expressed as observed-to-expected (O/E) ratios with 95% confidence intervals (CIs) obtained by simulation.Three elective procedures (cholecystectomy, inguinal hernia repair, and hysterectomy) served as control series, and alternative counterfactual specifications were tested.Results: Over the 11-year period, 1,382,600 female sterilizations and 502,473 vasectomies were recorded.The female sterilization rate rose from 151.0 per 100,000 women in 2019 to 519.9 per 100,000 women in 2025.Between March 2023 and December 2025, 761,822 female sterilizations were performed, compared with 370,898 expected (O/E 2.05; 95% CI 1.88-2.26),whereas the control procedures had O/E ratios of 1.09 to 1.20; relative to each control procedure, the female O/E ratio was 1.72 to 1.88.The female O/E ratio ranged from 1.87 to 2.34 across alternative specifications.Vasectomy did not depart detectably from its projected trend (O/E 0.98; 95% CI 0.86-1.13),although this estimate was sensitive to the assumed trend (range 0.89-1.26).The female-to-male sterilization ratio in hospital records increased from 2.03 in 2019 to 3.55 in 2025 (1.41 to 2.64 between 2019 and 2024 when outpatient vasectomies were included), and the proportion of public-system cesarean sections that included tubal ligation rose from 4.7% in 2019 to 17.9% in 2025.Conclusions: The entry into force of the reform was followed by female sterilization volumes that were approximately twice those projected from pre-pandemic trends, an increase much larger than that observed for other elective procedures, whereas vasectomy did not depart detectably from its projected trajectory, although this estimate depended on the assumed trend.The imbalance between female and male sterilization in the public system widened.Monitoring of counseling quality, regret, and access to vasectomy is warranted.