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Studies have examined the impact of contextual factors on the use of contraceptives among adolescents and found that many measures of income and social inequality are associated with contraceptive use. However, few have focused on maternal and primary health indicators and its influence on adolescent contraceptive use. This paper assesses whether maternal mortality rates, antenatal care visits, and primary healthcare coverage are associated with pill and condom use among female adolescents in Brazil.

Sixty-five percent of female adolescents reported using pill while 21.9% reported using condom during the last sexual intercourse. Adolescents living in municipalities with low maternal mortality and high antenatal care coverage were significantly more likely to use pill during the last sexual intercourse compared to those from municipalities with high maternal mortality and low antenatal care coverage. Primary healthcare coverage (proportion of the population covered by primary healthcare teams) was not significantly associated with either condom or pill use during the last sexual intercourse.

Cross-regional and -national differences in condom and pill use among adolescents have been explained by contextual factors, such as the sexual education programs at schools, availability of adolescent health services, and quality and access to family planning services and supplies [11]. Such contexts have often been ignored in investigations of adolescent contraceptive behavior, which have tended to focus on individual aspects, for example, age, socioeconomic status, behaviors such as alcohol use, and exposure to violence. Notably, the interventions that focus only on the individual level are likely to have a limited impact on contraceptive behavior [12]. Some studies that have examined the impact of contextual factors on the use of contraceptives have found that many measures of inequality, such as the Human Development Index and Gini coefficient, as well as poverty and investments in education, are associated with contraceptive use, especially condoms [13, 14].

Identifying contextual characteristics associated with individual practices could guide the implementation of effective family planning programs tailored to adolescent contraceptive needs [13]. Thus, our objective was to assess individual and contextual factors that influence the use of oral pill and condoms among Brazilian female adolescents. Our hypothesis is that female adolescents living in municipalities that present a better performance in some health indicators are more likely to use a condom or pill at the last sexual intercourse than their peers living in municipalities with inadequate performance on these indicators.

In the Brazilian context, 80% of adolescents report the use of contraceptive methods at the last sexual intercourse [15, 16]. While male condom was used by 69% of the adolescents, with no statistical difference by type of school (public/private) or region of residence, the use of pill was reported by only 13%, with significant differences between the regions [15]. Although male condoms are widely available in primary healthcare facilities, pills are available only with medical prescription in such contexts. The purchase of oral contraceptives without medical prescription is a common practice in the country, though not allowed. LARCs are rarely reported in Latin America and the Caribbean, including Brazil [17, 18].

All analyses were conducted using Stata® software version 14.0 and took into account sample weights. We present the distribution of all female adolescents who had ever had sexual intercourse as well as those who used pill or condom during the last sexual intercourse by background characteristics.

We then estimated multilevel mixed-effects logistic regression models to examine the association between individual- and context-level factors and use of pill or condom during the last sexual intercourse, taking into account clustering of female adolescents at the municipality level.

We present (1) the empty model to obtain the variance attributed to the municipality, (2) the unadjusted models, (3) the association of all individual-level variables with each outcome (Model 1), and (4) the final model, that included both individual- and context-level factors. We present the crude and adjusted odds ratios with 95% confidence intervals (95%CI). Estimates with p-values less than 0.05 were considered statistically significant. We also computed the intraclass correlation coefficient (ICC), which provided the variation percentage of variation due to the contextual level, and proportional change in variance (PCV) of using the pill or a condom across the municipalities for Models 1 and 2. The PCV allowed us to assess the percentage change in the outcome variables attributed to the set of independent variables included in the models.

The Research Ethics Committees of each of the 26 states and the Federal District approved the study. Permission to conduct the study was obtained from all State and local Departments of Education and from all schools. All adolescents signed an informed assent form, and their parents signed a consent form.

Adolescent females who participated in the study were mainly non-white, attending public schools, not working in paid jobs, and were living with their mother or both parents. Almost half had their first sexual intercourse at the age of 14 years or earlier. The majority reported using condoms (65.3%) at the last sexual intercourse, while only one out of five (29.1%) reported using pill (Table 1).

Brazilian State capitals are very diverse: population varied from 228,000 in Palmas, in the North, to more than 11 million in São Paulo, located in the southeast region. The coverage of primary healthcare teams varied from 27.4% in São Paulo to 100.0% in Vitória. Capitals with the highest proportion of antenatal care visits were Curitiba and Vitória (88.1% and 78.9%, respectively) while in Macapá and Porto Velho, only 33.8% and 34.6% of newborns had more than seven antenatal care visits. MMR varied from 27.81 deaths per 100,000 women in Palmas to 165.70 in Belém (Table 2).

There was a wide variation in the use of pill among female adolescents across capitals, ranging from 4.8% in Macapá to 47.9% in Porto Alegre (data not shown in table). Results from the fully adjusted model showed that MMR and antenatal care coverage were significantly associated with use of pill during the last sexual intercourse among female adolescents. At the municipality level, higher MMR was inversely associated with using pills while higher antenatal coverage was positively associated with use of the method during the last sexual intercourse. The coverage of primary healthcare teams was not significantly associated with using pills. At the individual level, older adolescents, non-whites, those working in paid jobs, those living with no parents, and those whose mothers had medium or high educational level were significantly more likely to use pill compared with the respective sub-groups of adolescents.

In the null model, the ICC showed that approximately 9.7% of the total variance on the use of pill was attributed to municipality level and 90.3% to individual level factors. The inclusion of individual-level variables explained 10.2% of the context-level variance (Model 1). In Model 2, the PCV showed that 64.9% of the variance at the municipality level were credited to the individual and contextual variables related to pill use (Table 3).

The use of a condom ranged from 50.1% in João Pessoa to 77.5% in Macapá (data not shown in table). No contextual variable was significantly associated with use of condom in the unadjusted model. In the null model, the ICC showed that approximately 2.7% of the total variance in condom use was attributed to municipality level and 97.3% to individual level factors. Given such a low ICC, the full-adjusted model with the context-level variable was not estimated. Results from the model adjusted for individual-level factors showed that older adolescents, non-white, and those living with no parents were significantly less likely to use a condom, while those who had first sexual intercourse at age 15 or older were significantly more likely to use a condom compared with the respective comparison sub-groups (Table 4).

This study presents new insights regarding the association between health indicators and use of contraceptives among female adolescents from cities of a middle-income country with advanced primary health care services but high levels of social inequality [23]. Specific interventions to promote the use of contraceptives that have proven effective include training providers in adolescent contraceptive counseling, providing free or over-the-counter contraceptives for adolescents, and making health services adolescent or youth-friendly [31,32,33]. Our findings suggest that the context in which adolescents live also matter for use of certain contraceptive methods. The findings, for instance, show that living in a municipality with low MMR or a high number of antenatal visits is positively associated with use of pills among female adolescents.

Our findings are consistent with those of a European study which found that geographical differences in adolescent pill and condom use could be explained by diverse access to reproductive health services and contraceptive supplies [10]. Certainly, in countries where there is high MMR, there is low prenatal care coverage and limited access to contraceptives [34]. Consequently, general investments in maternal health may result in improvements in the uptake of some family planning methods among adolescents as initiatives dedicated to women in general, not adolescent-specific, seem to influence contraceptive usage.

Adolescents could therefore benefit from improvements in reproductive health services that expand availability and access to contraceptives in primary healthcare facilities. Access to pills, especially where there are restrictions on contraceptive methods available to adolescents, is likely to contribute to prevention of unintended pregnancies and associated adverse health and socio-economic outcomes among this subset of the population. This is especially relevant because worldwide trends show that adolescent fertility rates in Latin America are the second highest in the world [35] and that Latin America is the only region where unintended pregnancies resulting in birth, as a proportion of all births, have increased [36], with limited progress in reducing adolescent pregnancy in the region. 781b155fdc