Abstract

Introduction

The prevalence of contraception has increased rapidly in the last thirty years in Brazil. In 1986, 66.2% of childbearing-age Brazilian women living with a partner used some contraceptive ¹1. Amorim FA, Bonifácio GMO. Tendências e diferenciais na prevalência dos métodos contraceptivos: uma análise a partir das DHS's realizadas no Brasil. In: XVII Encontro Nacional de Estudos Populacionais. População e desenvolvimento: decifrando conexões, 2010. http://www.abep.nepo.unicamp.br/encontro2010/docs_pdf/tema_5/abep2010_2594.pdf (acessado em 28/Out/2016).
http://www.abep.nepo.unicamp.br/encontro... , increasing to 76.7% in 1996 ²2. Sociedade Civil Bem-Estar Familiar no Brasil. Pesquisa Nacional sobre Demografia e Saúde, 1996. Rio de Janeiro: Sociedade Civil Bem-Estar Familiar no Brasil; 1997. and 80.6% in 2006 ³3. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher: relatório. Brasília: Ministério da Saúde; 2008.. The last Brazilian National Demographic and Health Survey (2006) identified a tendency towards the expansion of the mix of contraceptives used, with greater participation by men, both an increase in male condom use and a higher vasectomy rate ³3. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher: relatório. Brasília: Ministério da Saúde; 2008.. The increase also occurred in sexually active young women 15 to 19 years of age and those living with partners, from 47.8% in 1986 to 66.1% in 2006, a year in which the rate was similar in young sexually active women not living with partners (66.9%) ³3. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher: relatório. Brasília: Ministério da Saúde; 2008..

In the last ten years, initiatives to expand access to modern (not behavioral) contraceptive methods were implemented in Brazil. These include the incorporation of injectable hormonal contraceptives by the National List of Medicines (RENAME), expansion of the distribution of contraceptives in the public healthcare system, and the inclusion of oral contraceptives and injectable hormonal contraceptives in the country’s Popular Pharmacy Program ⁴4. Portal da Saúde. Programa Farmácia Popular. http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/leia-mais-o-ministerio/346-sctie-raiz/daf-raiz/farmacia-popular/l1-farmacia-popular/18008-programa-farmacia-popular-do-brasil (acessado em 28/Out/2016).
http://portalsaude.saude.gov.br/index.ph... , for free supply in public healthcare services or in retail drugstores. A resolution by the National Agency for Private Healthcare introduced mandatory coverage of contraceptive procedures such as intrauterine device (IUD) and sterilization ⁵5. Agência Nacional de Saúde Suplementar. Rol de procedimentos e eventos em saúde. Resolução Normativa RN nº 167, de 9 de janeiro de 2008 e anexos. Rio de Janeiro: Agência Nacional de Saúde Suplementar; 2008.^,66. Agência Nacional de Saúde Suplementar. Resolução Normativa nº 192, de 27 de maio de 2009. Dispõe sobre a cobertura aos atendimentos nos casos de planejamento familiar e dá outras providências. http://www.ans.gov.br/images/stories/Legislacao/consultas_publicas/cp_31_docapoio_rn192_planejamento_familiar.pdf (acessado em 28/Out/2016).
http://www.ans.gov.br/images/stories/Leg... . New products have also reached the Brazilian market, like the transdermal contraceptive patch, vaginal ring, and subcutaneous implant, which are medium and long-acting methods. Known as LARC (long-acting reversible contraceptives), they have been promoted especially among adolescents in various countries, since they do not depend on daily use ⁷7. Sitruk-Ware R, Nath A, Mishell Jr. DR. Contraception technology: past, present and future. Contraception 2013; 873:319-30.^,88. Bahamondes L, Bahamondes MV. New and emerging contraceptives: a state-of-the-art review. Int J Womens Health 2014; 6:221-34..

In addition to these changes, the contraception pattern can also be influenced by societal changes such as greater access to information resulting from the growth of digital media, women’s growing participation in public life, new demands for dealing with inequalities in gender relations, and the expansion of discussion on men’s responsibility in reproduction.

Studies in the last decade have identified a higher prevalence of contraception among young people than in 2006. A population-based study in two health districts in the city of Porto Alegre, Rio Grande do Sul State, in 2009 found that 75% of sexually active females 10 to 19 years of age used some method. Of these, 61.8% used the pill and 38.2% male condoms ⁹9. Duarte HH, Bastos GAN, Del Duca GF, von Eye Cortela H. Utilização de métodos contraceptivos por adolescentes do sexo feminino da Comunidade Restinga e Extremo Sul. Rev Paul Pediatr 2011; 29:572-6.. The national school-based survey ERICA (Cardiovascular Risk in Adolescents) in 2013-2014 found that in sexually initiated boys and girls 12 to 17 years of age (n = 22,241), 80.3% of the boys and 85.2% of the girls reported having used some contraceptive method in their last sexual relations ¹⁰10. Borges ALV, Fujimori E, Kuschnir MCC, Chofakian CBN, Moraes AJP, Azevedo GD, et al. ERICA: início da vida sexual e contracepção em adolescentes brasileiros. Rev Saúde Pública 2016; 50 Suppl 1:15s.. Other studies focused on specific contraceptive practices. The Brazilian National Survey on Access, Use, and Promotion of the Use of Medicines (PNAUM), a nationwide urban household survey in late 2013 and 2014, showed 20.2% and 3.7% of women 15 to 19 years of age used oral and injectable hormonal contraceptives, respectively ¹¹11. Farias MR, Leite SN, Tavares NUL, Oliveira MA, Arrais PSD, Bertoldi AD, et al. Utilização e acesso a contraceptivos orais e injetáveis no Brasil. Rev Saúde Pública 2016; 50 Suppl 2:14s.. A study on emergency contraception use by young people 14 to 19 years of age in public schools in Pernambuco State in 2006 showed that 27.3% had used the method in the previous year ¹²12. Araújo MSP, Costa LOBF. Comportamento sexual e contracepção de emergência entre adolescentes de escolas públicas de Pernambuco, Brasil. Cad Saúde Pública 2009; 25:551-62.. The proportion was 24.9% in young people in public schools and 32.0% in private schools in São Paulo in 2011 ¹³13. Chofakian CBN, Borges ALV, Fujimori E, Hoga LAK. Conhecimento sobre anticoncepção de emergência entre adolescentes do Ensino Médio de escolas públicas e privadas. Cad Saúde Pública 2014; 30:1525-36..

None of these studies identified the prevalence of contraception in young women in the general population. They were limited to the school population or users of health services ¹⁴14. Heilborn ML, Portella AP, Brandão ER, Cabral CS. Assistência em contracepção e planejamento reprodutivo na perspectiva de usuárias de três unidades do Sistema Único de Saúde no Estado do Rio de Janeiro, Brasil. Cad Saúde Pública 2009; 25:269-78.^,1515. Gonçalves H, Machado EC, Soares ALG, Camargo-Figuera FA, Seerig LM, Mesenburg MA, et al. Início da vida sexual entre adolescentes (10 a 14 anos) e comportamentos em saúde. Rev Bras Epidemiol 2015; 18:25-41..

Considering São Paulo’s broad social heterogeneity, it is important to identify how contraceptive practice has occurred in young women in different areas of the city and different social groups and the effectiveness of new strategies to supply methods.

The current study aims to describe the prevalence of contraception and the contraceptives adopted by women 15 to 19 years of age living in the city of São Paulo. The study also aims to identify differences in contraception use and the main sources of methods.

The study is expected to provide backing for more appropriate policies to support young women’s reproductive planning in keeping with their needs and wishes.

Method

The population-based survey entitled Listening to Women: Contraception in the City of São Paulo focused on the sexual, reproductive, and contraceptive histories of women 15 to 44 years of age living in the city in 2015. The current study was based on the data for young women 15 to 19 years of age.

The sample was probabilistic, with a complex design. The sampling units were selected in two stages. In the first, census tracts were selected, and in the second, permanent private households. The total sample included all women 15 to 44 years of age living in the selected households. The sample was stratified according to the city’s five Regional Health Coordinating Divisions or CRS (North, Central, Southeast, East, and South), and 30 tracts were selected in each division. The survey was answered by 75% of the occupied households and 77% of the eligible women, totaling 3,985 women in 3,081 households.

Face-to-face interviews were conducted by female interviewers with at least a secondary education and appropriate training. Participants received explanations on the study and signed the Free and Informed Consent Form. For minors (< 18 years in Brazil), parents or guardians also signed the Informed Consent Form.

Data were recorded on tablets with an app developed by the study and saved daily to the central database (not saved permanently on the tablets). After analysis of the data’s consistency, the names were replaced with identification numbers, thus guaranteeing the participants’ anonymity.

Data were weighted by the design weight, aimed at compensating for the different probabilities of selection used in the CRS. These initial weights were adjusted for the response rates, since non-response was not uniform either. The response weight was associated with the census tract’s socioeconomic status, as represented by the residents’ mean income in the 2010 Census. Another adjustment was introduced by post-stratification, aimed at evening the sample’s age bracket distribution with that observed in the population, based on SEADE Foudation estimates for 2015.

The sample was described according to the following characteristics: (1) socio-demographic - CRS for the person’s place of residence in the city of São Paulo, age, self-reported skin color, expected schooling for age (having begun secondary school for young women 15 to 17 years of age and having finished secondary school for those 18 to 19 years of age), current religion (according to the classification used in the 2010 Census), own income, health insurance, and classification of consumer purchasing power according to the Brazilian Economic Classification Criterion for 2013 ¹⁶16. Associação Brasileira de Empresas de Pesquisa. Critério de Classificação Econômica Brasil. https://www.abep.org/Servicos/Download.aspx?id=01 (acessado em 14/Out/2016).
https://www.abep.org/Servicos/Download.a... ; (2) sexual life - having initiated sexual activity, age at first intercourse, sexual activity in the previous 12 months, sexual activity in the previous 30 days, lifetime number of sex partners, conjugal status (living with a partner); (3) reproductive - currently pregnant (yes/no), number of pregnancies, age at first pregnancy, live born children, age at birth of first live born child, history of abortion, number of unplanned live born children; (4) evidence of reproductive knowledge - knowledge of the person’s own fertile period and knowledge of contraceptives.

Contraceptive practice was depicted as the prevalence of contraception and types used, contraception in first sexual intercourse, use of emergency contraception at least once, sources of contraceptives, and unmet demand for contraceptives. Prevalence was estimated as the percentage of women that said they were currently using contraception among those who reported heterosexual relations at least once in the previous 12 months and were not pregnant. Contraception use was defined as an affirmative answer to the question: “Are you and/or your partner currently doing something or using some method to avoid pregnancy? Remember that this includes the rhythm method and ‘withdraw’”. The type of method was identified with the question: “What do you (and/or your partner) currently do or use to avoid pregnancy?”, which allowed multiple answers. When more than one method was mentioned, the contraceptive that was considered most effective was selected, as standardized in international demographic studies. The only exception was the combination of male condom plus the pill, which was cited so often that it was treated as “one method”. Unmet need was estimated as the proportion of women who did not want to become pregnant and were not using contraception because they had been unable to obtain it or did not know where to look for it, among those who reported heterosexual relations at least once in the previous 12 months and were not pregnant. Frequency of emergency contraception use was estimated as the proportion of women who said they had used “emergency contraception or the day after pill” some time in life, among those who had had heterosexual relations. Source of method was defined simultaneously by the type of establishment and financing. Thus, obtaining the product from a unit of the Brazilian Unified National Health System (SUS) or the Popular Pharmacy Program was defined as “public”. The supplementary health system (private health plans) was considered the source when the costs in private health services were covered by the person’s health plan. Purchase in retail pharmacies was disaggregated to account for the share of discounts covered by some health plans.

The study attempted to identify the main differences in the use of various methods and emergency contraception use, using multiple logistic regression analysis. Variables selected for the initial model were those whose associations with the outcomes were significant at 20% in the bivariate analysis. Next, the variables that were not significant at 5% were excluded one by one by order of significance (backward elimination). Reference category was defined as that with the lowest proportion of the respective event, except for color and religion, in which white and no religion were chosen as the references, respectively. All the variables were initially included in the model, Data processing took the complex sampling plan into account. Stata version 10.1 (StataCorp LP, College Station, USA) was used.

The study was approved by the Institutional Review Board of the Heliópolis Hospital of the São Paulo State Health Secretariat (CAAE 35805514.7.0000.5449).

Results

The study interviewed 633 women aged 15 to 19 years. Tables 1 and 2 show the information on all the young women and the two subpopulations exposed to contraception use: women who had initiated their sexual activity and who had had heterosexual relations (310) and those who had had heterosexual relations in the previous 12 months and were not pregnant at the time of the interview (248). Approximately 50% (316 women) were sexually initiated, and 94% of these reported having relations only with men, 4.1% with men and women, and 2% (6) only with women.

Of the total, the age group breakdown was distributed nearly equally according to simple age. The sample’s proportional distribution according to CRS was close to the distribution projected by the SEADE Foundation for the city in 2015: 20.1% in the North; 8.9% in the Central; 19.6% in the Southeast; 26.3% in the South; and 25% in the East (Departamento de Informática do SUS. Nascidos vivos - Brasil. http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sinasc/cnv/nvuf.def, accessed on 15/Mar/2016). These population values are inside the observed confidence intervals in this variable’s different categories. The majority had the expected schooling for their age, belonged to class C, did not have their own income or health insurance, and were black (42.9% brown plus 14.5% black). The majority were catholic (51.6%), with 27.6% evangelicals, and 6.6% with no religion (Table 1).

The breakdown of the other two sub-groups (sexually initiated women and those who had had relations in the previous 12 months) showed a higher share of those over 17 years of age, residents in the South of the city, had not reached the expected schooling for their age, belonged to classes D and E, and had their own income (Table 1).

About 20% of the young women knew the fertile period in their menstrual cycle, independently of whether they had initiated sexual activity (Table 2).

Reproductive and contraceptive history

Among the young women who had had heterosexual relations, 86.2% reported that their first sexual intercourse was intended, 12.5% stated that it was consented but not wanted, and 1.3% (4) had initiated their sexual life by rape. Mean age at first intercourse was 15.1 years (95%CI: 14.9-15.3), and 33.9% had had their first intercourse before they reached 15 years of age.

The majority reported having had more than one sex partner (53.1%). Nearly one-third (27.8%) had already been pregnant at least once, 18.8% had at least one live-birth, and 5.8% were pregnant at the time of the interview (Table 2). Some 4% of the young women reported having had a miscarriage and 1% had had an abortion. Among those who had been pregnant, 61% had at least one child born of an unintended pregnancy. Mean age at first pregnancy was 16.3 years (95%CI: 16.0-16.7), and mean age at first live-birth was 16.7 years (95%CI: 16.4-17.1).

The majority had a partner (70.1%), and 20.7% were living with the partner.

All of the women knew at least two modern non-surgical contraceptive methods, but less than 1% knew all of them. Female condom, implant, patch, and vaginal ring were the least known methods. Only 5.4%, 29.4%, 47%, and 42.3%, respectively, had heard of the latter. Nearly all (97.7%) had used contraception at least once, and the vast majority (80.7%) said they had used some protection in their first intercourse, with condom use reported by 75.6%.

Use of emergency contraception

Approximately 60% of those who reported heterosexual relations had used emergency contraception some time in life. The main reasons for using this type of contraception were: not having a condom with them at the time of sex (30.4%), not trusting the method they were using (16.6%), having had sex unexpectedly or unprepared (16.3%), the condom burst, was punctured, or was stuck (16%), and having used their customary contraceptive method incorrectly (9%).

Bivariate analysis showed a positive association between emergency contraception use (p < 0.05) and age, not having the expected schooling for age, and more than one lifetime sex partner. No statistically significant differences were observed in the percentage of women who had already used emergency contraception, according to CRS, consumer class, health insurance, race/color, age at first intercourse, contraception at first intercourse, conjugal status, live born children, knowledge of one’s fertile period, and history of gynecological visit (Table 3). The initial multivariate analysis included age, expected schooling for age, lifetime number of partners, and current contraception use (p = 0.127), although the difference appears to be related to the absence of sexual relations in the year prior to the interview, thus the absence of information on current contraceptive practice. Variables that remained associated with emergency contraception use were age and lifetime number of sex partners. The odds of emergency contraception were higher for women 18 to 19 years of age than for those 15 to 17 (OR = 2.05; 95%CI: 1.26-3.36) and for those with 2 to 3 lifetime partners (OR = 2.77; 95%CI: 1.48-5.19) or more than 3 partners (OR = 11.12; 95%CI: 3.17-39.03) when compared to those reporting one partner (Table 3).

Current contraception

Analysis of current contraception considered the 248 young women who reported heterosexual relations in the previous 12 months and were not pregnant.

Prevalence of contraception was 81.1%, with no statistically significant difference (p = 0.377) between those living with (84.7%) versus not living with a partner (80.1%) (Table 4). The main reasons for not using contraception were sporadic sexual relations (65%), followed by the desire to become pregnant (9.5%). Unmet demand for contraceptives was low, since only 2.6% of the young women reported not using any method because they were unable to obtain it or did not know where to find it.

The most common currently used methods were male condoms (28.2%) and oral contraceptives (23%), followed by the pill plus condom combination (14.7%) and injectable hormonal contraceptives (13.7%). No women reported tubal ligation, vasectomy, IUD, female condom, implant, patch, vaginal ring, or diaphragm. Although prevalence of use did not differ statistically between women with versus without a partner, the breakdown in the “mix” of contraceptives varied significantly (p = 0.000). The most frequent methods among those living with partners were oral contraceptives (30.8%) and injectable methods (28.9%), while the most frequent methods in those not living with partners were condoms (32%), followed by the pill (20.9%), and the combination condom plus the pill (17.1%) (Table 4 ).

According to the bivariate analysis, factors associated with current contraceptive use (p < 0.05) were current religion, sexual activity in the previous 30 days, lifetime number of partners, and gynecological visit in the previous year. In addition to these, the multivariate analysis included CRS, age bracket, race/color, consumer class, private health insurance, and contraception use in first intercourse (all with p < 0.20). The odds of current contraceptive use were higher among residents of the Central CRS, (OR = 6.19; 95%CI: 1.06-35.98), Catholics when compared to those with no religion (OR = 3.36; 95%CI: 1.09-10.32), history of sexual relations in the previous 30 days (OR = 10.38; 95%CI: 4.30-25.03), fewer than four lifetime sex partners - two or three partners (OR = 4.41; 95%CI: 1.46-13.32) and one partner (OR = 7.50; 95%CI: 2.46-22.88), and those reporting a gynecological visit in the previous year (OR = 3.96; 95%CI: 1.28-12.30) (Table 5).

Sources of contraceptives

Most of the women purchased contraceptives in retail pharmacies (75.2%), 23.6% obtained them from the SUS or the Popular Pharmacy Program, and the rest obtained them free in some other way (1.2%). The Popular Pharmacy Program was only cited by 5 women (1.8%), of whom 4 used the pill and 1 an injectable hormonal method. Only 2 women (1.4% of contraceptive users) reported obtaining a discount from pharmacies on the price of the pill, based on their private health plan. The predominance of purchases in retail pharmacies was even higher among those that used condoms (84.1%) and oral contraceptives (80.2%). The public health system was only cited as the most frequent source in the case of injectable methods (60.3%), especially for obtaining them in health units (58.1% of this method’s users). Most oral contraceptive users (70.7%) and condoms users (64.3%) had never been approached SUS to obtain them. The reasons cited for not using the SUS as a source of oral contraceptives and condoms, respectively, were: easier or quicker to purchase at the retail pharmacy (21.1% and 28.7%), not aware that they could obtain the method from the SUS (20.7% and 6.2%), never having thought of it (16.5% and 16.2%), using some other type or brand of the pill (15.9%), not trusting condoms from the SUS (9.1%), and not attending the SUS (9% for both).

The main source of emergency contraceptives was retail pharmacies: 94.2% reported having purchased their last emergency contraceptive in a pharmacy without having shown a prescription. No young women reported having obtained this method in the SUS.

Discussion

The proportion of sexually active young women was similar to that in Brazil in 2006 (55%). Mean age at first intercourse and the proportion of young women with sexual initiation before 15 years of age were also similar (15.2 years and 16.9% ¹⁷17. Garcia S, Koyama M. Longevidade sexual e práticas sexuais desprotegidas: desafios para a promoção da saúde sexual e reprodutiva das mulheres. In: Ministério da Saúde, organizador. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher - PNDS 2006: dimensões do processo reprodutivo e da saúde da criança. Brasília: Ministério da Saúde; 2009. p. 106-33., respectively).

The frequent mention of the use of some contraceptive method in first intercourse had also been observed in 2006 (80.3%), but reference to condom use was slightly lower in the country as a whole (67%) (Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher: baco de dados. http://bvsms.saude.gov.br/bvs/pnds/banco_dados.php, accessed on 19/Apr/2016). In 2006, nearly all sexually active young Brazilian women had used some contraceptive method (96%), a figure very close that of the current study in the city of São Paulo.

It was surprising to find such a high prevalence of contraceptive practice and a higher presence of modern methods, especially injectable methods, in the city of São Paulo compared to young Brazilian women as a whole in 2006 ³3. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher: relatório. Brasília: Ministério da Saúde; 2008. and in 2014 ¹¹11. Farias MR, Leite SN, Tavares NUL, Oliveira MA, Arrais PSD, Bertoldi AD, et al. Utilização e acesso a contraceptivos orais e injetáveis no Brasil. Rev Saúde Pública 2016; 50 Suppl 2:14s._. While 66.3% of young women living with partners and 66.9% of those not living with partners were using some contraceptive method in Brazil in 2006 ³3. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher: relatório. Brasília: Ministério da Saúde; 2008., the figures were 84% and 80%, respectively, in São Paulo. Since the national study was a decade ago, this same increase may have occurred in the country as a whole, although women’s higher average schooling and greater access to health services in São Paulo may have influenced the results.

Sexual activity in the previous month showed a strong association with current contraceptive use. This is probably the result of the association between sporadic relations and high prevalence of male condoms, the use of which is coitus-dependent. In fact, the main reason for not practicing contraception was having sex sporadically, which does not negate the use of a barrier method like condoms when sexual relations do happen. In addition, the fact that prevalence of contraception was lower among young women with more lifetime sex partners, and that they had used emergency contraceptives more often, both suggest a different way of dealing with contraception.

Unlike the current study, the interference of religion in contraception use was not captured by any of the national demographic and health surveys. The surveys have shown that catholic women tend to use contraception as frequently as other women, contradicting the catholic hierarchy’s discourse. It is difficult to understand why they would use contraceptives more often than women who do not profess a religion. Meanwhile, young pentecostal women reported lower prevalence of contraception, although the difference was not statistically significant. Restrictions on extramarital sex by pentecostal denominations may act as a barrier to information for the prevention of unintended pregnancy ¹⁸18. Silva CG, Santos AO, Licciardi DC, Paiva V. Religiosidade, juventude e sexualidade: entre a autonomia e a rigidez. Psicol Estud 2008; 13:683-92..

It is understandable that a gynecological visit in the year prior to the interview is associated statistically with contraceptive use, since gynecological visits provide the opportunity for a conversation on the need for the method, the available alternatives, and recommendation of a product. Although no Brazilian study could be found that would allow a comparison, another measure of access to health services, namely ease of access to transportation to reach such services, played a similar role in an analysis of data on adolescents in 2006 ¹⁹19. Rozenberg R, Silva KS, Bonan C, Ramos EG. Contraceptive practices of Brazilian adolescents: social vulnerability in question. Ciênc Saúde Coletiva 2013; 18:3645-52.. Interestingly, schooling was not a differential, and it was not possible to show a statistical association between consumer class and contraceptive practice. However, residence in the Central CRS of the city gained importance in the multivariate analysis. The Central is the city’s health region with the best infrastructure, best educational standards, and best transportation. In other words, a more favorable social and economic context, of which the Central of São Paulo city is an example, may be more conducive to the development of attitudes and means to regulate fertility than any of the individual factors.

Importantly, the fact that fewer than 3% of the women did not practice contraception because they could not obtain the product suggests that non-use involves more than difficulties in access to methods, and that there must both other cultural and behavioral factors involved, not addressed in this study. The ambiguity of the desire for pregnancy and the lack of life plans beyond motherhood may be two such factors ²⁰20. Brandão ER. Desafios da contracepção juvenil: interseções entre gênero, sexualidade e saúde. Ciênc Saúde Coletiva 2009; 14:1063-71..

Condoms and oral contraceptives remained as the methods most widely used by young women in São Paulo, similar to the pattern in developed countries ²¹21. World Health Organization. Health for the world's adolescents: a second chance in the second decade. Geneva: World Health Organization; 2014.. Use of injectable methods was twice as high as in Brazil as a whole in 2006 (6.8%) and even higher among young women living with partners (28.9% versus 6.8% for Brazil) ¹¹11. Farias MR, Leite SN, Tavares NUL, Oliveira MA, Arrais PSD, Bertoldi AD, et al. Utilização e acesso a contraceptivos orais e injetáveis no Brasil. Rev Saúde Pública 2016; 50 Suppl 2:14s.. This increase may have resulted from greater supply, acceptability, and access to this method. The other medium-acting methods like vaginal ring and patch, and the LARC, like implant and IUD, were not cited by the women in our study. LARC are more effective than condoms and the pill, since they do not depend on adherence or correct daily use, and they have been associated with positive impacts on reproductive control and a reduction in unintended pregnancy and abortion rates in adolescence ²²22. Blumenthal PD, Voedisch A, Gemzell-Danielsson K. Strategies to prevent unintended pregnancy: increasing use of long acting reversible contraception. Hum Reprod Update 2011; 17:121-37.^,2323. Connolly A, Pietri G, Yu J, Humphreys S. Association between long-acting reversible contraceptive use, teenage pregnancy, and abortion rates in England. Int J Womens Health 2014; 21:961-74.^,2424. Secura GM, Madden T, McNicholas C, Mullersman J, Buckel CM, Zhao Q, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med 2014; 371:1316-23.. Although copper IUD is free of cost in the SUS, it is rarely offered to women, particularly those who have not had children. Vaginal ring, patch, and implant have not been incorporated by the Brazilian Ministry of Health. The São Paulo Municipal Health Secretariat recently launched a project for the use of implants in adolescents in 2016 ²⁵25. Secretaria Municipal de Saúde de São Paulo. Rede Municipal adquire implantes contraceptivos de longa duração para ampliar gama do planejamento reprodutivo. http://www.prefeitura.sp.gov.br/cidade/secretarias/saude/noticias/?p=211815 (acessado em 03/Mar/2016.
http://www.prefeitura.sp.gov.br/cidade/s... .

Access to a wider variety of methods favors freedom of choice and thus greater consistency between the woman’s wishes, her life stage, and the method used, thus higher odds of preventing unintended pregnancies ²¹21. World Health Organization. Health for the world's adolescents: a second chance in the second decade. Geneva: World Health Organization; 2014.. Other countries have invested in this expansion: in Colombia, the subdermal implant has been supplied free of cost to the population since 2008; in Mexico, implants, patch, and IUD with levonorgestrel are available free of charge; in England, there are 15 types of contraceptive methods supplied free by the National Health Service, including vaginal ring, patch, and all the LARC.

The proportion of young women in São Paulo who had used emergency contraception at least once was six times higher than in Brazil as a whole in 2006 (10.4%) ³3. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher: relatório. Brasília: Ministério da Saúde; 2008.. This tendency has been identified by other authors ¹²12. Araújo MSP, Costa LOBF. Comportamento sexual e contracepção de emergência entre adolescentes de escolas públicas de Pernambuco, Brasil. Cad Saúde Pública 2009; 25:551-62.^,2626. Brandão ER, Cabral CS, Ventura M, Paiva SP, Bastos LL, Vidal NVB, et al. "Bomba hormonal": os riscos da contracepção de emergência na perspectiva dos balconistas de farmácias no Rio de Janeiro, Brasil. Cad Saúde Pública 2016; 32:e00136615.^,2727. Figueiredo R. Panorama da distribuição gratuita, venda e uso da contracepção de emergência no Brasil. In: Figueiredo R, Borges ALV, Paula SHB, organizadoras. Panorama da contracepção de emergência no Brasil. São Paulo: Instituto de Saúde; 2016. p. 83-101.^,2828. Sousa SRGR, Franca C, Colares V, Nóbrega ABS. Conhecimento e uso da contracepção de emergência na adolescência. Adolesc Saúde 2016; 13 Suppl 2:167-73.. This may be explained by women’s growing awareness of the method, its effective and safe action in unplanned sexual relations, and its availability in retail pharmacies. Although another study associated emergency contraceptives use by young women with higher socioeconomic status ¹³13. Chofakian CBN, Borges ALV, Fujimori E, Hoga LAK. Conhecimento sobre anticoncepção de emergência entre adolescentes do Ensino Médio de escolas públicas e privadas. Cad Saúde Pública 2014; 30:1525-36., none of the socioeconomic indicators used in our study acted as a differential. The only factors associated with emergency contraceptives were older adolescence and more lifetime sex partners, both of which may reflect time of exposure to sexual activity. Youth is the time of life in which the search for a partner and emotions is more intense, and in which encounters are more frequent, unexpected, and fleeting. The likelihood of unexpected sexual relations is high, and probably occurs in the lives of most people. The great benefit of emergency contraception is exactly to keep this context from leading to pregnancy. For that very reason, easy access to emergency contraception has been a prime strategy for more than two decades for reducing unintended pregnancy in adolescence in various countries. It is currently on the list of essential medicines for women’s and children’s health and in the family planning manual of the World Health Organization (WHO). Various organizations across the world support public policies to expand its use, and there are 148 countries with at least one type of emergency contraception available (International Consortium on Emergency Contraception. EC status and availability: countries with at least one EC. http://www.cecinfo.org/country-by-country-information/status-availability-database/countries-with-at-least-one-ec-pill-brand-registered/, accessed on 27/May/2016).

The introduction of the “day after pill” in Brazil’s public health system is more recent and has faced resistance from religious institutions and conservative politicians. It was approved for the market by the Brazilian National Health Surveillance Agency (Anvisa) in 1999, but its supply to local governments by the Brazilian Ministry of Health was irregular until 2004. Since then, the Brazilian Ministry of Health has expanded the distribution of the “day after pill” for dispensing in primary healthcare services and the dissemination of technical information through publications targeting health professionals ²⁹29. Departamento de Ações Programáticas Estratégicas, Secretaria de Atenção à Saúde, Ministério da Saúde. Anticoncepção de emergência: perguntas e respostas para profissionais de saúde. Brasília: Ministério da Saúde; 2005.. Nevertheless, the difficulties in the public sector tend to hinder access. The “day after pill” has to be taken within five days after the unprotected sex, and its efficacy decreases with each day. The fact that most of the primary care units are only open to the public during “business hours” and the need for a physician or nurse to obtain the “day after pill” have made this access very difficult ²⁷27. Figueiredo R. Panorama da distribuição gratuita, venda e uso da contracepção de emergência no Brasil. In: Figueiredo R, Borges ALV, Paula SHB, organizadoras. Panorama da contracepção de emergência no Brasil. São Paulo: Instituto de Saúde; 2016. p. 83-101.. It is thus not surprising that nearly all the young women who had used emergency contraceptives had purchased it in retail pharmacies. Pharmacies were the leading source of all contraceptives, through out-of-pocket payment, except in the case of the injectable method. Even with free availability of oral contraceptives and male condoms in public healthcare units, the majority of users had never gone to the SUS to obtain them. Unfamiliarity with this supply and the lack of practicality for obtaining these products from the SUS were the main barriers. The Popular Pharmacy Program was rarely cited as the source of oral or injectable contraceptives. Subsidies for contraception through this program would greatly facilitate women’s lives, since they could use the wide-reaching retail pharmacy network, thus facilitating geographic access. However, this right has hardly been publicized, and there is a need to inform the population on the available products in order to make the initiative effective (although there is still the limitation of having to show a physician’s prescription).

Despite the high frequency of contraceptive use in the city, nearly 19% of sexually active young women had at least one child, resulting from an unwanted pregnancy. But this paradox is not exclusive to Brazil and has become a priority reproductive research issue in developed countries ³⁰30. Bajos N, Le Guen M, Bohet A, Panjo H, Moreau C; the FECOND group. Effectiveness of family planning policies: the abortion paradox. PLoS One 2014; 9:e91539.. Meanwhile, it is impossible not to think of inadequate use of contraception, since an alarming 80% of the young women could not identify the fertile period in their menstrual cycle.

The study’s cross-sectional design for responding to the main objective, to establish a profile of contraceptive practices by young women in the city of São Paulo, involves limitations. The first is that it does not allow inferring causal relations between the associated variables. The number of sexually active adolescents that were interviewed limited the analytical power of some results, hindering a more in-depth analysis of some aspects of contraceptive practice. Further, although the quantitative approach allows depicting the situation of contraception in the female population, it does not capture the complexity of managing sexual and reproductive life, which is not a purely rational experience.

Final remarks

The study highlighted the growing prevalence of contraception use by young women and particularly the considerable rate of male condom use for dual protection, especially associated with the pill. Use of male condoms was cited by nearly 50% of the women not living with partners, which indicates the need for protection from STDs and that condoms have been adopted by part of this generation, although condom use is not as frequent in the context of “marriage”. This was also the first population-based survey to estimate the proportion of young women who had ever used emergency contraception.

However, the range of different contraceptives used is narrow, and among the medium and long-acting methods, only injectable hormonal methods appeared in the sample. The public healthcare system has still not incorporated the supply of new options like patches, vaginal rings, and implants. And although the IUD is available, it remains scarcely known and apparently rarely offered.

The free availability of some contraceptives in public health services and the subsidized supply of the pill and injectable methods in Brazil’s Popular Pharmacy Program have still not proven efficient.

Likewise, although nearly a third of the young women reported having a private health plan, virtually none of them cited such plans as the source of contraceptives. The nearly universal coverage of contraception in this population segment was thus due mainly to women’s individual out-of-pocket purchases.

Above all, it is necessary to break with the structural barriers to access to contraceptives in the SUS and to their free supply. Government urgently needs to publicize the availability of contraceptives in the Popular Pharmacy Program, via all types of media, and to include the day after pill in the program.

It is alarming to note that nearly 30 years after the introduction of contraceptive care in the Women’s Comprehensive Healthcare Program, Brazilian women can still not rely on government support to exercise their sexual and reproductive rights.

Acknowledgments

The authors wish to acknowledge Department of Science and Technology of the Brazilian Ministry of Health and Research for SUS Program/São Paulo State Reserach Foundation (PPSUS/FAPESP; grant 2014/50115-1) for the research funding and the Technical Cooperation between the São Paulo State Health Secretariat and Pan-American Health Organization (PAHO-Brazil; Letter of Agreement BR/LOA/15000060.001)

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