Contraceptive use and the intention to become pregnant among women attending the Brazilian Unified Health System

Objective: to analyze the use of contraceptive methods and the intention to become pregnant among women attending the Brazilian Unified Health System. Method: a cross-sectional study conducted with 688 women aged 18-49 years old, attending the Family Health Strategy Facilities in the eastern part of the city of São Paulo, Brazil, who were awaiting medical or nursing consultation. Data were obtained through interviews with a structured instrument, allocated in tablets. The analysis was conducted with “strong desire to avoid pregnancy” as the dependent variable. Chi-square and multiple logistic regression were used, calculated in Stata 14.2. Results: 56.5% used some contraceptive method, covariates of the strong desire to avoid pregnancy were marital status (OR=0.49; CI95%=0.33-0.74), parity – two and more children (OR=15.9; IC95%=4.29-59.1); and pregnancy planning – planned (OR=0.69; IC95%=0.73-0.94) and ambivalent (OR=2.94; IC95%=1.30-3.83). There was no statistical difference between the strong desire to avoid pregnancy and the type of contraceptive used. Conclusion: women with a strong desire to avoid pregnancy used basically the same types of contraceptive methods as women in general, which shows that they have not been supported to achieve their reproductive preferences.


Introduction
Sexual health is widely understood as a state of physical, emotional, mental, and social well-being in relation to sexuality. It is not only related to certain aspects of reproductive health, but also to the possibility of having a pleasant and safe sexual life, free from coercion, discrimination, and violence. Achieving the highest attainable standard of sexual health is closely linked to the respect, protection, and fulfillment of human rights, nondiscrimination, privacy and confidentiality, to be free from violence and coercion, as well as the rights to education, information, and access to the health services (1) .
In the Action Program of the 1994 International Conference on Population and Development (2)(3) , the governments committed to enabling people to make choices about their sexual and reproductive health considering the fundamental human rights, as millions of women globally want to avoid pregnancy, but neither they nor their partners use a contraceptive, or use them inappropriately and discontinuously, or even use ineffective and short duration methods (4) .
On the other hand, many women worldwide use contraceptive methods to prevent pregnancy, but they fail for a number of reasons, such as not having received clarifying instructions on how to use the method properly, not having obtained the method best suited to their clinical, social, and reproductive health needs, and limited availability of health services (5) .
Brazil has shown a significant drop in the fertility rate in the last decades, from 6.3 children per woman in 1960 to 1.7 children in 2018 (6) . The historical series of the Demographic and Health Survey (Pesquisa Nacional sobre Demografia e Saúde, PNDS) show that the contraceptive prevalence rate among married women aged 15 to 49 years old increased from 66.2% in 1986 to 80.6% in 2006 (7) .
The occurrence of unintended pregnancies represented 44% of the pregnancies that occurred in the five years prior to PNDS 2006 (8) , findings ratified by the Nascer no Brasil (Being born in Brazil) survey of 2014, which indicates that 55.4% of the pregnancies were unintended. It is known that unintended pregnancies can have negative effect on women and their children; they contribute to the occurrence of induced abortions resulting in the main cause of maternal mortality in countries with restrictive abortion laws. In addition, unintended births are associated with an increased risk of obstetric complications, late prenatal care and babies more likely to have low birth weight, premature birth, and maternal depression (9)(10) .
A study conducted in Oklahoma, USA, examined the effect of pregnancy intentions at three different times: the prenatal period, the immediate postpartum period, and the period of early childhood. The estimated effects were stronger in the prenatal period and decreased at two years of age, suggesting that, over time, mothers adjust to unintended births and respond to the health needs of their young children, regardless of the status of the pregnancy intention. In the prenatal period, women with unintended pregnancies were less likely to engage in health-promoting behaviors than women with intended pregnancies (11) .
That said, it is essential to assess women's access to family planning and track their reproductive intentions and preferences, precisely to support the provision of   The sample size calculation was based on the probability sampling technique (13) , with which, from a sample, one can generalize the characteristics of the population and expand the data to the group of women between 18 and 49 years old from the city of São Paulo.
In view of the purpose of this study, for dimensioning the sample size (n), we chose to use the "use of contraceptive methods" variable as a parameter, in order to estimate the percentage of women aged 18 to 49 years old who have already used contraceptive methods at least once in their lifetime in the Southeastern region, according to PNDS 2006 (14) . The calculation showed that it would be  (16) ).
For the analysis of the reproductive and contraceptive behavior, the following variables were analyzed: age at menarche; age of sexual initiation; number of sexual partners in life; previous pregnancy (yes or no); age at first pregnancy; number of pregnancies; history of abortion (yes or no), and number of children.
In order to analyze the relation between reproductive preferences and contraceptive practices, the measurement of pregnancy planning using the London Measure of Unplanned Pregnancy (LMUP), Brazilian version, was chosen. This instrument is short, and consists of six items that make up the pregnancy-planning domain. One of the potentialities of the LMUP is the classification beyond the dichotomous and artificial position of "planned" or "did not plan the pregnancy", since it makes it possible to classify women as having an ambivalent pregnancy planning. This means that the instrument does not ignore the complexity of female experiences related to reproduction, including ambivalences or uncertainties (17) . The use of contraceptives was defined as the use of any method during the period of interview. The variable "strong desire to avoid pregnancy" was created by combining the variables "I would like to get pregnant" (do not want to get pregnant (any more), or immediately, between 1 and 2 years, 2 years or more, don't know/not sure); "Importance of preventing pregnancy" (very important, indifferent, not very important); "Time to become pregnant" (wrong, neither right/nor wrong, right); and "Feelings if an unexpected pregnancy occurs" (sad/unhappy, indifferent, don't know, happy). Therefore, the "strong desire to avoid pregnancy" variable is the sum of the codes of these four variables, which varied from 4 to 12: the higher the score, the stronger the desire to avoid pregnancy; and the lower the score, the weaker the desire to avoid pregnancy. The variable, however, was analyzed in a dichotomous way, with code 0 (zero) being attributed to women whose score was up to 10 and code 1 (one) to women whose score were 11 and 12, i.e., they reported at least three situations that express they really did not want to get pregnant, among the four possible (18) .
The aspects associated with having a strong desire to avoid pregnant were analyzed using multiple logistic regression, in which the variables were inserted simultaneously in the model. The main independent variable was the type of contraceptive method used. This variable considered the effectiveness of the reversible and permanent methods according to the Effectiveness of Family Planning Methods (19) being "High efficacy" (less than 01 pregnancies per 100 women/year); "Medium efficacy" (6-12 pregnancies per 100 women/year) and "Low efficacy" (18  In order to know the intention of getting pregnant, women were asked whether or not they would like to have (more) children, and the results were statistically significant for age (p<0.001), no health insurance (p<0.005), and parity (p<0.001). Regarding how important it was to prevent pregnancy, there was an association between parity (p<0.001) and not using any contraception method (p<0.001), according to Table 2.    were associated with a strong desire to avoid pregnancy.   There was no statistical difference between having a strong desire to avoid pregnancy and the type of contraceptive method used, i.e., women with a strong desire to avoid pregnancy used basically the same types of contraceptive methods as women in general.
Contraceptive use was defined as the use of any contraceptive method during the period of interview.
No particular contraceptive method was associated with a strong desire to prevent pregnancy. It is noteworthy that even not using any method was similar (Table 5). Even though the non-use of contraceptive methods by a considerable number of women who did not wish to become pregnant can be compared to data from the PNDS, the use of contraceptive methods increased substantially in Brazil, but it cannot be ignored that contraceptive practice is based on subjectivity and not in rationality (9) .
Although the use of contraceptive methods is high in the country, a nationwide study showed that most women did not intend to become pregnant, wanted to wait longer and had no desire to be mothers at any time (10) .
In a prospective analysis with Latin women from the United States of America (USA)-Mexico border, it was investigated to what extent the use of contraceptive methods was associated with the desire to prevent pregnancy. Using the National Survey of Family Growth (NSFG), women who replied that they did not want another pregnancy were not using contraceptive methods nor did they care about getting pregnant (17,20) .
Pregnancy intentions can be complex, involving a variety of emotional and psychological factors, the product of individual intentions, and multiple intertwined Understanding a woman's pregnancy intentions can help to ensure that she uses more effective and/or more consistent methods, thereby reducing the likelihood of an unintended pregnancy, provided they have access to the means to do so (20)(21) .
The relation between motivation to avoid pregnancy and incongruous intentions and feelings is often examined by looking at the type of contraceptive method used and its correct use. There is evidence that women's ambivalence in avoiding pregnancy is associated with inconsistent or incorrect use of contraceptives or with the use of less effective methods. Thus, the use of contraceptive methods may not occur consistently and continuously, resulting in situations of contraceptive vulnerability (22) . Many women express ambivalence about their intentions to become pregnant. Formulating plans for a pregnancy may seem unrealistic to many, as they do not perceive themselves as having reproductive control (22) .
Another consideration is whether the use of contraceptives alone should be interpreted as evidence of an intention to prevent pregnancy. In this study, most women who were users of some type of contraceptive method answered that it was very important to prevent pregnancy and, if pregnancy occurred, this would be at the wrong time, but they would feel happy, showing ambivalent feelings.
A study carried out in the USA between 2008, 2012 and 2014 on the use of contraceptive methods showed that women used and discontinued the use of methods based on the characteristics of these methods, including side effects, efficacy and ease of use (17) being limited to access, planned services, discrimination in health care environments, and financial barriers (18) .
Many women may find methods difficult to use correctly because they are dissatisfied with certain aspects, such as interference with sexual function, negative side effects, or non-acceptance by intimate partners (e.g. male and female condoms and pill) (23)(24) .
In this regard, The Contraceptive CHOICE Project (CHOICE) sought to reduce unwanted pregnancies by removing barriers to cost, education, and access to highly effective contraceptives. It was a prospective cohort study of more than 9,000 women aged 14 to 45 years old who received staggered contraceptive counseling to raise awareness of all available reversible methods, particularly Long-Acting Reversible Contraceptive (LARC) methods.
Most of the study participants chose the levonorgestrel intrauterine device, subdermal implant, and copper intrauterine device respectively (25) , generating substantial cost savings due to increased acceptance of highly effective contraceptives and consequent prevention of unwanted pregnancies and births (26) .
Our results showed that a considerable proportion of women who had a strong desire to avoid pregnancy did not use contraception methods. For those who used some method, the use of medium and low efficiency methods was verified (19) , which shows that women may not be supported to achieve their reproductive preferences.
An analysis of the prevalence of modern and traditional contraceptive methods by type of method in Brazil found that most women used the pill or did not use any method (23) , corroborating our results.
It is imperative that the health services organize themselves to offer quality and quantity contraceptives to meet the demands of the users. The lack of contraceptives or even the lack of access and supply are among the most cited reasons in low-and middleincome countries for unmet demand, non-use, and discontinuation of contraception (23) .
Contraceptive availability goes beyond simply supporting better health for women. It is important to develop and establish reliable systems in the supply chain to ensure that goods and services meet women's contraceptive needs. If efficient, they improve the quality of care and support for choosing modern methods of contraception. Strengthening the supply chain can improve contraceptive security, as all customers will be able to freely choose, obtain and use good quality contraceptives (27) .
The limiting aspect of this investigation is its execution limited to one region and the non-inclusion of all regions of the city. Thus, its replication is recommended to learn about other scenarios. Despite this limitation, the results of the present study may bring new contributions to elucidate the intention to become pregnant, the importance of preventing it, the opportune moment to get pregnant, feeling about unexpected pregnancy, not using contraceptive methods or discontinuity associated with the intentionality of the pregnancy.

Conclusion
Assessing pregnancy intention is an essential element to understand why women with a strong desire to avoid pregnancy use the same types of contraceptive methods as women in general. This study confirms the strong relation between unintended pregnancy, ambivalence, and the use or not of contraceptive methods, indicating the need for public policies that guarantee not only access, but the expansion of options Rev. Latino-Am. Enfermagem 2020;28:e3328.
for more effective contraceptive methods. The evidence suggests a promising path for future research on the health impacts of unintended pregnancy.