MARCH 2025

Country context: Taking stock of family planning and reproductive health

Brazil is an upper-middle-income country with a diverse population of 212.6 million and enduring social and economic divisions. Early family planning interventions were the remit of privately-run organizations such as BEMFAM, an NGO that received international support and financing, including from UNFPA and the International Planned Parenthood Federation (IPPF). Family planning, and SRHR more broadly, only became a priority of the Brazilian government in the mid-1980s, previously remaining outside of public policy as a legacy of deep-rooted Catholicism, and the socially conservative, pro-natalist views of the two-decade-long military dictatorship. Following the dissolution of the dictatorship, family planning was enshrined as a universal right in the 1988 Brazilian Constitution, in which it is framed as:

“A free decision of the couple, with the State being responsible for providing educational and scientific resources for the exercise of this right, it being forbidden for official or private institutions to practice any kind of coercion.”

Since the constitution’s enactment and through this rights-based approach, Brazil has achieved a number of family planning and SRHR goals, bringing the total fertility rate down to 1.6 as of 2021, and significantly increasing the availability and uptake of modern contraceptive methods. However, challenges remain: Both the total fertility rate and measures of unmet need for family planning vary dramatically across states and regions, and among different ethnic and racial groups. Indeed, resource constraints, inadequate infrastructure, and discrimination have impacted the state’s provision of care, with previous controversies—such as accusations of mass sterilizations of indigenous women in the Amazon region in the 1980s—undermining public trust.

Expanding modern contraceptive prevalence

UNFPA estimates the modern contraceptive prevalence rate (mCPR) at around 80 percent as of 2019, with an unmet need for contraception of 4 to 6 percent, but estimates vary. The size of the population and vast geographical scope impact the collection of high-quality data that reflects Brazil’s diversity. Compounding this challenge, the most recent National Health Survey (NHS) to include a focus on family planning and reproductive health was in 2019. The available data therefore does not reflect recent socioeconomic changes such as the impacts of COVID-19 or policy changes as a result of changes in administration. Nonetheless, mCPR is reported at consistently high levels. Currently, nine types of contraception are available, free of charge, to all Brazilians through the Unified Health System (SUS), one of the largest health systems in the world. Brazil’s National List of Essential Medicines (RENAME) specifies the available contraceptives as: condom (male or female); injectable (monthly or quarterly); copper IUD; combined oral contraceptive pill; progestin-only oral contraceptive pill (minipill); emergency contraception; diaphragm; spermicide; and sterilization (male or female).

Permanent methods, such as sterilization, were historically the most popular forms of contraception—while they remain popular, their prevalence is decreasing in favor of reversible methods. As of the 2019 NHS, oral contraceptives represented 50.6 percent of all usage, followed by sterilization (22.9 percent), and condoms (20.4 percent). Indeed, in 2020 alone, the Ministry of Health distributed around 354 million male condoms and 15 million female condoms. By contrast, the copper IUD has extremely low uptake, used by around 4 percent of women in 2019, while hormonal IUDs and implants are not available at all via the SUS. According to Luis Bahamondes, Professor of Gynaecology at the State University of Campinas Medical School, implants are available free of charge for the most vulnerable social groups—such as adolescents, HIV-positive people, drug users, and homeless people—but in practice, poor implementation and lack of training in administering these highly effective contraceptives reduce their availability and uptake. As a result, LARCs represent a potential area of growth in Brazil’s family planning landscape, particularly in addressing unintended pregnancy, which remains a significant challenge with more than half of all pregnancies unplanned as of 2021.

Ensuring access to family planning and reproductive care

Despite Brazil’s high mCPR for both married and unmarried women, unintended pregnancy is a major health and rights challenge. Relatedly, maternal mortality remains high despite a long legacy of women’s health strategies, sitting at 117.4 deaths per 100,000 live births in 2021, compared to a regional average of 68 deaths per 100,000 in 2022. While this high rate can be partially attributed to difficulties delivering maternal and postnatal care during the COVID-19 pandemic, in 2019 the rate was already too high (57.9 per 100,000) given that the Brazilian government’s own target for 2030 is to decrease this to 30 per 100,000. Moreover, 38.5 percent of live births are among women and girls under the age of 24, representing a critical demographic for health and SRH intervention. Child marriage continues to drive adolescent pregnancy. By absolute numbers, Brazil had the sixth-highest number of child marriages globally as of 2020, with 21.9 million women aged 20 through 24 married or in a union before the age of 18. Additionally, adolescent girls of Afro-descent account for nearly three-quarters (73.9 percent) of all live births among girls aged 15 through 19, demonstrating the uneven distribution of pregnancies and the inequities that persist among different demographic groups. These disparities point to the need for greater education and access to family planning among women from traditionally underserved groups.

Overcoming entrenched barriers to family planning and contraceptive uptake will be key to reducing unintended pregnancy and maternal mortality in Brazil. While 100 percent of the costs of nine major contraceptive methods are covered by the Brazilian government under the SUS, in practice access to contraceptives is not universal, and many women and girls rely on goods and services from the private sector, for which they pay out of pocket. Barriers to accessing family planning services and contraceptives via the SUS include lack of information about contraceptive methods, racism and discrimination on the part of providers, limited pharmacy operating hours, and difficulties in scheduling appointments with medical providers to access prescriptions. Lack of availability of LARCs, specifically, likely also contributes to the high levels of unintended pregnancies and maternal mortality, as short-acting methods are more likely to prove ineffectual.

Preventing and managing reproductive cancers and diseases

Although HIV/AIDs has been on the public health agenda in Brazil for decades, it was deprioritized between 2019 and 2022, and the disease continues to represent a major health challenge, particularly among historically marginalized groups such as people of Afro-descent. In 2023, UNAIDS estimated that there were approximately one million people of all ages living with HIV/AIDS in Brazil. Moreover, there has been a noticeable increase in HIV detected among youth aged 15 through 19, with cases among young men of this age group rising by almost 50 percent between 2011 and 2021. The SUS is a major conduit for HIV prevention, detection, and treatment, distributing over nine million HIV tests as part of its COVID-19 response in 2020, but coverage across the country is uneven.

Reproductive cancers such as cervical cancer and breast cancer also represent serious health challenges. In 2022, cervical cancer incidence and mortality were 12.7 cases per 100,000 people and 6.5 deaths per 100,000, respectively, compared to a regional average of 11.5 and 5.4. HPV vaccination is offered free of charge to girls and boys under the SUS, but coverage is only at 57.4 percent for girls and 36.5 percent for boys, indicating that cervical cancer prevention is far from adequate, and more needs to be done to spread awareness of the effectiveness and ease of getting vaccinated. Breast cancer rates—while high—are lower than the regional average. Breast cancer incidence in Brazil in 2022 was 63.1 per 100,000, compared to a WHO regional average of 100.0, while mortality was 13.9 per 100,000 cases, compared to a regional average of 13. While Brazil has a broad-focus cancer control plan, it does not appear to focus on reproductive cancers specifically, despite their high incidence and mortality. Prevention and treatment of reproductive diseases, both communicable and non-communicable, need to be better integrated into primary health and specialist care alongside family planning as part of a life-course approach to reproductive health care.

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Policies and programs: Assessing multistakeholder efforts

Family planning policy is covered by several different strategies and policy documents, reflective of the government’s integrated approach, where family planning and reproductive health care are addressed as part of primary health care, women’s health, COVID-19 response, and universal health coverage (UHC) strategies. Family planning, reproductive health, and contraceptive services are included in the priorities of the SUS, which articulates the reduction of unwanted pregnancies as a major goal. Almost three-quarters (71.5 percent) of the Brazilian population receive their health care via the SUS, making it a significant pathway to extending family planning services to all. The National Family Planning Policy, launched in 2007, emphasizes the government’s commitment to free contraceptives via the SUS and public pharmacies. Family planning is also integrated into women’s health policies, including the National Policy for Comprehensive Care for Women’s Health (PNAISM), first launched in 2004 with the explicit aim of reducing women’s mortality and morbidity.

Between 2019 and 2022, the government took a series of legislative and policy steps that produced notable negative impacts on the provision of family planning for all. These included signing Decree No. 10,531 and the international Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family, both of which take an anti-abortion, pro-natalist position in which life (and thus the right to life) begins at conception. The government, as of 2023, has undone many of these actions and re-committed to Brazil’s demographic and family planning goals, including re-establishing the department for HIV/AIDS, and adopting ministerial policies to improve MNC-H and older people’s health. However, the effects of the earlier regression on rights and protections linger and, combined with the legacy of COVID 19, undermine an effective rights-based approach to family planning. Significantly, abortion remains completely illegal in Brazil, except in cases of rape or incest or if the fetus is anencephalic (as a result of Zika).

Anticipating and targeting demographic change

A large and growing population, Brazil is experiencing a significant youth bulge, as one-fifth (21 percent) of the population is between 10 and 24 years of age. Over one-third of live births are recorded among women and girls under the age of 24, indicating that this phenomenon is likely to continue. Indeed, Latin America and the Caribbean has the second-highest rate of teenage pregnancy in the world, and it is the only region where the trend in pregnancies in girls under age 15 is going up. As Kathleen Mogelgaard, President and CEO of the Population Institute, noted, “We know that universal access to reproductive health care and reproductive autonomy is something that shapes population trends and has important implications for a broad range of objectives for sustainable development.” Adolescents and younger women are therefore a major target for education, information, and expanded access to family planning services. Adolescent girls are covered under the PNAISM and thus have the right to receive all care offered by this program—including family planning services. However, the PNAISM is not tailored toward the specific needs of adolescents and does not include a focus on age-appropriate care. Similarly, while adolescents over the age of 15 can make use of SUS services independently, a 2017 study of SUS SRH services in Rio de Janeiro found that at least 10 percent of facilities still required an adult to be present during treatment and appointments, and only one-third of doctors had received any training specific to adolescent health care, impeding adolescents’ access to private, age-appropriate care.

For those adolescents who wish to make use of the SUS, whether with or without a parent present, barriers persist. Prescriptions from public facilities can only be collected by the recipient, for example, which could prevent some adolescents from accessing their prescribed medicines if they can only be collected during school hours. Family planning policies and strategies directed specifically at adolescents have been undermined by policies implemented by the conservative government that was in power between 2019 and 2022, such as banning informational booklets on condom usage aimed at young people. While many of these policies have since been reversed, their impact on this generation—which represents Brazil’s socioeconomic and demographic future—cannot yet be fully assessed. Addressing the challenge and harnessing the potential dividends of Brazil’s youth will require tailored family planning campaigns, including services to ensure that the needs of adolescents are met.

Brazil has become home to a significant migrant community from Venezuela, the majority of whom have settled in the North and Northeast, close to the border, where they receive health care from a patchwork of actors, including SUS, UNHCR, the Brazilian army, and private providers, and represent a significant proportion of the local population in need of health services. Indeed, close to one-third of births in the public hospital in Boa Vista city in 2019 were by Venezuelan migrant women. Ensuring that these and other underserved groups receive affordable family planning services is key to securing their long-term health and well-being, as well as achieving Brazil’s long-term public health goals.

Funding and coordinating family planning and reproductive health

Family planning activities are financed primarily by the Brazilian federal government—as an upper-middle-income country, Brazil is no longer eligible for international aid aimed at lower-income countries. USAID, for example, ended all ODA, including for family planning, to Brazil in 2000. Similarly, major philanthropic foundations—such as the Bill and Melinda Gates Foundation or CIFF—largely interact with the Brazilian government in service of goals unrelated to family planning, such as agricultural productivity or clean energy. However, Brazil still receives financial and technical assistance from UNFPA. The latest country programme commits USD 30 million between 2024 and 2028, and program priorities are aligned with Brazil’s national priorities. These include increasing the presence and coverage of care in the poorest regions; enhancing the integration of SRHR and gender-based violence services into the SUS; strengthening SRH information services, including increasing culturally sensitive and age-appropriate communication; and capacity-building for stronger family planning data collection.

As discussed above, the SUS is the most significant provider of family planning and contraceptive services, including via its primary health system, the Family Health Strategy (FHS). The FHS is the largest primary health care model in the world, and it provides care to around 60 percent of the population, including maternal, newborn, and child health services. Interventions include the deployment of community health workers (CHW) who visit FHS patients in their homes on a monthly basis. CHWs act as a liaison between patients and doctors and nurses, and also provide support such as pre- and postnatal care, breastfeeding assistance, sexual health advice, and chronic disease management. As of 2017, nearly 240,000 CHWs were deployed across Brazil, however, obstacles to the full coverage of the SUS, FHS, and CHWs remain, preventing comprehensive family planning support.

Effective coverage has been undermined over the past decade by successive austerity measures implemented since 2016, threatening the financial health and sustainability of the SUS as a whole. In some cases, where adequate financing is not available, municipal and local governments have taken responsibility for financing what they identify as critical family planning interventions. Luis Bahamondes, for example, noted that some municipalities have begun offering LARCs free of charge, despite not being covered under the SUS, in recognition of the economic imperatives of reducing the unintended pregnancy rate. As municipalities are responsible for funding the health and education services of all children under the age of 12, bringing the total fertility rate in line with the national average represents a significant economic goal. Gaps in SUS and FHS coverage are additionally supplemented by private health facilities. While a necessary aspect of the family planning ecosystem, out-of-pocket payments for contraceptives and other services could be catastrophic for those living in underserved regions, who often represent the poorest segments of the Brazilian population.

As an additional challenge, households with access to the SUS may not realize or take advantage of this fact: the 2019 NHS found that 11 percent of respondents were unaware of whether they were in fact enrolled in one or more SUS programs. The first step to ensuring universal access to family planning may therefore be communication. Improving the coverage of CHWs is another opportunity for growth. The 2019 NHS noted a decrease in visits by CHWs, driven by a combination of more women working outside the home and increased bureaucratic responsibilities on the part of CHWs. Adapting community-based care to meet the needs of a modern population with high female labor force participation will be key to ensuring the effectiveness of this health strategy utilized around the world. Brazil, as an enthusiastic participant in South-South cooperation, could look to other countries such as India and Indonesia for replicable practices, as well as to other countries across Latin America and the Caribbean.

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Looking ahead: Pursuing untapped opportunities and key priorities

Despite a recent history of de-prioritizing family planning and reproductive health services, Brazil has made significant progress toward international targets such as the SDGs, yet challenges remain to ensuring access to high-quality care across the entire country.

Access to abortion, for example, remains highly limited. The government regularly makes clear that its commitment to family planning services does not encompass abortion and even avoids using the terminology of SRHR in official documents. Access to safe, legal abortion is a key tool in reducing unwanted pregnancies and protecting maternal and newborn health, both of which represent continued challenges to Brazil’s achievement of global public health goals. Civil society organizations, NGOs, and supportive legislators can coalesce around expanding abortion access as a key lever for improving Brazilian public health outcomes, and make use of research by policy analysts and academics to demonstrate the social, economic, and health benefits of safe and legal abortion.

Beyond legislation, policy interventions to reduce unintended pregnancy must include expanding access to LARCs such as copper and hormonal IUDs and contraceptive implants. This process includes improving the training of health care workers to enable them to administer and insert all forms of contraceptive, in order to support the right of all women to choose their contraceptive method. Public-private partnerships, and collaboration with Brazilian universities, can provide up-to-date training and reskilling programs for health care workers, including ensuring that they are trained on the use and insertion of specific contraceptive methods such as IUDs.