Income inequality is associated with adolescent fertility in Brazil: a longitudinal multilevel analysis of 5,565 municipalities

BACKGROUND Brazil has one of the highest adolescent fertility rates in the world. Income inequality has been frequently linked to overall adolescent health, but studies that analyzed its association with adolescent fertility have been performed only in developed countries. Brazil, in the past decade, has presented a rare combination of increasing per capita income and decreasing income inequality, which could influence future desirable pathways for other countries. METHODS We analyzed every live birth from 2000 and from 2010 in each of the 5,565 municipalities of Brazil, a total of 6,049,864 births, which included 1,247,145 (20.6%) births from women aged 15 to 19. Income inequality was assessed by the Gini Coefficient and adolescent fertility by the ratio between the number of live births from women aged 15 to 19 and the number of women aged 15 to 19, calculated for each municipality. We first applied multilevel models separately for 2000 and 2010 to test the cross-sectional association between income inequality and adolescent fertility. We then fitted longitudinal first-differences multilevel models to control for time-invariant effects. We also performed a sensitivity analysis to include only municipality with satisfactory birth record coverage. RESULTS Our results indicate a consistent and positive association between income inequality and adolescent fertility. After controlling for per capita income, college access, youth homicide rate and adult fertility, higher income inequality was significantly associated with higher adolescent fertility for both 2000 and 2010. The longitudinal multilevel models found similar results. The sensitivity analysis indicated that the results for the association between income inequality and adolescent fertility were robust. Adult fertility was also significantly associated with adolescent fertility in the cross-sectional and longitudinal models. CONCLUSION Income inequality is expected to be a leading concern for most countries in the near future. Our results suggest that changes in income inequality are positively and consistently associated with changes in adolescent fertility.