[Long-acting reversible contraception methods in the Brazilian Unified National Health System: the debate on women's (in)discipline]

Effectiveness and continuation rates of the etonogestrel-subdermal contraceptive implant versus short-acting contraceptive methods offered at no cost in Campinas, Brazil

OBJECTIVES

To compare the efficacy, reasons for discontinuation and continuation rates of the etonogestrel (ENG)-subdermal contraceptive implant when offered at no cost, and the basis of free choice versus short-acting reversible contraceptive (SARC) methods including combined oral contraceptives (COCs), once-a-month injectables, vaginal ring, and patch.

METHODS

We conducted a prospective study at the University of Campinas, Brazil, involving women aged 18 to 40 years. They were counseled on various contraceptive methods before entering the study and followed up every 3 months for up to 24 months. Satisfaction was assessed using a Likert scale. Survival rates were estimated using the Kaplan-Meier test, and curve comparisons were performed using the log-rank test.

RESULTS

We enrolled 609 women including 358/609 women (58.8%) who chose the ENG-implant and 251/609 (41.2%) who chose SARC methods. Contraceptive failure and all other reasons for discontinuation were significantly higher in SARC users compared to the ENG-implant users (P < 0.001 and P = 0.002, respectively). The continuation rate was higher among ENG-implant users (89.9% and 75.4%) compared to SARC methods users (27.2% and 15.9%) up to 1 and 2 years after study initiation, respectively. Satisfaction was high in both groups (>82%).

CONCLUSIONS

The ENG-implant showed higher contraceptive effectiveness and higher continuation rates than SARC methods up to 2 years after study initiation. Furthermore, users from both groups were highly satisfied with their contraceptive. The main reason for discontinuing use of the ENG-implant was bothersome uterine bleeding, while for SARC methods it was for personal reasons.

Outcomes of Intrauterine Device Insertion by Certified Midwives and Obstetric Nurse Practitioners

OBJECTIVES

to evaluate the outcomes of Interval Copper Intrauterine Device (IUD) insertion performed by certified midwives and obstetric nurse practitioners at a Peri-Hospital Birth Center.

METHODS

a cross-sectional study was conducted involving 75 women who underwent IUD insertion between January 2018 and February 2020. Data collection was carried out using medical records and telephone interviews.

RESULTS

no instances of uterine perforation were observed. Expulsion rates of the devices were 1.3% within 30 to 45 days of use and 5.3% within the first year of use. The follow-up removal rate was 4.0%. The average pain score reported was 4.2 (SD = 3.3). Among those who continued using the device, 93.1% expressed satisfaction.

CONCLUSIONS

the findings demonstrate that IUD insertion by certified midwives and obstetric nurse practitioners is a safe procedure, yielding outcomes comparable to those reported in the existing literature.

Contracepção Reversível de Longa Duração (Larc): solução ideal para tempos pandêmicos?

RESUMO O artigo discute uma correlação muito frequente notada a partir do desencadeamento da pan- demia de Covid-19 no mundo e no Brasil, ou seja, maior abertura e incentivo aos métodos Contraceptivos Reversíveis de Longa Duração (Larc) em decorrência das restrições sociais trazidas pela crise sanitária. De certa forma, a gravidade da pandemia justifica social e humanitariamente o recurso mais sistemático aos métodos de longa duração, na tentativa de evitar uma gravidez imprevista. A pesquisa antropológica se apoia em vasto material empírico documental no sentido de analisar e compreender as lógicas sociais subjacentes a esses expedientes, amplamente disseminados em contextos de pobreza e de precariedade social. A ampliação da oferta de métodos contraceptivos nos sistemas públicos de saúde é sempre desejável, respeitando-se a autonomia reprodutiva das mulheres e sua liberdade para escolher e decidir o que melhor lhes convém em determinado momento de sua vida. O problema reside na compreensão generalizada de que nem todas as mulheres têm condições para escolher e decidir, devendo ser ‘aconselhadas’ a aceitar um método de longa duração, por razões médicas/de saúde. Os limites tênues entre autodeterminação e coerção ou compulsoriedade obrigam a refletir sobre quão arriscada pode se tornar essa aposta.

Vidas precárias: tecnologias de governo e modos de gestão da fecundidade de mulheres “vulneráveis”

Resumo Lacunas no planejamento reprodutivo, após 25 anos da Lei de Planejamento Familiar, no Brasil, têm promovido uma ressignificação do controle reprodutivo. As expressivas dificuldades para realização da laqueadura tubária no Sistema Único de Saúde têm permitido o florescimento de estratégias governamentais fomentando acesso estratificado e racializado a métodos contraceptivos reversíveis de longa duração (LARC). A pesquisa etnográfica apoiou-se em fontes documentais sobre iniciativas institucionais para inclusão de LARC no sistema público de saúde, tomando-se o município de São Paulo como caso empírico paradigmático. Envoltas no ideário da cidadania, argumenta-se que tais tecnologias de governo são acionadas na direção contrária à ampliação de direitos sexuais e reprodutivos, para reificar estereótipos sociais que subtraem a autonomia reprodutiva das mulheres. Tomando o conceito de “coerção contraceptiva” como categoria de análise, demonstra-se como tais expedientes ferem o paradigma da justiça reprodutiva no Brasil ao se institucionalizar a exclusão social pelo útero das mulheres “vulneráveis”.

Contraception use and family planning inequalities among Brazilian women

BACKGROUND

Brazil has shown a considerable decline in fertility rates in recent decades. However, sociodemographic differences still have a direct impact on access to family planning in the country.

OBJECTIVE

To estimate the prevalence of contraceptive use according to sociodemographic variables among Brazilian women in reproductive age.

METHODS

A cross-sectional study conducted with 17,809 women who have responded to the National Health Survey. We estimated the prevalence as well as the 95% confidence intervals and we used Pearson's chi-square test at a significance level of 5% to analyze differences between groups.

RESULTS

More than 80% of the women reported to use some contraception method, the most used method was oral contraceptive (34.2%), followed by surgical (25.9%) and condoms (14.5%). Black/Brown, northerly, and low-educated women are more frequently sterilized, while white women, with higher schooling and those living in the south and southeast are the ones who use oral contraception and double protection the most.

CONCLUSION

Despite the observed improvements, there was no decrease in the prevalence for not using any CM and there are inequalities in access to contraception in the country.

[Availability of inputs for reproductive planning in three cycles of the Program for Improvement of Access and Quality in Basic Healthcare: 2012, 2014, and 2018]

The objective was to assess the availability of inputs for reproductive planning in basic healthcare units (UBS in Portuguese) that participated in the National Program for Improvement of Access and Quality of Basic Care (PMAQ-AB) and their distribution according to contextual factors. A comparative study was conducted of the three cycles of the PMAQ-AB (2012, 2014, and 2018). The study assessed the availability in the UBS of ethynyl-estradiol + levonorgestrel, norethisterone, norethisterone + estradiol, levonorgestrel, medroxyprogesterone, male and female condoms, IUDs, and rapid pregnancy tests. The study considered the availability and presence of all the inputs. Availability was assessed according to contextual factors in the city where the UBS was located. Availability of total inputs increased from 1.5% to 10.9%. In all the cycles, ethynyl-estradiol + levonorgestrel and male condoms showed the highest availability, and IUDs the lowest. Individual input´s availability also increased, with the highest increase of 36p.p. for female condoms, rapid pregnancy tests, and norethisterone + estradiol and the lowest of 15p.p. for ethynyl-estradiol + levonorgestrel, norethisterone, and IUDs. The North of Brazil showed the worst results. The largest increases were in the UBS in the municipalities with the lowest HDI and in those that participated in all the cycles of the PMAQ. Condoms are the only widely available inputs, and it is important to expand the availability of the other inputs, mainly IUDs and rapid pregnancy tests. The period under study experienced the promotion of equity, but regional inequalities need to be overcome. It is essential to monitor the inputs´ availability in order to improve reproductive planning.

Youth, gender and reproductive justice: health inequities in family planning in Brazil's Unified Health System

Sexual initiation is a gradual process of experimentation and learning the cultural repertoire of gender, reproduction, contraception, sexual violence and other topics surrounding youth sociability. Unlike sexual abstinence-based approaches promoted as a panacea for reducing "early pregnancy" in Brazil, reproductive justice is posited as a framework for addressing health inequities in family planning. This article discusses the challenges faced by public health policies in supporting adolescents and young people in their sexual and reproductive trajectories, drawing on the concept of intersectionality. We focus on public institutional initiatives providing long-acting reversible contraceptives (LARC) on the Brazilian Unified Health System (SUS) implemented over the last decade. We conducted a documentary anthropological study drawing on empirical data on contraceptive technologies in order to problematize what we call the "selective provision" of these devices and discriminatory and stigmatizing practices. Advocating the expansion of the provision of contraception on the SUS, with universal access to LARC for all women, distances itself from what we call "contraceptive coercion" among specific social groups.

Dating Applications, Sexual Behaviors, and Attitudes of College Students in Brazil's Legal Amazon

Although dating applications (apps) have become popular among young adults, there is a dearth of information regarding the sexual health implications among Brazilian college students. This study examined risky sexual behavior and attitudes of dating app users, based on their sex in Brazil’s Legal Amazon. Three hundred and fifty-nine students reported their sociodemographic data, dating app use, and sexual behaviors and attitudes through self-administered questionnaires. Bivariate analyses and analysis of variance (ANOVA) with Bonferroni post-hoc tests were performed. Dating app use was reported by 238 (66.3%) subjects, most of whom had an encounter and sex with a casual partner. Women frequently requested condom use. Trust in one’s partner or having repeated encounters were the main reasons for engaging in risky sexual behavior. Men had a greater number of sexual partners and less protective attitudes. Sexual health awareness by apps was not reported by 97% of women, and most of them were not tested for sexually transmitted infections. A positive attitude toward sexual health was not a predictor of safe sex. Important similarities and differences regarding risky sexual behaviors and attitudes were observed between the sexes, many of which correlated with increased sexual vulnerability during the sexual encounters arranged through the dating apps. This cross-sectional study supports efforts on sexual health promotion and sexual education implementation in the face of growing usage of apps among young adults for sexual matters.

Essure no Brasil: desvendando sentidos e usos sociais de um dispositivo biomédico que prometia esterilizar mulheres

Resumo Denúncias graves de efeitos colaterais sofridos por mulheres em vários países (Estados Unidos, nações da Europa e Brasil) desvelaram controvérsias na difusão de um dispositivo permanente para controle reprodutivo, designado Essure, pelo laboratório farmacêutico Bayer. Este trabalho busca compreender a circulação internacional e a introdução desse artefato biomédico no Brasil, a partir de pesquisa documental em sites de agências regulatórias, do laboratório farmacêutico e da divulgação pública feita por hospitais no país, associados ao Sistema Único de Saúde, para convocarem mulheres para o procedimento. Trata-se de primeira aproximação ao tema para se inquirir sobre as condições sociais da implantação do dispositivo em usuárias desses serviços de saúde no período em que ele esteve disponível no país, de 2009 a 2017. Apresentado como um dispositivo seguro, inócuo e de fácil manejo clínico, a promessa de um objeto permanente que impediria a gravidez sem necessidade de recorrer ao método cirúrgico foi vendida pela Bayer ao staff médico como solução simples, prática e moderna de controle reprodutivo. O percurso do dispositivo no Brasil evidencia certo entusiasmo médico com a nova técnica, não acompanhado de monitoramento clínico de longo prazo, principalmente quando as mulheres passaram a demandar a sua retirada em razão de muitas sequelas e efeitos colaterais dele decorrentes.