Individual educational intervention on the progestogen-only minipill in pregnant women's knowledge: a before-and-after study

Emmanuel Calisto da Costa Brito¹,Ana Luiza Barbosa da Silva Negreiros²,Juliana Brito Martim³,Camila Fonseca Bezerra⁴, Poliana Guerino Marson⁵,Leila Rute Oliveira Gurgel do Amaral⁶, Danielle Rosa Evangelista⁷

^1,2,3,5,6,7Universidade Federal do Tocantins. Palmas (TO), Brasil. ⁴Universidade Regional do Cariri. Crato (CE), Brasil.

Introduction

Reproductive life planning (RLP) is a strategy developed and supported globally by the World Health Organization (WHO), which governs care actions in this area. It involves consultation activities, educational actions, and professional assistance focused on eligibility criteria and the woman's empowerment throughout the process.¹ RLP encompasses a set of basic actions, in the form of direct health care, medications, and supplies that enable people to decide whether or not to have children, as well as the number and interval between them.²

A well-planned pregnancy, resulting from an efficient RLP, leads to positive consequences during the prenatal period, such as a lower rate of complications during this period, as well as greater parental involvement in the care and resources offered by professionals.³

Another relevant factor in reproductive planning is educational initiatives focused on contraception and sex education, which are part of the daily routine of public health services in Brazil. This scenario is promising from an educational and psychosocial point of view, and contraception has potential within it.⁴ There are various contraceptive methods, divided into oral and injectable, permanent and temporary. Among temporary contraceptives, oral contraceptives are subdivided into “combined” and “progestogen-only”. They stand out due to their ease of use, practicality in handling by healthcare professionals, and easy access for women.¹

Progestogen-only pills (POPs), also known as mini-pills, are medications that contain low doses of progestogen. Because they do not contain the active ingredient estrogen, they are prescribed in situations where there is an absolute or relative contraindication to the use of estrogens and during breastfeeding, as they do not interfere with breast milk production. This makes them a favorable option in the postpartum period, although the idea of ​​their use should be discussed between a healthcare professional and the woman during prenatal care.¹

The postpartum period, an important time after childbirth, is understood as a phase in which actions involving sexual and reproductive health should be initiated and well-developed, given the gradual risk of a new unplanned pregnancy. The months following childbirth represent the risk of new pregnancies, and during this period, it is essential that reproductive planning is carried out correctly and supported by appropriate guidance from healthcare professionals, including nurses.⁵

Educational interventions on reproductive planning aimed at women during pregnancy are poorly described in the scientific literature, although they are fundamental, including the planning of future pregnancies and strategies aimed at preventing complications that affect the sexual and reproductive health of this population.⁶

Health education strategies during prenatal care demonstrate a positive effect on increasing pregnant women's knowledge, although they are generally applied through group approaches. Furthermore, they contribute to strengthening the bond between the healthcare team and the patient and promote a sense of belonging for the woman, favoring pregnancy planning, the development of autonomy, co-responsibility, and the practice of self-care focused on her health.⁷

It is known, in this context, that reproductive life planning should begin during pregnancy, characterized by the provision of sexual, reproductive, and family health care. However, during a literature review conducted for the preparation of this publication, a knowledge gap was identified regarding individual educational activities directed at pregnant women on contraception and reproductive planning.

This research, motivated by the experience of one of the researchers, in which short intervals between pregnancies were observed, had the objective to assess the effects of an educational booklet on progestogen-only pills on pregnant women's knowledge.

Method

This quantitative, prospective, before-and-after study was developed through the implementation of a socioeconomic and reproductive research questionnaire, a knowledge assessment questionnaire before and after the intervention, and individual intervention among pregnant women using an educational booklet on the use of the progestogen-only pill as a contraceptive method during lactation.

The study, conducted between April 2021 and April 2023, was carried out in two Basic Health Units (BHU) belonging to the Primary Care Network of the Municipality of Palmas, Tocantins, located in the Capim Dourado health region, with an estimated population of 306,296 inhabitants.⁸

The study population consisted of 145 pregnant women residing in the areas covered by BHUs 409 North and 603 North, located in the northern part of the city. The sample, of a non-probabilistic and intentional nature, included 114 pregnant women, identified during the data collection period, who met the eligibility criteria (pregnant women, over 18 years of age, who participated in prenatal consultations and/or other activities exclusively within the participating units of the study) and agreed to participate in the study. The selection process began with mapping and choosing participants based on their medical records. Women who did not reside in the municipality of Palmas and those with physical, cognitive, neurological, or mental limitations that prevented them from participating in the research were excluded.

After presenting the research and signing the Free and Informed Consent Form (FICF), two questionnaires were administered, with an average duration of 20 minutes. The first study aimed to characterize the social, economic, gynecological, and obstetric profiles of pregnant women. The second aimed to assess prior knowledge about the progestogen-only minipill, covering aspects related to its main characteristics, method of use, most frequent side effects, correct and incorrect methods of administration, and everyday situations associated with its use.

Next, an individual educational intervention was carried out with each participant, through the presentation of the booklet “Progestogen-only pill and its use during breastfeeding: educating in prenatal care”, developed by the principal researcher within the scope of the Postgraduate Program in Health Sciences at the Federal University of Tocantins.

The intervention lasted a maximum of 20 minutes and took place in a private room at the BHUs, through a dialogue between the researcher and each pregnant woman. During the meeting, the entire content of the booklet was presented, clarifying information about myths and truths regarding POP, its most common side effects, eligibility criteria, and recurring situations among users of the method. At the end, the participant received a copy of the booklet to take with her.

The educational booklet measures 148 × 105 mm, totaling eight double-sided pages, organized into ten topics: 1. What are progestogen-only pills? 2. How do they prevent pregnancy? 3. Which POP are available free of charge through the SUS in Palmas-TO, and where can they be obtained? 4. Are they really effective? 5. How should I use them? 6. What are the advantages of using them while breastfeeding? 7. Who can use them and who cannot? 8. What are the disadvantages? 9. If I stop taking the pills, will it take longer for me to get pregnant? 10. Other important information about POPs.

Ten days after each interview and educational activity, the knowledge assessment questionnaire used in the first phase was reapplied, with an average time of 30 minutes. At the end, a brief closing speech was given to conclude the data collection, lasting approximately 10 minutes.

For quantitative analysis, SPSS statistical software, version 22.0, was used. For categorical variables, descriptive statistics were applied using absolute and relative frequencies. Numerical variables were analyzed using measures of central tendency and dispersion, according to the data distribution, assessed by the Shapiro-Wilk normality test.

To verify the association between the exposure variables and the outcome “pregnant women's knowledge about the minipill”, chi-square or Fisher's exact tests were applied, considering the dependent variable to be dichotomous, with a score of 1 point per question. Participants scoring between 0 and 5 were classified as having unsatisfactory knowledge, and those scoring between 6 and 10 were classified as having satisfactory knowledge. The comparison between knowledge levels before and after the educational intervention was performed using the McNemar test, which is suitable for paired analyses of dichotomous data.⁹

The ethical guarantee of the study was ensured through the signing of the Data Use Agreement Commitment with the Municipal Health Department of Palmas. The study obtained approval from the Research Ethics Committee of the Palmas Public Health School Foundation, under Opinion No. 5,829,489.

Results

Tables 1 and 2 describe, respectively, the socioeconomic profile and the sexual and reproductive aspects of the participants.

 Table 1 - Distribution of pregnant women according to socioeconomic profile. Palmas, Tocantins, Brazil, 2022.

Characteristics	n		%
Race/Color White Brown/Black Yellow Absent	18 90 1 5		15.8 78.9  0.9  4.4
Age range Up to 27 years old 28 years old Absent	60 52 2		52.6 45.6  1.8
Marital status Common-law partner/Engaged/Married Single Absent	80 31 3		70.2 27.2  2.6
Religion Catholic Evangelical Don't know/Don't have/Didn't want to say Absent	18 90 1 5		15.8 78.9  0.9  4.4
Education Elementary school Secondary school Technical education Higher education Master's degree Absent	10 68 7 27 1 1		8.8 59.6  6.1 23.7  0.9  0.9
Income Up to 3000 reais Above 3000.01 reais Absent		80 26 8	70.2 22.8   7.0

Table 2 - Distribution of pregnant women according to gynecological and obstetric data. Palmas, Tocantins, Brazil, 2022.

Characteristics	n	%
Menarche 9 to 12 years old 13 to 17 years old Absent	57 53 4	50.0 46.5   3.5
Sexual debut 12 to 17 years old 18 to 24 years old Absent	67 41 6	58.8 36.0   5.3
Number of pregnancies 1  pregnancy 2  pregnancies 3  to 4 pregnancies 5 or more pregnancies	31 32 38 13	27.2 28.1 33.3 11.4
Number of births 1 and 2 births 3 or more births Not applicable	55 18 41	48.2 15.8 36.0
Number of births by cesarean section 1 and 2 births 3 or more births Not applicable	31  3 80	27.2   2.7 70.2
Number of normal births 1 and 2 births 3 and 4 births 5 or more births Not applicable	37  9  1   67	32.5   7.9   0.9 58.8
Number of abortions 1  abortion 2  abortions 3  abortions 4  No abortions	24  7  2 81	21.1   6.1   1.8 71.1

The average age of sexual debut among the pregnant women interviewed was 16.92 years, with a standard deviation of 2.473.

Table 3 presents the absolute and percentage values ​​obtained, according to the classification of the participants' knowledge as satisfactory (scores from 6 to 10) and unsatisfactory (scores from 0 to 5). This table also includes the result of the chi-square test, applied to verify the statistical association between socioeconomic and reproductive variables and the level of knowledge of pregnant women before the individual educational intervention.

Table 3 - Distribution of pregnant women according to sociodemographic characteristics, gynecological-obstetric characteristics, and level of knowledge before individual educational intervention. Palmas, Tocantins, Brazil, 2022.

Characteristics	Satisfactory knowledge n [%]	Unsatisfactory knowledge n [%]	p-value
Race/Color (n=109/05 AC†) White Brown/Black Yellow	7 [38.9] 22 [24.4]     0 [0.0]	11 [61.1] 68 [75.6] 1 [100.0]	0.374*
Age range (n=112/02 AC†) Up to 27 years old 28 years old or older	13 [21.7] 15 [28.8]	47 [78.3] 37 [71.2]	0.382*
Marital status (n=113/01 AC†) Married/Engaged/Common-law partner Single	23 [28.0]   6 [19.3]	59 [72.0] 25 [80.7]	0.345*
Religion (n=112/02 AC†) Catholic Evangelical Don't know/Don't have/Didn't want to say Another	13 [40.6] 12 [21.5]   4 [17.4]     0 [0.0]	19 [59.4] 44 [78.5] 19 [82.6] 1 [100.0]	0.144*
Education (n=113/01 AC†) Elementary school Secondary school Technical education Higher education Master's degree	1 [10.0] 17 [25.0]   2 [28.5]   8 [29.7] 1 [100.0]	9 [90.0] 51 [75.0]   5 [71.5]  19 [70.3]     0 [0.0]	0.348*
Income (n=106/08 AC†) Up to 3000 reais Above 3000.01 reais	20 [25.0]   7 [26.9]	60 [75.0] 19 [73.1]	0.845*
Menarche (n=110/04 AC†) 9 to 12 years old 13 to 17 years old	17 [29.8] 12 [22.6]	40 [70.2] 41 [77.4]	0.393*
Sexual debut (n=108/06 AC†) 12 to 17 years old 18 to 24 years old	18 [26.9] 11 [26.9]	49 [73.1] 30 [73.1]	0.997*
Number of pregnancies (n=114) Up to 2 pregnancies 3 or more pregnancies	15 [23.8] 14 [27.4]	48 [76.2] 37 [72.6]	0.657*
Number of births (n=73/41 AC†) 1 and 2 births 3 or more births	15 [27.2]   5 [27.8]	40 [72.8] 13 [72.2]	0.594**
Number of Abortions (n=33/81 AC†) Up to 1 abortion 2 or more abortions	3 [12.5] 4 [44.4]	21 [87.5]   5 [55.6]	0.046*

*Chi-square test   **Fisher's exact test   †Missing Cases

Table 4 presents the association between socioeconomic and gynecological-obstetric characteristics and the level of knowledge — classified as satisfactory or unsatisfactory — after the educational intervention, indicating the p-value obtained by the chi-square test.

 Table 4 - Distribution of pregnant women according to sociodemographic, gynecological-obstetric characteristics, and knowledge after individual educational intervention. Palmas, Tocantins, Brazil, 2022.

Characteristics	Satisfactory knowledge n [%]	Unsatisfactory knowledge n [%]	p-value
Race/Color (n=106/08 AC†) White Brown/Black Yellow	18 [100.0]   80 [92.0]   1 [100.0]	0 [0.0] 7 [8.0] 0 [0.0]	0.441*
Age range (n=109/05 AC†) Up to 27 years old 28 years old or older	55 [91.7] 47 [96.0]	5 [8.3] 2 [4.0]	0.311**
Marital status (n=110/04 AC†) Married/Engaged/Common-law partner Single	76 [95.0] 28 [93.3]	4 [5.0] 2 [6.7]	0.523**
Religion (n=109/05 CA†) Catholic Evangelical Don't know/Don't have/Didn't want to say Another	32 [100.0]     9 [92.5]   20 [87.0]   1 [100.0]	0 [0.0] 4 [7.5] 3 [13.0] 0 [0.0]	0.256*
Education (n=110/04 AC†) Elementary school Secondary school Technical education Higher education Master's degree	9 [90.0] 63 [95.4]   6 [85.7] 24 [92.3] 1 [100.0]	1 [10.0]   3 [4.6] 1 [14.3]   2 [7.7]   0 [0.0]	0.832*
Income (n=103/11 AC†) Up to 3000 reais Above 3000.01 reais	72 [93.5] 25 [96.2]	5 [6.5] 1 [3.8]	0.525**
Menarche (n=107/07 AC†) 9 to 12 years old 13 to 17 years old	52 [92.8] 48 [94.2]	4 [7.2] 3 [5.8]	0.552**
Sexual debut (n=105/09 AC†) 12 to 17 years old 18 to 24 years old	63 [95.4] 36 [92.3]	3 [5.6] 3 [7.7]	0.395**
Number of pregnancies (n=111/AC†) Up to 2 pregnancies 3 or more pregnancies	57 [91.9] 47 [96.0]	5 [8.1] 2 [4.0]	0.327**
Number of births (n=71/43 AC†) 1 and 2 births 3 or more births	52 [96.3] 16 [94.2]	2 [3.7] 1 [5.8]	0.566**
Number of Abortions (n=32/82 AC†) Up to 1 abortion 2 or more abortions	2 [95.6] 8 [88.9]	1 [4.4] 1 [11.1]	0.490**

*Chi-square test   **Fisher's exact test   †Missing Cases

Table 5 presents the participants' knowledge levels before and after the educational intervention, analyzed using the McNemar test. Knowledge was considered unsatisfactory when pregnant women obtained a score of 0 to 5, and satisfactory when the score obtained was 6 to 10.

 Table 5 – Distribution of pregnant women according to their level of knowledge before and after individual educational intervention. Palmas, Tocantins, Brazil, 2022.

Level of knowledge	Pre-intervention knowledge		Post- Intervention knowledge		p-value McNemar
	n	%	n	%
Unsatisfactory knowledge 0 to 5 points	85	74.6	7	6.1
Satisfactory knowledge 6 to 10 points					< 0.001
	29	25.4	104	91.2
Total	114	100.0	111	97.3

 Discussion

The findings of this research are consistent with the national profile, which shows a decline in fertility among women of all races between 2001 and 2015, with rates of 2.10 for white women in 2001 and 1.69 in 2015; 2.75 for black women in 2001 and 1.88 in 2015; and 2.65 for mixed-race women in 2001 and 1.96 in 2015.¹⁰

The average age of 27.62 years among the participants corroborates national data, which indicates a higher occurrence of pregnancy among women aged 20 to 24. This finding suggests that Brazilian women exercise control over their fertility at a young age, which differentiates the country from developed nations, such as some European countries, where the fertility transition occurs at more advanced ages. Despite this, it is observed that the fertility rate of Brazilian women continues to decline.¹¹

Smaller-scale studies conducted in Brazil also corroborate the findings of this research, analyzing the profile and factors associated with the use of combined oral contraceptives, highlighting that the use of these methods was significantly more prevalent among women aged 20 to 35 years.¹²

The finding of single pregnant women in this research highlights the prevalence of single parenthood in this group. In this context, the associated social impacts are reflected, such as greater vulnerability, difficulty accessing formal employment, and the challenge of raising children independently.¹³

The average salary of pregnant women was less than three minimum wages, with the majority reporting earnings of less than R$ 3,000.00. These data, analyzed in light of the literature, reflect a persistent social problem in Brazil: the prevalence of pregnancies among women with low family income, combined with insufficient remuneration to ensure an adequate livelihood for a Brazilian family. In 2023, considering the nominal minimum wage in February (R$ 1,302.00), the amount needed to ensure a good quality of life would be R$ 6,547.58, well above the average salary observed among pregnant women in this study.¹⁴

A national study, also involving pregnant women, obtained results similar to those of this research. In that study, the majority of pregnant women (62.6%) reported income equal to or less than three minimum wages, with 7.6% reporting family income below one minimum wage, highlighting a worrying pattern similar to that observed in this research.¹⁵ To make matters worse, a higher frequency of low birth weight was observed among children of women with an income of up to one minimum wage.¹⁶

When analyzing fertility, another national study identified that low family income, postpartum women under 19 years of age, and low levels of education constitute an unfavorable social context associated with a higher prevalence of unplanned pregnancies. In this study, the average age at which participants began sexual activity was 15.3 years, a value close to that observed nationally for young Brazilians.¹⁷

It is worth considering that sexual and reproductive parameters, such as the age of menarche and sexual debut, combined with factors such as low income and limited access to information, constitute important indicators for the development of professional actions aimed at sex education during adolescence. These findings are especially relevant when considered in the context of promoting guidance on the most appropriate contraceptive method for each woman, given that the Brazilian female population still has significant gaps in information about reproductive planning, its benefits, and specificities.⁴

Considering the average number of pregnancies, this research revealed a tendency for at least two children per pregnant woman. This finding differs from the literature, which indicates that first-time mothers are the majority. However, a more in-depth analysis of the number of children and their relationship with causal factors allows us to understand this difference. First-time mothers are predominant and, up until their first pregnancy, generally engage in reproductive planning; however, from the third pregnancy onwards, this situation tends to be described as inopportune or unplanned.¹⁸

This research found a significant number of cesarean sections among the participants. A global overview of cesarean births indicates that the situation is clearly increasing, with a global cesarean rate of 21.1%, revealing widespread use of the procedure, especially in Latin America, which stands out as one of the regions with the highest incidence of cesarean sections.¹⁹ In its guidelines for providing adequate maternal and child health care, the WHO prescribes that the ideal cesarean section rate in a healthcare institution should be between 10% and 15%.²⁰

Although this research did not delve deeply into the causes of reported abortions, the significant prevalence of this variable can be incorporated into national data by describing unsafe abortion as a public health concern, considering its association with maternal death and the fact that it is more prevalent among women in situations of social vulnerability.²¹

A slight increase in the percentage of satisfactory knowledge is observed with increasing level of education. The study discusses the statistical correlation between the number of years of schooling of pregnant women and the use of contraceptive methods, since the higher their level of knowledge, the more attention the woman pays to her reproductive planning.²²

The percentage of mixed-race and Black women was also higher among those with unsatisfactory knowledge, when compared to white women. The literature highlights that sexual and reproductive health care offered to Black women is often insufficient, which is directly related to higher maternal mortality rates in this group. This context reinforces the need for comprehensive and qualified care during the pregnancy and postpartum period, considering the possible complications arising from illnesses during this time.²³

Regarding abortion and contraceptive use, it is observed that women who have experienced this situation demonstrate knowledge of the main contraceptive methods available - especially pills, male condoms, injectable contraceptives, and the intrauterine device (IUD). However, there is a low demand for specialized consultations with healthcare professionals to choose the method most appropriate to their sexual behavior, which may contribute to failures in the use of the aforementioned methods.²⁴

There was no statistical association between the variables and the level of knowledge after the intervention in the sample examined, nor between socioeconomic characteristics such as age group, income, religion, education, marital status, and race, and knowledge, based on the individual educational activity carried out. Similarly, sexual and reproductive characteristics (menarche, sexual debut, number of births, abortions, and pregnancies) did not show a statistically significant association, even after the educational intervention, highlighting that these variables do not interfere with the level of knowledge of a pregnant woman who underwent the educational intervention. However, studies reveal a duplicated pattern of vulnerability associated with reproductive education for Brazilian women, where the most vulnerable, such as Black, mixed-race, and/or northern women who reside in rural areas and have lower levels of education, suffer from a lack of health education focused on RLP, as well as insufficient access to contraceptive methods.²⁵

For the sample analyzed, the interpretation indicates that the educational activity, carried out in a dialogued, horizontal, and individual manner, with explanation of the educational booklet and clarification of doubts during the presentation, constitutes an effective method of health promotion, with potential application in other actions aimed at pregnant women, differentiating itself from conventional group strategies in Primary Health Care.

Combined with comprehensive prenatal care tailored to the pregnant woman's needs and involving all professional categories within the FHS, educational activities, whether individual or in groups, are valuable, improve the quality of gestational care, and promote changes in the woman's self-care process. This reinforces the findings of this research, both due to the individual nature of the educational activity and its connection to the Family Health Strategy.^26-27

Regarding the characteristic of horizontality in health education for pregnant women, practice demonstrates its potential as prenatal care develops, which is centered on the woman and her family. It also highlights that the health professional plays a fundamental role in promoting horizontality during the provision of health education.²⁸

In this context, an Ethiopian study shows that educational actions and counseling are essential activities for women, especially when they address sexual and reproductive health issues attractively and playfully. African research corroborates the findings of this article, identifying a statistically significant association between health education and improved knowledge among pregnant women who participated in educational activities using “illustrative images”, technology, which contributed positively to increased access to and use of folic acid among the participants.²⁹

The methodological limitations of this study include non-probabilistic sampling and the intentional selection of BHUs, which prevents the generalization of results.

Conclusion

The study revealed that socioeconomic, reproductive, and obstetric factors are not associated with pregnant women's knowledge about the progestogen-only pill. However, individual educational activities, dialogued and supported by the booklet, showed significant potential to promote changes in participants' knowledge about the RLP during prenatal care. However, further studies with larger samples are needed to consolidate these findings.

Individual and dialogued health education on the use of the minipill, provided by nurses in Primary Health Care prenatal, proved to be an important strategy for strengthening care and promoting the reproductive health of pregnant women.

Establishing a theoretical and scientific foundation for individualized health education is essential to strengthening nursing actions in the sexual and reproductive health of women using the Unified Health System.

Contribuições dos autores

Concepção do estudo: Emmanuel Calisto da Costa Brito. Coleta de dados: Emmanuel Calisto da Costa Brito, Ana Luiza Barbosa da Silva Negreiros, Juliana Brito Martim. Análise e interpretação dos dados: Emmanuel Calisto da Costa Brito, Danielle Rosa Evangelista. Redação do manuscrito: Emmanuel Calisto da Costa Brito, Danielle Rosa Evangelista. Revisão crítica do manuscrito: Emmanuel Calisto da Costa Brito, Danielle Rosa Evangelista, Camila Fonseca Bezerra, Poliana Guerino Marson, Leila Rute Oliveira Gurgel do Amaral. Aprovação da versão final do texto: Emmanuel Calisto da Costa Brito, Danielle Rosa Evangelista.

Conflito de interesse 

Os autores declararam que não há conflito de interesse.   

Referências

1. World Health Organization and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), Knowledge SUCCESS. Family Planning: A Global Handbook for Providers (2022 update). Baltimore and Geneva: CCP and WHO; 2022.

2. Associação para o planejamento da família. Métodos Contraceptivos [internet]. Lisboa; 2022 [citado 2020 jul 10]. Available from: apf.pt/informacao-tematica/metodos-contracetivos/

3. Santos JM, Matos TS, Mendes RB, Freitas CK, Leite AM, Rodrigues ID. Influence in the reproductive planning and the women’s satisfaction with the discovery of being pregnant in the quality of prenatal care in Brazil. Revista Brasileira de Saúde Materno Infantil [Internet]. 2019 Sep 1 [citado 2022 mai 22]. DOI: https://doi.org/10.1590/1806-93042019000300003

‌4. Ribeiro MCC, Alves RN. Gravidez na adolescência: um olhar sob a ótica psicossocial. RSD [Internet]. 14º de agosto de 2022 [citado 29 de junho de 2024];11(11):e29111133281. DOI: https://doi.org/10.33448/rsd-v11i11.33281

5. Canario MA dos SS, Gonçalves MF, Teixeira Érica MB, Silva Áurea FAQ, Ferrari RAP, Pelloso SM, Cardelli AAM. Planejamento reprodutivo e a vulnerabilidade após o parto: uma coorte do sul do Brasil. Rev Enferm UFSM [Internet]. 27º de outubro de 2020 [citado 29º de junho de 2024];10:e87. DOI: https://doi.org/10.5902/2179769240659

6. Herval AM, Oliveira DP, Gomes VE, Vargas AM. Health education strategies targeting maternal and child health. Medicine [Internet]. 2019 Jun 1 [citado 2022 mai 20]; 98(26): e16174–4. DOI: https://doi.org/10.1097/MD.0000000000016174

‌7. Alves FL, Castro EM, Souza FK, Lira MC, Rodrigues FL, Pereira LP. Grupo de gestantes de alto-risco como estratégia de educação em saúde. Rev Gaúcha Enferm. 2019 [citado 2022 mai 20]; 40:e20180023. DOI: https://doi.org/10.1590/1983-1447.2019.20180023

8. Ministério da Economia (BR). Instituto Brasileiro de Geografia e Estatística – IBGE. Panorama Palmas-Tocantins [internet]. Brasília; 2022 [citado 2022 nov 12]. Available from: cidades.ibge.gov.br/brasil/to/palmas/panorama

9. Field A. Descobrindo a estatística usando o SPSS. 5. ed. Porto Alegre: Penso Editora; 2021.

10. Ministério da Economia (BR). Instituto Brasileiro de Geografia e Estatística – IBGE. PNAD Contínua - Pesquisa Nacional por Amostra de Domicílios Contínua [internet]. Brasília; 2023 [citado 2023 jul 01]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/trabalho/9171-pesquisa-nacional-poramostra-de-domicilios-continua-mensal.html?=&t=destaques.

11. Fundo de População das Nações Unidas no Brasil. Fecundidade e dinâmica da população brasileira. Brasília: UNFPA; 2018 [citado 2023 mar 08]; 44p. Disponível em: https://brazil.unfpa.org/sites/default/files/pub-pdf/swop_brasil_web.pd.

12. Costa DJ, Rohweder M, Iukary Takenami. Perfil e fatores associados ao uso de anticoncepcionais orais combinados em mulheres férteis atendidas em um centro de planejamento familiar. Journal of Health & Biological Sciences [Internet]. 2021 Out 4 [citado 2022 mar 20]; 9(1):1–1. DOI: https://doi.org/10.12662/2317-3076jhbs.v9i1.3718.p1-6.2021

13. Dalsenter TV, Almeida V. Famílias monoparentais, vulnerabilidade social e cuidado. Revista Brasileira de Direito Civil [Internet]. 2021 [citado 2022 mar 22]; 28(02). DOI: https://doi.org/10.33242/rbdc.2021.02.004

14. Departamento Intersindical de Estatística e Estudos Socioeconômicos. Pesquisa
nacional da cesta básica de alimentos. Salário-mínimo nominal e necessário [internet]. São Paulo: DIEESE. 2023 [citado 2023 mar 10]. Disponível em: https://www.dieese.org.br/analisecestabasica/salarioMinimo.html.

15. Xavier RB, Janotti CB, Martins AC, Silveira K. Reproductive risks and comprehensive care of pregnant women with hypertensive syndromes: a transversal study. Online braz j nurs (Online) [Internet]. 2013 [citado 2023 mar 15]. Available from: http://dx.doi.org/10.5935/1676-4285.20134249

16. Silva RCC, Machado MMT, Alencar CH, Lindsay AC. Fatores associados ao baixo peso ao nascer em Sobral – CE. Sanare (Sobral, Online) [Internet]. 2020 [citado 2023 mar 16]. Disponível em: https://sanare.emnuvens.com.br/sanare/article/view/1475.

17. Lelis C de F, Prietsch SOM, Cesar JA. Gravidez não planejada no extremo Sul do Brasil: prevalência, tendência e fatores associados. Ciênc saúde coletiva [Internet]. 2024;29(5):e11122023. Available from: https://doi.org/10.1590/1413-81232024295.11122023.

18. Pedro CB, Cosacio GD, Zilly A, Ferreira H, Ferrari RA, Silva RM. Fatores relacionados ao planejamento familiar em região de fronteira. Escola Anna Nery [Internet]. 2021 Jan 1 [citado 2023 mar 20]; 25(3). DOI: https://doi.org/10.1590/2177-9465-EAN-2020-0180

19. Betrán AP, Ye J, Moller AB, Souza JP, Zhang JJ. Trends and projections of caesarean section rates: global and regional estimates. BMJ Global Health [Internet]. 2021 Jun 1 [citado 2023 mar 22]; 6(6):e005671–1. DOI: https://gh.bmj.com/content/6/6/e005671

20. Angolile CM, Max BL, Mushemba J, Mashauri HL. Global increased cesarean section rates and public health implications: A call to action. Health Sci Rep. 2023 May [citado 2024 jun 30]; 18;6(5):e1274.DOI: https://doi.org/10.1002/hsr2.1274

21. Domingues RMSM, Fonseca SC, Leal M do C, Aquino EML, Menezes GMS. Aborto inseguro no Brasil: revisão sistemática da produção científica, 2008-2018. Cad Saúde Pública [Internet]. 2020;36:e00190418. Available from: https://doi.org/10.1590/0102-311X00190418.

22. Azees AS, Ehiem EC, Isa A, Awosan KJ, Suleiman AM. Prevalence, pattern and determinants of contraceptive use among pregnant women attending antenatal clinic (ANC) in a secondary health facility in Kebbi State: a cross-sectional study. Pan African Medical Journal [Internet]. 2022 Jan 1 [citado 2023 mar 20]; 41. Disponível em: https://pubmed.ncbi.nlm.nih.gov/35573440/ doi: 10.11604/pamj.2022.41.179.30352.

23. Silva B. Mortalidade materna de mulheres negras em município da região metropolitana de São Paulo: iniquidades, lacunas e possibilidades de intervenção. BIS Boletim do Instituto de Saúde [Internet]. 2021 [citado 2023 mar 15]; 22(2):15–28. Available from: periodicos.saude.sp.gov.br/bis/article/view/38627

24. Silva AR, Franco AP, Leite DS. Conhecimento, uso e falha de métodos contraceptivos dentre as mulheres marabaenses que já tiveram aborto. Research, Society and Development. 2021 Aug 5; [citado 2023 mar 15]; 10(10):e62101018549. DOI: http://dx.doi.org/10.33448/rsd-v10i10.18549

25. Trindade RE, Siqueira BB, Paula TF, Felisbino-Mendes MS. Uso de contracepção e desigualdades do planejamento reprodutivo das mulheres brasileiras. Ciencia & Saude Coletiva [Internet]. 2021 Jan 1 [citado 2023 mar 10]; 26(suppl 2): 3493–504. DOI: https://doi.org/10.1590/1413-81232021269.2.24332019

26. Schwab FC, Ferreira L, Martinelli KG, Esposti CD, Pacheco KT, Oliveira AE, et al. Fatores associados à atividade educativa em saúde bucal na assistência pré-natal. Ciencia & Saude Coletiva [Internet]. 2021 Mar 1 [citado 2023 mar 15]; 26(3): 1115–26. DOI: https://doi.org/10.1590/1413-81232021263.12902019

27. Bezerra, TB, Oliveira, CAN. A percepção de puérperas sobre a assistência recebida no pré-natal. Rev enferm UFPE on line. 2021;15(2):e247826. Avaliable from: https://doi.org/10.5205/1981-8963.2021.247826

28. Teodoro LP, Morais VM, Silva Filho JA, Torres GM, Figueiredo ID, Cândido JA, et al. Só engravida quem quer? Práticas educativas nas ações de planejamento reprodutivo. Saúde e Pesquisa [Internet]. 2021 Jan 19 [citado 2023 jul 31]. DOI: https://doi.org/10.17765/2176-9206.2021v14n4e9094

29.Berhane A, Belachew T. Effect of Picture-based health education and counselling on knowledge and adherence to preconception Iron-folic acid supplementation among women planning to be pregnant in Eastern Ethiopia: a randomized controlled trial. J Nutr Sci. 2022 Jul 13;11:e58. DOI: https://doi.org/10.1017/jns.2022.51

Corresponding Author

Emmanuel Calisto da Costa Brito

E-mail: emmanuelcalistocb@gmail.com

The Author(s) 2026.  This work is licensed under Creative Commons Attribution 4.0 International. License text for use: https://creativecommons.org/licenses/by/4.0/deed.pt_BR