key: cord-0978992-rsxfbuwg authors: Barbieri, Mariane Massaini; Herculano, Thuany Bento; Dantas Silva, Amanda; Bahamondes, Luis; Juliato, Cassia Raquel Teatin; Surita, Fernanda Garanhani title: Acceptability of ENG‐releasing subdermal implants among postpartum Brazilian young women during the COVID‐19 pandemic date: 2021-04-29 journal: Int J Gynaecol Obstet DOI: 10.1002/ijgo.13663 sha: 3246fc781db9ab835b7e7dfe672015188cbacc69 doc_id: 978992 cord_uid: rsxfbuwg OBJECTIVE: To evaluate etonogestrel (ENG)‐implant acceptance during the immediate postnatal period among adolescents and young women during the COVID‐19 pandemic, and to compare variables according to choice and discuss possible implications of this measure during the pandemic period. METHODS: A cross‐sectional study was designed. All women aged up to 24 years, who delivered between April 25, 2020, and June 24, 2020, at Women's Hospital, University of Campinas, São Paulo, Brazil were considered. The ENG‐implant or other contraceptive methods were offered prior to hospital discharge. The participants were split into two groups: (1) those who chose the ENG‐implant and (2) those that refused the implant. Descriptive, bivariate, and multivariate analyses were performed. RESULTS: 151 women were included, with 76.2% selecting the ENG‐implant. The average age was 19.5 years; 73.2% of pregnancies were unplanned, 32.5% already had a previous pregnancy, 74% were single, and 75.5% were not in full time education. Further, 70.5% had previously used contraceptives, with 89.1% unsatisfied with their previous method that opted for the ENG‐implant (P = 0.07). CONCLUSION: Offering the ENG‐implant to youths during the immediate postnatal period is evidence‐based care, and contraceptive provision is an essential health promotion tool, even during a pandemic. Thinking quickly about public policies in times of crisis is important to guarantee sexual and reproductive rights. and with the current situation, this number is likely to increase significantly. 3 Offering long-acting reversible contraceptive (LARC) methods during the immediate postnatal period, prior to hospital discharge, is paramount when considering the current pandemic. 4 LARCs are considered the best reversible methods for preventing unplanned pregnancies, which include those that are mistimed, and rapid repeat pregnancies (RRP), defined as pregnancy occurring less than 18 months after a live birth. 5 When applied during the immediate postnatal period, these methods lead to a significant drop in the rate of RRP compared to other contraceptives. 6 Strategies to prevent teenage pregnancy are of utmost importance, and this issue remains a public health problem worldwide. Recently, the concept of adolescence has been updated in order to provide a more comprehensive definition, which incorporates the biological growth and social changes that occur from 10 to 24 years of age. This new age group, known as 'young women', is more comprehensive and better adapted to the standards and requirements of a modern society, which leads to improved support, protection, and empowerment. 7 In general, teenage pregnancy-and more specifically, RRPexposes young mothers and their offspring to a number of health and socioeconomic risks, including increased rates for preterm birth, low birth weight, small for gestational age, and infant and early childhood mortality. In addition, these women are more likely to drop out of school and to earn lower salaries when they do work. 8, 9 From the beginning of this study, an upward trend in the number of COVID-19 cases was observed in the reference municipality. The aim of this study was to evaluate the acceptance of the ENG-implant during the immediate postnatal period among young women, prior to hospital discharge, during the COVID-19 pandemic, as well as to compare some variables according to the chosen contraceptive method (Table 1 ). This study was approved by the Ethics and Research Commission of UNICAMP (CAAE: 92869018.5.0000.5404) and followed the Declaration of Helsinki and Resolution 466/12 of the National Health Council according to the guidelines and regulatory norms of research involving human beings. All participants signed a consent form. If the woman was a minor, counseling and obtaining information was carried out in the presence of the parents or a legal representative. After reading, understanding, and clarifying any doubts, all participants under the age of 18 signed an informed consent form, and a counter signature from their legal representative was also obtained. Participants over the age of 18 years signed their own consent form. The subdermal implant is not routinely available in Brazilian public hospitals due to its high cost. The sample was intentional, comprising all young women up to 24 years of age that gave birth in our hospital during the study period. Exclusion criteria were those who chose not to use any The multivariate analyses do not converge, possibly due to interaction between variables, and all of them presented a non-significant prevalence ratio (data not shown). Our study showed a high acceptance rate of the ENG-implant in young women who had just given birth, although this contraceptive method is not offered as routine in the Brazilian public health service due to cost. More than any difference between the young women who accepted or not to use the implant, we would like to highlight the general characteristics of the population studied, which is composed of young women with a mean age of less than 20 years of age, with an unplanned pregnancy, out of the educational system, without a partner and who are non-white. These characteristics are indicators of social vulnerability, which is added to the current early pregnancy and the fact that a quarter of these individuals already have more than one child. The acceptance of ENG-implant in the postpartum period, before discharge, is still little being explored. 13 A study involving 127 women found an acceptance rate of 42% for ENG-implant versus non-hormonal methods, 14 a rate lower than the one we found, but the authors included an overweight or obese older population. When compared with other contraceptive methods, LARCs are highly effective in preventing RRP, particularly when started during the postnatal period. 4 The immediate postnatal period is the ideal time to start using LARCs, as women who have just given birth are more motivated to uptake contraception. 15 In our sample, most women reported previous use of some contraceptives, however, many were not satisfied with their method. Only one participant had used an IUD, while almost half had used oral contraceptives. Additionally, women who do not exclusively breastfeed may resume ovulation as soon as 21 days after delivery, and a large proportion (57%) have unprotected sexual intercourse before their 40-day postpartum check-up. 16 The percentage of women who do not attend their postpartum consultation is also high (40%), which often leads to further unplanned pregnancy and RRP. 17, 18 Implant insertion is quick and safe, unlikely to interfere with breastfeeding, and should be an option to all eligible and interested postpartum women. 19 Important influencing factors that increase the rate of young women about their contraceptive options, so that they can make a free-choice, which in turn leads to better adherence. 21 The acceptance rate of ENG-implants among women who had their antenatal care at the study center was high, more than 80%, where educational groups of contraceptive methods are routinely held. Our study sample showed a positive association for ENGimplant acceptability among non-white women as described previously. 22 It has also been suggested that cultural differences between ethnicities could influence the choice of contraceptive methods, however, this relationship has not been proven. 23 The issue of guiding and choosing the method of contraception in relation to vulnerable groups cannot be seen in a simplistic way, and it is important to remember the structural racism that may interfere with the provision of contraceptive methods by healthcare providers. 24 Our study has some limitations. The sample was intentional, due to ENG-implants not being offered routinely. Therefore, the difference between the number of women in the two groups-those who accepted the ENG-implant and who did not-may not be representative. It was not possible to perform long-term follow-up of these women due to the restrictions imposed at the hospital during the pandemic. ENG-implant during the postnatal period generates a high cost. Removing this barrier significantly increases the preference for LARCs, mainly the ENG-implant. 25 Family planning remains an essential health activity during the pandemic, especially in Brazil where there are high rates of early pregnancy and a lack of access to contraception. Offering the ENG-implant to young women during the immediate postnatal period is vital for reducing the incidence of unplanned pregnancy and RRP. 26 Despite the limited number of implants, we were able to offer an effective method of contraception in a period with many difficulties and restrictions. The wider acceptance of the ENG-implant among young women must be considered and expanded. Further studies are required to assess methods for making the implementation of ENG-implants feasible and routine in the immediate postnatal period. This may be achieved through public policies that value and prioritize female sexual and reproductive health, with reduced costs and greater accessibility. 27 Interventions such as those carried out in our study are small and will not have a large-scale impact ; however they are a way of pointing out the need to implement measures to improve quality assistance to young women, guaranteeing access to effective contraceptive methods and thereby their right to planned pregnancy. We would like to thank Sirlei Siani Morais for the statistical analysis of this study and Amy Louise Brown for the translation of this article. LB received an honorarium from MSD as a member of the Board. 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Reproductive autonomy and the promotion of long-acting reversible contraceptive methods Cost sharing, postpartum contraceptive use, and short interpregnancy interval rates among commercially insured women Family planning: an essential health activity in the pandemic of SARS-CoV-2 Patients and providers' knowledge, attitudes, and beliefs regarding immediate postpartum long-acting reversible contraception: a systematic review Acceptability of ENG-releasing subdermal implants among postpartum Brazilian young women during the COVID-19 pandemic The other authors do not have any conflicts of interest. All authors contributed to the overall study design and specific methodologies. TH, ADS and MMB inserted the ENG-implants.MMB and FGS wrote the first draft. In a meeting, the article was discussed and suggestions from LB and CRTJ were incorporated. All authors contributed to approved of the final version for submission.