Barreiras e facilitadores para acesso a métodos contraceptivos femininos na atenção primária à saúde no brasil – revisão sistemática

Abstract

Sexual and Reproductive Health (SRH) is a human rights prerogative and a priority action within Primary Health Care (PHC). However, the implementation of SRH still faces challenges in ensuring women's sexual and reproductive rights. SRH care is often insufficient, leading to high rates of unplanned pregnancies, unsafe abortions, and avoidable maternal deaths. This study aims to identify barriers and facilitators to accessing contraceptive methods in Brazil through a systematic review. The search strategy utilized MeSH terms and Boolean operators "or" and "and" and was adapted for major databases: PubMed, Embase, Scopus, Web of Science, Cinahl, ProQuest, and the Virtual Health Library (VHL). The search was conducted in August 2023. Studies addressing reproductive planning and contraceptive use among women of reproductive age in Brazil were included, without restrictions on language or publication period. Initially, 2,043 studies were identified, resulting in 46 after the selection stages conducted by two independent researchers. The identified barriers were categorized as social and cultural; economic and financial; geographic; barriers related to knowledge, information, and user behavior regarding the choice and adherence to contraceptive methods; and access barriers due to shortages of supplies and health services. Facilitators included institutional, social, and family support; infrastructure resources; conveniences found in private services; the existence of protocols, work processes, teamwork, training programs; satisfaction with medical and nursing care; communication and information facilitation through social media; and legislation, public policies, free services, and Family Health Strategy (FHS ) coveragethat in the descriptive analysis, the latter were highlighted as the main facilitators, and the most significant barriers were linked to professional unpreparedness, bureaucratic work processes, and users' lack of knowledge and information. The methodological quality assessment was performed using the Joanna Briggs Institute's, with an average score of 9.5/10, 4.22/8, and 5.5/11 for qualitative, cross-sectional, andcohortstudies, respectively. A meta-analysis was possible only for the assessment of access barriers, conducted with six eligible studies (N = 3,460 participants), resulted in a meta-analytic measure of 20% (95% CI: 7%–37%, p = 0.00) with high statistical heterogeneity (I-squared of 98.50%). Therefore, the summary prevalence of access barriers to contraceptive care was 20%, possibly reflecting the very low quality of evidence, as per the GRID system, marked by high inconsistency and a high risk of publication bias. The low prevalence of access barriers demonstrated might be underestimated, given the high proportion of unplanned pregnancies, abortions, and the substantial prevalence of short-term and less effective contraceptive methods. This study emphasizes the need for investments in health policies to ensure the qualification of health professionals, the de-bureaucratization of access, and contraceptive care, which should be effectively and equitably organized for women in PHC. Keywords: Access to primary care; Family planning; Sexual and Reproductive Health; Health Services; Barriers (free term).