INTRODUCTION

The pandemic caused by the SARS-CoV-2 (COVID-19) coronavirus has compromised society as a whole. What was thought to be a brief event has become a global health crisis that has lasted for more than two years and especially affects women ¹. The redirection of health services to deal with the COVID-19 emergency has left women without access to sexual and reproductive health services, essential for providing information and support regarding their decisions to continue or postpone pregnancy². Thus, it is estimated that 25% of Latin American or Caribbean adolescents were unprotected from unwanted pregnancy due to lack of an effective reproductive planning policy during the pandemic ³

It can be seen that difficulties in exercising sexual and reproductive rights have exposed women to a number of situations that compromise their health, including the consequences of an unplanned pregnancy. This is considered a public health problem, since it takes young women and adolescents out of school and the labor market ⁴. As an aggravating factor, it is projected that more than 47 million women worldwide have had access to contraceptive methods hindered during the COVID-19 pandemic, which can result in 7 million unplanned pregnancies ⁽⁵.

Contrary to the reality imposed by the pandemic, the World Health Organization (WHO) warned of the need to guarantee access and continuity to contraceptive methods and sexual and reproductive health services, sharing information by accessible means and dialogical interaction between the university and society⁶.

Reproductive planning is the right of all Brazilians, so contraceptive care is a basic activity of the Unified Health System (SUS) ⁷. In this sense, in 2002 the Ministry of Health (MH) created the “Technical Manual of Assistance in Family Planning”, reaffirming the importance of reproductive planning and providing health professionals with the necessary knowledge to apply it in Primary Health Care (PHC) ⁸.

The Basic Health Unit (BHU) has been a strategic place to work on reproductive planning, as most women seek the unit both to perform their prenatal care and to have access to contraceptive methods. In this context, nurses play an important role in reproductive planning supported by the nursing consultation and their duties highlighted in the National Primary Care Policy ⁹.

It is observed that the Intrauterine Device with copper (IUD TCu 380A) is a long-term contraceptive method, with high efficacy (99%), low cost and should be available in the public network as a method of guaranteeing the sexual and reproductive rights of women, requiring qualified professionals and with the necessary knowledge to carry out the procedure of insertion, revision and removal of the IUD TCu 380A in primary health care ^10,11.

This procedure performed by nurses was regulated by COFEN Resolution 690/2022, through theoretical-practical training with pre-defined workload and permanent education for constant technical and scientific updating ¹². In addition, the regulation of the insertion and withdrawal of the IUD in Brazil is also based on Ordinance 526/2020, which included in the SUS procedure Table the insertion and removal of the IUD by both physicians and nurses of primary health care ¹³.

However, Brazil presents the use of IUD much lower than expected and the reasons found are related to the lack of supply and training of professionals and the centrality of insertion by gynecologists ¹⁴. Thus, the knowledge of nurses to perform such practice and to discuss reproductive planning is extremely important in the field of sexual and reproductive rights of women. The insertion of IUD by nurses becomes, therefore, a strategy for the expansion of the supply and access of this contraceptive method, as well as for the prevention of unplanned pregnancy ¹⁵.

In this sense, this study aimed to verify the knowledge of nurses about the intrauterine device in the context of basic health units.

METHOD

This is an observational cross-sectional study with a quantitative approach carried out in Family Health Units in a municipality in the state of Paraíba, northeastern Brazil.

The sample consisted of nurses working in primary care in the municipality who agreed to participate in the research. Active nurses from the Family Health Strategy linked to the Health Department were included. Nurses who were away from their work activities (vacation, maternity leave or sick leave) during data collection and those who after three attempts to send the research instrument, with a return period of 15 days, did not return it were excluded.

The data collection instrument was a questionnaire prepared through a literature review ^{8)(10)(11)(14)(16)(17)(18}. Then, the instrument was evaluated by seven specialists in the area of women's health, using the snowball sampling method. The experts evaluated the adequacy of the content and indication of scores of the knowledge section of each question taking into account the degree of difficulty of the answer (Easy: 1.0; Median: 1.5; Hard: 2.0 points) and the significance of each item. For knowledge, 20 questions were composed, of the true or false type, totaling 25 points.

After adequacy of the questionnaire, a pilot test was carried out with 05 nurses from the primary health care of the municipality of this study, who evaluated it positively and determined the mean time for its resolution of 25 minutes.

For data collection, the questionnaire was sent to the electronic address of the participants through a virtual form. The questions were structured on participants' profile and knowledge about sexual and reproductive rights, eligibility, supply and IUD insertion. Data collection took place between October 2021 and January 2022.

The data were tabulated in spreadsheet creation software and analyzed in statistical software. The analysis was performed using descriptive and inferential statistics. The descriptive analysis was performed by means of absolute and relative frequency, as well as evaluation of measures of central tendency and dispersion (mean, standard deviation, minimum and maximum).

Regarding knowledge analysis, the questionnaire score was subdivided into five categories: 0 to 5, being classified as very unsatisfactory knowledge; 6 to 10, unsatisfactory knowledge; 11 to 15, regular knowledge; 16 to 20, satisfactory knowledge; 21 to 25, very satisfactory knowledge.

In the inferential analysis, Pearson's Chi-square test and Fisher's exact test were applied, the latter only in cases where the number of frequencies with data lower than 5 exceeded 20%. For all analyses, a significance value of 5% (p-value<0.05) was used.

The research was approved by the Research Ethics Committee of a public university through the opinion number 4,736,330. It is noteworthy that the ethical considerations present in Resolution 466 of December 12, 2012 of the National Health Council for research with human beings ¹⁹ were respected. In addition, the Informed Consent Form (ICF) was obtained from each participant.

RESULTS

The sample consisted of 66 nurses. Regarding the sociodemographic and training data of the participants, it was observed that the majority were female (n=64; 97.0%), with a mean age of 43.8 years (SD=11.8), brown (n=40; 60.6%), had specialization/residence (n=46; 69.7%) and had more than 10 years of professional experience (n=41; 62.1%). It was also observed that most participated in some training on sexual and reproductive health (n=44; 66.7%) during professional practice and carried out educational actions in reproductive planning in the health unit (n=48; 72.7%).

Table 1: Distribution of sociodemographic and training data of respondents. João Pessoa, Paraíba, Brazil, 2022. (n=66). 

With regard to knowledge about the contraceptive method, 69.7% (n=46) answered correctly about the classification/mechanism of action and the effectiveness of the copper IUD, while 89.4% (n=59) knew its side effects. Participants also answered that the intrauterine device with copper does not interfere with breastfeeding (n=64, 97%), does not protect against STI (n=61, 92.4%), does not increase the chances of developing cervical cancer (n=63, 92.4%) and that the woman does not delay returning to fertility after withdrawal (n=65, 98.5%). All participants answered that the IUD does not cause discomfort to the woman during sex (n=66, 100.0%). However, 87.8% (n=58) of participants answered that the method cannot be used for emergency contraception.

Regarding the eligibility criteria for IUD insertion, most participants knew that nulliparous adolescents (n=46, 69.7%), diabetic women (n=64, 97%) and hypertensive women (n=64, 97%) can use the intrauterine copper device. However, 66.7% (n=44) were unaware that not all women with AIDS can use the IUD.

Most agreed that the IUD can be inserted in women who did not go through an educational group (n=46, 69.7%). Regarding the performance of transvaginal ultrasound and Pap smear with normal results, 86.4% (n=57) were unaware that they are not eligibility criteria.

Regarding the insertion of the intrauterine device with copper, 56.1% (n=37) of the participants believe that the IUD should be inserted only in the menstrual period and immediate postpartum; 63.6% (n=42) considered that uterine perforation is the most frequent risk during IUD insertion.

Most participants (n=59, 89.4%) answered correctly that nurses can perform IUD insertion, as well as 78.8% (n=52) answered that married women do not need their partner's authorization to insert the device. Most participants (n=65, 98.5%) answered correctly regarding the materials needed for IUD insertion.

Table 2: Knowledge of participants about the IUD. 

Regarding the sum of the knowledge of each participant, most nurses had their knowledge classified as satisfactory (n=50, 75.8%) (Tabela 3)

Table 3: Classification of the level of prior knowledge of the participants. 

Regarding the sociodemographic data, it was observed that there was no statistically significant association between the variables. However, the predominance of satisfactory knowledge was identified in professionals aged up to 44 years (n=6; 17.6%), who had a master's degree (n= 2; 28.6%), and had more than 10 years of professional experience (n=7; 17.1%)

DISCUSSION

The study observed that primary care nurses have satisfactory knowledge for offering, reviewing and inserting IUD with copper. However, in the municipality of the study, which has coverage of 96% of the Family Health Strategy, the IUD offer is still incipient. In the year 2021, in Paraíba, according to information contained in DataSUS, 298 IUD insertions were performed in outpatient units ²⁰.

International studies show that the factor of knowledge is extremely important with regard to the contraceptive method, changing conceptions and the general scenario of use of methods. Thus, women feel more informed and secure when they realize that the professional has mastery of the subject, demystifying the subject and expanding the offer/insertion ^21)(22)(23

An English study showed that the nurses interviewed reported that the main barriers to access the IUD with copper involve the lack of training to perform the insertion and insufficient knowledge about the method ²². Regarding the knowledge of the participants of our study, it was found that nurses have a theoretical basis about the classification, mechanism of action, effectiveness, side effects, potential and weaknesses of the intrauterine device. This situation reflects the need to implement a practical training policy for nurses, since they have the theoretical knowledge of the method, but without its applicability in the offer/insertion of the IUD during the nursing consultation in gynecology.

Regarding the knowledge about the use of IUD during breastfeeding as a safe method, a study conducted in the United States identified that only 16.4% of the nurses in the study understand IUD as a safe method for breastfeeding ²⁴. This discrepancy points to a better update of the Brazilian nurses in this study when compared to the Americans, since only 16% of nurses had previous contraceptive education ⁽²⁴, while in our study 66.7% of nurses reported training in sexual and reproductive health.

Thus, associating theoretical knowledge with practical knowledge in offering the postpartum IUD may contribute to the spacing between pregnancies and the improvement in the quality of care for children and mothers. Because it is a long-lasting method, women will have more autonomy when they choose to become pregnant. Moreover, it can contribute to the reduction of maternal deaths due to unsafe abortion.

Regarding the association of the IUD with the increased chance of developing cervical cancer and increased discomfort for women during sex, a Peruvian study that analyzed the same variables with women observed that 57.6% concluded that the intrauterine device can cause cervical cancer and 27.3% concluded that the IUD threads bring discomfort to the partner during sex, classifying these topics as possible reasons for refusing the method²⁵. However, it is observed that there are no associations between IUD and the higher incidence of cervical carcinogenesis by Human Papillomavirus (HPV), since it acts as a protective agent of this neoplasm by stimulating the immunity of cervical cells ²⁶.

It is also noticed that the lack of knowledge about the use of the IUD as an emergency contraceptive method decreases women's options to avoid unwanted pregnancies in emergency contraception situations, especially for PHC nurses, as a gateway to SUS. This situation keeps users uninformed, since health professionals are the main source they have access to regarding the passage of reliable information about emergency contraception ²¹.

Regarding the knowledge of the eligibility criteria for IUD insertion, it was observed that nurses know that the IUD can be inserted in hypertensive and diabetic women. The supply of IUDs with copper for hypertensive and diabetic women results in a decrease in the supply of hormonal contraceptives (HCC), which shows itself as a potentiality, by contributing to the reduction of morbidity and mortality due to high blood pressure, thrombosis and deaths from stroke, as well as reducing the worsening of the condition of diabetes due to the interaction of HCC with the drugs used for its treatment ^27,28.

A Brazilian study conducted with primary care workers showed that most professionals do not indicate the IUD for adolescents (62.2%), but that they offer the IUD for nulliparous women (62.2%) ²⁹. Due to the lack of information, it is possible that nurses are failing to offer the IUD as a long-term method and few side effects for adolescents, so that not offering it increases the risk of teenage pregnancy, since the use of condoms and HCC for adolescents have risks of failure due to discontinuity, due to forgetfulness, inconvenience in its use, health concern or side effects ³⁰.

Part of the professionals stated that for IUD insertion it is essential to perform transvaginal ultrasound and Pap smear with normal results and participation of an educational group of reproductive planning, and the need for such procedures are not conFigured as true. These data are in line with a study that observed that 71.6% of the participants stated that it was necessary to perform exams and 25.4% the participation of an educational group ¹¹. Thus, the implementation of unnecessary eligibility criteria represents a barrier that prevents women from having access to the intrauterine device.

Another misconception observed refers to the lack of knowledge of the participants when they affirm that women with AIDS cannot enjoy the IUD with copper as a contraceptive method. One study shows that 26.9% of respondents adopt HIV as a clinical condition that prevents IUD insertion ¹¹. However, according to the Ministry of Health, the copper IUD can only be inserted in women with AIDS in clinical stages 3 and 4, so women who have HIV and AIDS clinical stage 1 and 2 can use the method⁹.

Regarding the IUD insertion, it was observed that some nurses conditioned the insertion of the method exclusively to the menstrual period and immediate postpartum. In disagreement, a study showed that 89.6% of participants (physicians and nurses) know that the IUD can be inserted at any stage of the menstrual cycle ²². Conditioning the IUD supply to the menstrual period means reducing the chances of access to the method, since in the municipality of this research the IUD insertion is performed by scheduling and not by spontaneous demand. Therefore, in this perspective, it would be necessary to coincide the menstrual period with the day of insertion, characterizing itself as a barrier.

As for the risks of the method, most nurses still pointed to uterine perforation as the most frequent risk. However, even though it is not an everyday risk, a study showed that 40.5% of professionals consider uterine perforation as a barrier to supply and 52.0% as a barrier to the insertion of the intrauterine device in the scope of primary care ²⁹. Accordingly, research shows that nurses feel insecure at the time of insertion due to fear of perforation. However, the risk of uterine perforation is low, usually associated with not performing the measurement of the internal length of the uterine cavity and lack of careful technique in insertion, which shows the importance of practical training for correct and safe insertion ⁹.

This study has limitations that may lead to biased results, including the limitation of the sample and the choice of non-random form, considering the ease of contact with the participants. Data collection was done remotely and without supervision, which may have given room for participants to research the issues in the virtual environment. The results of this study may not be generalizable.

As strengths, it is clear that this study enables an overview of services that promote sexual and reproductive health, which opens space for reflection and enables the implementation of public policies of continuing education that aim to train nurses for the offer/revision/insertion of the intrauterine device. The incorporation of such practices is a positive point, as it directly impacts the work process of nurses, promoting greater efficiency and quality care for the population ²³.

FINAL CONSIDERATIONS

The lack of knowledge of nurses, in the context of primary health care, about the IUD TCU 380A regarding the eligibility criteria, side effects, mechanism of action and need for previous examinations, as observed in this study, becomes a barrier that limits access to the contraceptive method.

The insertion, revision and removal of intrauterine device with copper during the nursing consultation in gynecology, in health units, based on care protocols and through practical training, have the potential to reduce unwanted pregnancy, unsafe abortion and maternal deaths in Brazil. Therefore, the skills of nurses should be strengthened through continuing education for the qualification of primary health care and thus increase the possibility of women to obtain access to contraception methods, especially IUD TCU 380A.

Thus, governmental efforts are necessary for the establishment of a training policy that qualifies nurses regarding the technique of insertion, revision and removal of the IUD in the context of basic health units. The establishment of a policy of continuing education guarantees advanced practice in nursing care as well as minimizes barriers to contraception and enables means to guarantee women's sexual and reproductive rights.