Reflections about Reproductive Planning in Brazil During the Covid-19 Pandemic

: Background: Reproductive planning in Brazil has historically been the responsibility of individual women, with limited availability of health services. During the health crisis caused by the COVID-19 pandemic, the shortcomings of this system became even more evident. Methods: An integrative review was conducted using LILACS, MEDLINE, and SCOPUS databases, including publications in Portuguese, English, or Spanish, from March 2020 to April 2022, using the descriptors: family planning and COVID-19. A total of 1,030 publications were found, 69 of which were selected after reading the title and summary. After a review of abstracts, 4 were included in the final analysis. Results: Studies about the topic included a reflection article, a narrative review, a letter to the editor, and an orientation guide for healthcare professionals. Three analytical categories appeared: (1) Reproductive planning: recognition as an essential service; (2) Weaknesses in the provision of sexual and reproductive health services; and (3) Women as a vulnerable group. Discussion and Conclusion: With the advent of the COVID-19 pandemic, there were setbacks in Brazilian reproductive health care, such as a reduction in reproductive health services and a decrease in the supply of contraceptive and conception methods. These issues may explain the increase in the number of unplanned pregnancies, unsafe abortions, and the increase in maternal mortality rates that compromise the reproductive rights of Brazilian women.


Introduction
Reproductive rights in Brazil have been marked by the feminist struggle against a patriarchal society.Historically, women have been denied rights, even over their own bodies.This denial of autonomy reflects the country's patriarchal structure, which is a system of domination that oppresses women in order to exploit both their work and their bodies to ensure their production and reproduction (Saffioti, 2015).
In the 1990s, some international events were important milestones in the design of new public policies involving the reproductive and sexual rights of women worldwide.The International Conference on Population and Development in Cairo in 1994 and the 4th International Conference on Women in Beijing in 1995 prompted the recognition of reproductive and sexual rights as human rights (Nielsson, 2020).
The concept of reproductive rights originated within feminist movements in the struggle for the recognition of female rights, and within this feminist perspective, the concept is related to equality and freedom in the sphere of reproductive life.Sexual rights refer to respect for equality and freedom in the exercise of sexuality.In addition, the importance of treating the fields of sexuality and reproduction separately is emphasized to ensure the autonomy of these two spheres, allowing them to be related to each other and to other dimensions of social life (Lima, 2014).The concept of reproductive rights has been expanding to include aspects such as survival and life, freedom and security, non-discrimination and respect for choices, information and education, self-determination and the responsibility of motherhood and fatherhood, and social protection for the family (Telo & Witt, 2018).The aim was to develop an understanding that goes beyond contraceptive methods and the idea of reproduction as a female duty or destiny (Telo & Witt, 2018).However, in Brazil, reproductive and sexual rights have not advanced enough to meet the needs for access to reproductive planning services.This scenario was even worse during the COVID-19 pandemic, when women were affected in various ways: an overload of domestic work, care for children, care for sick or elderly family members, a need to contribute to family income inside or outside of the home, unemployment and physical and mental exhaustion (Sousa et al., 2021).
Since the COVID-19 outbreak, the way in which women's reproductive health has been addressed at the level of public policies and care stands out in Brazil.Reproductive planning in Brazil has historically been the individual responsibility of women i.e., fertility.In prepandemic Brazil, women's needs have been compromised due to the limited availability of health services to meet their demands; during the current COVID-19 pandemic women were even more affected, social distancing measures created difficulties in accessing health services as those infected by the coronavirus were prioritized for medical care (Guedes et al., 2021).Therefore, this study aimed to analyze the impact of the COVID-19 pandemic on sexual and reproductive health in Brazil.

Methods
The integrative literature review was conducted from April to June 2022, and included the following steps: elaboration of the research question, literature search, organization of studies by category, critical evaluation of findings, interpretation of results and presentation of the results (Mendes et al., 2019).The guiding question of this review was constructed using the population, concept and context (PCC) strategy (Munn et al., 2018), where P = "population in general or women, I = reproductive planning and Co = COVID-19 pandemic were considered.The guiding question was: "What is the knowledge produced in the scientific literature about the impact of the COVID-19 pandemic on reproductive planning?"A search was performed for articles published from March 2020 to April 2022 and indexed in the following databases: Latin American and Caribbean Health Sciences Literature (LILACS), MEDLINE and SCOPUS.
The selected descriptors and synonyms are in accordance with the Health Sciences Descriptors (DeCS): family planning "and" COVID-19.National studies were

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included, with qualitative and quantitative approaches and mixed methods, derived from primary studies published in English, Portuguese or Spanish.Exclusion criteria were studies with thematic titles and abstracts that did not reference the review question.
For the search and selection of scientific evidence, the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMAScR) tool was used to guide the research (Tricco et al., 2018).The tool's main objective is to support researchers in recording the review process.Data from the selected studies were extracted using an excel sheet structured by the researchers, which included study title, authorship, journal, year of publication, study location (country, city, region), objectives, detailed methodological and sampling details, main results and conclusions.A total of 1,030 publications were found, of which 69 were selected for title and summary.The final sample consisted of 4 studies, included after researchers read the full text and applied the inclusion criteria.
Figure 1 shows the process of search, selection and inclusion of selected studies, according to the PRISMA tool.

Results
After considering the inclusion and exclusion criteria, 1 reflection article, 1 narrative review, 1 letter to the editor and 1 guide for health professionals were included.The 4 selected articles were read exhaustively, and the information obtained through reading was presented in the form of a table, where three analytical categories regarding reproductive planning during the COVID-19 pandemic were obtained: (1) Reproductive planning: recognition as an essential service; (2) Weaknesses and strategies in the provision of sexual and reproductive health services in the Brazilian context; and (3) Women as a vulnerable group in sexual and reproductive health.For the characterization, analysis and synthesis of the publications included in this study, Table 1 was prepared and specifies the title, authors/year, objectives and main result.

Reproductive planning: recognition as an essential service
With the COVID-19 outbreak, there were setbacks in Brazilian reproductive health care, such as the reduction of services and the decrease in the supply of conception and contraceptive methods.The consequences of these setbacks have raised hypotheses about the increase in the number of unplanned pregnancies, unsafe abortions and maternal mortality rates that compromise the reproductive rights of Brazilian women and men, especially those who are socially vulnerable (Ferreira-Filho & Machado, 2020).
Sexual health and reproductive health in Brazil are important public health issues, leveraging an urgent and fundamental demand, which is the inclusion of sexual and reproductive health services as essential services, so the flow of referrals would not be interrupted as a result of the measures of social isolation imposed by the COVID-19 pandemic.Among the points of special concern are reproductive planning services and access to contraception.Maintenance of the methods in use, respecting the medical eligibility criteria for contraceptive use.
The risk of pregnancy while using LARC for more than 1 to 2 years is low, and prolonged use may be advised.
There are no concerns about pharmacological interactions between hormonal methods and therapies for COVID-19.

Guideline
Article that provides recommendations for reproductive planning given the significant risk of an unintentional increase pregnancies during the COVID-19 pandemic, we encourage women, health care professionals, policymakers and society to discuss sexual and reproductive issues.
Women must have adequate access to effective contraceptive methods, as well as consistent information.Women adapted to their current contraceptive methods can maintain them.
Those who are not using contraceptives or need to change should seek reproductive counselling.
Digital technologies are useful.
Face-to-face consultation is a required health protocol.
Proper use of contraceptives must be ensured.

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It is understood that access to contraceptive methods is a precarious issue in the Brazilian scenario, considering that half of the pregnancies are considered unplanned (Coutinho et al., 2020).The concerns highlighted are linked to the increase in the number of unwanted pregnancies and unsafe abortions due to difficulties in accessing contraceptive methods from public health services (Ferreira et al., 2020;Ferreira-Filho et al., 2020;Ferreira-Filho & Machado, 2021;Ferreira & Souza, 2021).
The United Nations Population Fund projects that more than 47 million women worldwide may have difficulty accessing contraceptive methods during the pandemic, which could result in 7 million unplanned pregnancies.Unplanned pregnancies can be accompanied by complications and even culminate in unsafe abortion, which increases maternal and neonatal morbidity and mortality rates (Riley et al., 2020; United Nations Population Fund [UNFPA], 2020).
Public health emergencies prior to COVID-19 showed that the interruption of health services considered essential and the increase in gender and social class inequalities were a reality, as evidenced by the Zika virus epidemic in Brazil and the Ebola epidemic in Africa (Coutinho et al., 2020).In addition, in the case of the Ebola virus, there was a considerable decrease in the distribution of contraceptives, approximately 65% in Liberia and 23% in Sierra Leone, during the peak of the epidemic (Ferreira-Filho et al., 2020).
In the case of COVID-19 in Brazil, the restrictions to ensure access to reproductive planning range from the fear or impediment of women seeking health services, as in the very production and capillarization of methods, since some services may have suffered from problems in the circulation of inputs and distribution of goods (Kumar, 2020).Thus, the incidence and lethality of the COVID-19 pandemic, which is understood as one of the world's most serious health problems in the 21st century, leveraged the concern of Brazilian government responses regarding the promotion of sexual and reproductive health; unfortunately, these responses were unsatisfactory.The proposed actions seem contrary to the reduction of bureaucracy in access to family planning measure and strengthening women's comprehensive health care, based on the absence of a federal mandate to minimize the effects of the pandemic on access to contraception (Coutinho et al., 2020).
In addition, several Brazilian health services limited the access of people who wanted to access irreversible contraceptive methods and had their surgeries and elective procedures, such as vasectomies and tubal ligations cancelled (Silva et al., 2020).Access to public reproductive planning services saves lives, and sexual and reproductive health services should be considered essential in Brazil (Bahamondes & Makuch, 2020).The articles in this review consider these services essential.Thus, society, especially the actors involved in the formulation of strategies to combat the pandemic, should consider sexual and reproductive health services

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as a priority, with emphasis on contraception as a priority service to be maintained.

Weaknesses in the provision of sexual and reproductive health services
Three articles in this review underscored the weaknesses in the strategies of sexual and reproductive health services in the Brazilian context and suggested some possibilities for maintaining consultation and counselling and distribution of contraceptive methods (Ferreira-Filho et al., 2020;Ferreira & Souza, 2021;Ferreira-Filho & Machado, 2021).
The authors of these articles agree that continuous access to sexual and reproductive health services, especially reproductive planning and contraception, is essential.It is necessary to develop new methodologies to ensure sustainable access to modern contraception and reproductive planning services as a strategic response to mitigate the impact of COVID-19 on the health of Brazilian women.
The reproductive choice of deciding how many children you want to have, when and if you want to have them is one of the most fundamental human rights, in which contraception is a major step towards greater gender equality (Cleland, 2012).To this end, the articles cite seven solutions to maintain the service and ensure the health security necessary for a global crisis.
1) The use of a well-adapted contraceptive method, prescriptions can be renewed without face-to-face evaluation for an additional 6 to 12 months during the COVID-19 pandemic, respecting the eligibility criteria (Ferreira & Souza, 2021;Ferreira-Filho et al., 2020); 2) Women using long-acting reversible contraception (LARC) can have its use prolonged for one to two years (Ferreira-Filho et al., 2020); 3) Clientele who wish to prevent pregnancy during the COVID-19 pandemic must receive reproductive counselling via telemedicine (Ferreira & Souza, 2021); 4) Efforts should be launched to restructure essential health services with a view to tracking asymptomatic individuals and making correct diagnoses of symptomatic individuals (Ferreira-Filho et al., 2020;Ferreira-Filho & Machado, 2021); 5) It is recommended to use adequate personal protective equipment (PPE) by health professionals in face-to-face consultations (Ferreira-Filho et al., 2020;Ferreira-Filho & Machado, 2021); 6) There are studies that indicate contraindication to the use of any contraceptive method when a person is under COVID-19 treatments (Ferreira-Filho et al., 2020); 7) It is acceptable, although not mandatory, to change the contraceptive method for fear of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) (Ferreira-Filho & Machado, 2021).
The use of telemedicine was also suggested (Ferreira & Souza, 2021), demonstrating several advantages of the use of telehealth due to the possibility of its use by health professionals belonging to risk groups, as well as for the elimination of geographical barriers and reduction of the wait time to access health services.However, little is known about the access for marginalized women to the internet, computer or even cell phone.Thus, telehealth is an alternative for the more affluent classes, but it does not become an alternative for the more vulnerable classes in Brazil who still experience digital exclusion even during the pandemic (Souza & Guimarães, 2020).
When analyzing the articles little information was found about the options for women who wanted to become pregnant during the pandemic; only one side of reproductive planning was emphasized: contraception due to the significant risk of increased unplanned pregnancies during the pandemic.Ferreira et al. (2020) and Ferreira-Filho and Machado (2021) contend that women are considered one of the vulnerable groups regarding sexual and reproductive health, and this situation was reinforced during the COVID-19 pandemic.The concept of vulnerability has been used since the 1990s and was established during the HIV/AIDS epidemic (Carmo & Guizardi, 2018).It points to a set of factors, levels and different magnitudes in which the interaction influences

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an increase or reduction in the possibility of a person becoming ill, thus enabling planning for preventive interventions (Carmo & Guizardi, 2018).
The invisibility of the sexual and reproductive health problems in Brazil during the pandemic anchors the place of women and their problems in society.In this context, the causes for increasing vulnerability of female vulnerability are multifactorial, involving social anomie resulting from female social distancing from support and protective networks.
Historically and culturally, all modern societies have, to a greater or lesser extent, the influence of the patriarchal system on social organizations and gender relations, which consequently were established as a result of domination and control over women (Lima et al., 2022).To understand the Brazilian government's stance on women's demands, reflection on the culture of exclusion of women's rights and citizenship is inevitable.When women who die as victims of clandestine abortions or due to lack of assistance during childbirth, these events are seen as a naturalized part of sexual and reproductive health, sexual harassment, rape and female murder.Often, the victim is blamed.The women living with the invisibility are often black women, indigenous women, prisoners, sex workers, and rural workers, forest and water workers, among other vulnerable groups.(Carmo & Guizardi, 2018) The recognition of women's rights only occurs through claims and struggles.These processes imply the recognition of exclusionary and discriminatory contexts that are often naturalized and socially invisible.The COVID-19 pandemic has exacerbated all of these government gaps in Brazil.These inequalities reinforce the vulnerability of women in regard to sexual and reproductive health issues, which were already pronounced and worsened during the pandemic (Ferreira et al., 2020;Ferreira-Filho & Machado, 2021).
The practice of social distancing was one of the most efficient measures to contain the spread of COVID-19, and to mitigate the disease (Aquino et al., 2020;LippiI et al., 2020;The Lancet Respirator Medicine, 2020).This implicated in the closure of educational, commercial, recreational and even health care institutions, which focused almost exclusively on caring for infected people (Aquino et al., 2020).
The burden on the health system imposed by the pandemic was reflected in the quality of care for sexual, reproductive and women's health, from the availability of contraceptive methods at health centres, access to early diagnosis and treatment of diseases and conditions, to quality of maternal and child health care from prenatal care to delivery (Coutinho, 2020).These effects have consequences on the health of the population, especially in vulnerable segments, such as women (Ferreira-Filho et al. 2020).

Conclusion
The analyzed studies in this review indicated that reproductive planning actions and services in Brazil should be considered essential; Currently, reproductive planning services are fragile in the face of one of the greatest health crises of the 21st century, the COVID-19 pandemic.All actions that guarantee the right to sexual and reproductive health are compromised by new health demands, whether they are public health crises, difficulties in the health care supply chain, or the reinforcement of women as a vulnerable social segment with rights.The Brazilian government stopped responding to demands for such services in December 2022, and the promotion of sexual and reproductive health resources was already insufficient and declining even in the pre-pandemic period.
There is a mismatch in Brazilian society between the advancement and emancipation of women and the real participation of men/partners in sexual and reproductive health.As the results of this review indicate, the medicalization of the female body still consists of solutions most described/used in clinical practice, often without the involvement of the women's sexual partners, or even the women themselves.This enhances the historical practice of individual responsibility for women in the couple's reproductive planning.
Thus, it is necessary to discuss the subject in the post-pandemic period, giving a voice to women who had

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reproductive needs that were not met amid that pandemic, to build a health system that considers the needs of all women regardless of differences in ethnicity or social, political, economic and reproductive desires.