INTRODUCTION

The puerperium is a period that begins after delivery, that is, after the expulsion of the placenta and ovular membranes and where involution of the woman's organism occurs after pregnancy^(1-2). Regarding the end of the puerperium, studies state that it can last until the sixth week postpartum or up to twelve months after delivery⁽³⁾. However, the World Health Organization recommends follow-up until the sixth puerperal month.

In addition to the knowledge of the physiology of the postpartum period, the changes are intense in the psychological, social, professional, family and conjugal aspects of the woman, observing the need for a support network⁽¹⁾. When considering such changes, it is observed that this period can lead to injuries and consequently to significant morbidities for public health, making one of the focuses of public policies focused on women in all their integrity⁽⁴⁾.

In order to guarantee qualified, comprehensive, humanized care, with access to rights and means of services and stimulation, the reduction of female morbidity and mortality in Brazil, the National Program for Integral Care for Women's Health (PNAISM), based on the principles of the Unified Health System (SUS)was created in 2004⁽⁵⁾_. From the legitimation of a public policy for women in all life cycles, it is noted that the puerperium began to be included in primary care⁽⁶⁾.

Among the factors that concern public health authorities are: the lack of access to information for unassisted people, about the duration of infertility caused by breastfeeding; intervals shorter than eighteen months between two pregnancies that can lead to increased risk of fetal-neonatal pathologies; and increased female morbidity and mortality and increased recurrence of gestational diabetes⁽⁷⁾. Therefore, it is suggested that there are longer intervals between pregnancies, as there is a decrease in infant and maternal morbidity and mortality, in addition to the quality of health of both⁽⁸⁾.

For these reasons, actions related to reproductive health play an important role for maternal-fetal well-being, because the individuals responsible for reproduction have the right to determine the gestational interval and avoid an unscheduled new pregnancy⁽¹⁾. Reproductive or family planning functions as a strategy to assist in fertility control, among the choices, contraceptive methods should be discussed with the health professional⁽⁵⁾.

The contraceptive methods used in the postpartum period should be chosen according to the criteria of the World Health Organization (WHO), where the health professional must perform a reception with qualified listening, global evaluation, guide and choose according to the needs of each patient⁽⁹⁾. Among the methods, there are lactation and amenorrhea, barrier methods, intrauterine devices, hormonal methods and surgical methods⁽¹⁰⁾.

This study permeates the need to promote actions that seek to guarantee the sexual and reproductive rights of the individual, still little discussed in health services. In addition, the aim of this study was to analyze the knowledge of women about contraception in the puerperium. In this sense, in the face of this problem, the following guide question was elaborated: what is the knowledge of women about contraception in the puerperium?

METHODOLOGY

An integrative review of the literature on women's knowledge of contraception in the puerperium was performed. This type of study enables the synthesis of knowledge on a given theme, as well as the inclusion of significant results of studies in practice^(11-13).

To this end, six steps were performed: 1. identification of the theme and selection of the hypothesis or research question; 2. determination of criteria for inclusion and exclusion of studies, as well as the search in the literature; 3. delimitation of the information that will be extracted from the selected researches; 4. categorization and evaluation of the included studies; 5. interpretation of the extracted results and 6. synthesis of the knowledge demonstrated⁽¹⁴⁾.

In order to obtain efficiently and accurately, the best available information was elaborated, a research question was elaborated and used for the bibliographic search the PICo strategy (Population, Intervention, Control and Outcome/Outcome), which aims at the selection of search terms, besides, has adequate sensitivity to obtain qualitative researches related to human and social experiences. It contemplates the population, or the patient or the problem addressed (Population/Patient/Problem), the phenomenon of interest (Interest) and the context (Context)⁽¹⁵⁾.

In this perspective, p refers to the puerperous women; I contraception; Co to knowledge. After establishing the variables, the following guide question was formulated: What is the knowledge of women about contraception in the puerperium? The bibliographic search was performed in the following databases: MEDLINE/PubMed, Web of Science, Excerpta Medica dataBASE (EMBASE) and Latin American and Caribbean Literature in Health Sciences (LILACS) and Nursing Database (BDENF). After definite, the search strategy for the articles was used as an inclusion criterion: primary studies that include the knowledge of women about contraception in the puerperium, published from 2010, in the Portuguese, English and Spanish languages and that had full text available. The gray literature was used as an exclusion criterion.

The controlled (DC) and uncontrolled (DNC) descriptors were selected by consulting the terms in the Medical Subject Headings (MeSH), by titles extracted from EMTREE and the Descriptors in Health Sciences (DeCS) library, which will be integrated through the Boolean operators AND and OR and the keywords on each basis.

Data collection was performed between October and November 2020, by two researchers simultaneously, and divided into four stages, in the first stage, the articles collected in the databases were submitted to a pre-selection according to the inclusion and exclusion criteria mentioned above, initially examined by reading the titles and abstracts.

Therefore, the selected studies were analyzed considering the potential for inclusion in the present review, evaluating the property of answering the guide question, the type of research developed, objectives, methodology, discussion and conclusions. Regarding the fourth stage, the articles were read in full in the defined sampling. The last phase corresponded to the interpretation of the results and discussion. Of the five databases included in the study, a total of 843 articles were obtained. There were 63 duplicate articles, after the removal of the repeated ones, we obtained a number of 780 articles. Of these, 731 did not fit the inclusion criteria and the proposed objectives. After reading the titles and abstracts, 49 studies were obtained, and after reading the complete articles, 11 studies were composed of the final sample.

The exclusions of the articles after reading the complete texts had as main justifications the fact of not presenting the opinion of the puerperal women in relation to contraceptive methods, or even when the interviewees' opinion was collected there was no separation of the puerperal women with the pregnant women, other justifications found is the fact that the research was carried out long after the puerperium, and the occurrence of some studies conducting a previous orientation on contraceptive methods before evaluating the participants' knowledge.

Most of the studies included were derived from descriptive or qualitative research, and only one was a cohort study. Descriptive or qualitative studies were classified with evidence level 6 and the cohort study had evidence level 4. Subsequently, the papers were arranged in a table in Excel to present the results of the data obtained, it was performed descriptively containing data regarding authorship, basis where the article was found, study objective, type of study, level of evidence and outcome in relation to the knowledge of the puerperal women about contraceptive methods.

RESULTS

Among the eleven articles selected, it was found that most studies were published in international journals (n=10) and only one in a national journal (Journal of Nursing, UFPE). The articles were written in Portuguese and English, published between 2012 and 2019, with a total of fifty-six writers involved in the study's research, ranging from one to nine authors per manuscript. Regarding the methodological approach, the majority was quantitative (9) and two studies used the qualitative approach. It is observed that in recent years the intensification of publications was significant (Chart 1).

Chart 1 – Characterization of studies according to title, authorship, journal, year of publication, methodology, objective and outcome.

Author/Title	Periodical /year	Study Type	Objective	Outcome
O'shea MS, Rosenberg NE, Hosseinipour MC, Stuart GS, Miller WC, Kaliti SM, et al.⁽¹⁶⁾ Effect of HIV status on fertility desire and knowledge of long-acting reversible contraception of postpartum Malawian women.	AIDS Care (2016)	Cohort, prospective.	Describe the intentions of pregnancy and family planning preferences of HIV-infected and HIV-uninfected postpartum women, and to assess whether HIV status is associated with fertility desire and knowledge of both contraception intrauterine and subdermal contraceptive implant.	less likely to know that reversible contraception was safe to use during pregnancy breast-feeding.
Lima GKS, Santos AAP, Silva JMO, Comassetto I, Correia SR, Ferreira DCS.⁽¹⁷⁾ Self-care of adolescents in the puerperal period: application of the Orem theory	Revista de Enfermag em UFPE (2017)	Qualitative, descriptive study.	To identify the knowledge of adolescent mothers about the self-care based on the theoretical framework of Dorothea Elizabeth Orem.	Seven adolescent puerperal women had a deficit in self-care through negative knowledge about contraception and the benefits of breastfeeding;
Potgieter F, Kapp P, Coetzee F.⁽¹⁸⁾ Factors influencing post- partum women’s choice of an implantable contraceptive device in a rural district hospital in South Africa.	South African Family Practice (2018)	Estudo qualitativo	Explore the factors that influence women's choice of a subdermal contraceptive implant.	Interviews with ten participants, where the knowledge about available contraceptive methods among postpartum participants remained insufficient.
Patel R, Panchal P, Mehta A, Shah S.⁽¹⁹⁾ A knowledge, attitude and practice study of contraception among Stim mediate post-partum patients in a tertiary care institute 2016.	Pesquisa e prática de medicina atual (2017).	Quantitative transversal.	Assess knowledge and see attitude and practice of contraception use among patients in the immediate postpartum period.	Most respondents knew about contraceptives barrier - male condoms (91.3%), followed by hormonal pills (72.2%), IUD (64.3%) and DMPA (11.3%). Only 20% knew about emergency contraception.
Bajracharya A.⁽²⁰⁾ Knowledge, attitude and practice of contraception among postpartum women attending Kathmandu Medical College Teaching Hospital.	Kathman du Universit y Medical Journal (2015)	Descriptive, quantitative	Determine knowledge, attitude and practice of contraception among puerperal women treated at a teaching hospital.	Of the 400 women interviewed, the majority (90.8%) were aware of the use of contraceptives. Among 60.5% of women who had already used contraceptives, you oral contraceptives were the most common.
Özsoy S, Aksu H, Balkaya NA, Horta GD. ⁽²¹⁾ Knowledge and Opinions of Post-partum Mothers about the Lactational Amenorrhea Method: The Turkish experience	Journal of the Academy of Breastf eeding Medicine (2018)	Descriptive, quantitative	To investigate the opinion and knowledge of mothers about the contraceptive characteristics of breastfeeding.	Of the 400 postpartum women, 38.9% of mothers are aware of the contraceptive effect of breastfeeding.
Rossman B, Asiodu I, Hoban R, Patel AL, Engstrom JL, Medina- Poeliniz C, et al.⁽²²⁾ Priorities for contraception and Lactation among Breast pump- Dependent Mothers of Premature Infants in the Neonatal Intensive Care Unit	Journal of the Academy of Breast f eeding Medicine (2019).	Descriptive, quantitative	Determine knowledge and priorities for Postpartum contraception and lactation in mothers of premature babies.	Of the 25 premature mothers interviewed, 60% of the mothers planning to use contraceptives had doubts about the correct form of consumption.
Giacomo PD, Sbarlati A, Bagnasco A, Sasso L^.(23) Woman's contraceptive needs and preferences in the postpartum period: an Italian study.	Revista de Enfermag em Clínica (2013)	Descriptive, quantitative	Describe what puerperal women know about postpartum contraception and identify their needs and expectations.	Of the 300 postpartum women during the pregnancy and postpartum, 45.5% of women reported having received adequate information about contraception.
Lathrop E, Telemaque Y, Haddad L, Stephenson R, Goedken P, Cwiak C, et al.⁽²⁴⁾ Knowledge and use of and opportunities for emergency contraception in Northern Haiti.	Revista Internacio nal de Ginecologia e Obstetrícia (2013)	Descriptive, quantitative	Assess knowledge, experience and desire for emergency contraception (EC) in women in postpartum in Haiti.	Of the 249 women, 145 (58.2%) knew the concept of AE as an emergency measure in the post-coital period. Of these, 130 (89.7%) knew only traditional methods.
Shabiby MM, Karanja JG, Odawa F, Kosgei R, Kibore MW, Kiarie JN, et al.⁽²⁵⁾ Factors influencing uptake of contraceptive implants in the immediate postpartum period among HIV infected and uninfected women at two Kenyan District Hospitals.	Revista Saúde do Homem BMC (2015)	Quantitative transversal	Determining acceptance and factors influencing Immediate postpartum intake of contraceptive implants among HIV-infected and uninfected women.	Of the 185 interviewed, most were aware of modern methods with injectable contraceptives (93%) and birth control pills (92%). Natural methods such as lactational amenorrhea (LAM) (3%) and rhythm methods (2.7%) were among the least known methods.
Credé S, Hoke T, Constant D, Green MS, Moodley J, Harries J.⁽²⁶⁾ Factors impacting knowledge a nd use of long acting and permanent contraceptive methods by post part um HIV positive and negative women in Cape Town, South Africa: a cross- sectional study.	Revista de Saúde Pública BMC (2012)	Quantitative transversal.	Compare the factors that influence the choice in contraception and in the knowledge and attitudes of women in relation to the IUD and female sterilization for HIV status.	An interview occurred with 265 HIV positive women and 273 HIV-negative postpartum women. It was found that insufficient knowledge about long-term and permanent methods is probably contributing to the poor acceptance of these methods.

Source: The authors

Chart 2 - Synthesis of knowledge according to thematic categories.

Types of contraception in the puerperium	Study	Results/Conclusions
	O'shea MS, Rosenberg NE, Hosseinipour MC, Stuart GS, Miller WC, Kaliti SM, et al.⁽¹⁶⁾	Despite the low knowledge about the safety of contraceptive methods, the most known and used by this population were breastfeeding, implantation and condoms.
	Lima GKS, Santos AAP, Silva JMO, Comassetto I, Correia SR, Ferreira DCS^.(17)	The interviewees had uncertainties when asked about the use of contraceptives, the ideal time to start using them and if there are any specific ones for this period.
	Potgieter F, Kapp P, Coetzee F.⁽¹⁸⁾	The study demonstrates that women fear to use implantable contraceptives due to lack of knowledge. In addition, knowledge of modern contraceptives among postpartum participants remained insufficient.
	Patel R, Panchal P, Mehta A, Shah S.⁽¹⁹⁾	Most respondents knew about barrier contraceptives - male condoms, hormonal pills, intrauterine device (IUD) and injectables. Only 20% knew about emergency contraception. The most common source of knowledge came from friends and relatives.
	Bajracharya A.⁽²⁰⁾	The contraceptives best known by the participants were condoms (84%), oral contraceptive pills (82%) and injectable supplies (71.50%). Family planning information was obtained in the media (55.70%), followed by
		health professionals (25.30%), friends/relatives (13.50%) were largely responsible for the sources of awareness of contraception.
	Özsoy S, Aksu H, Balkaya NA, Horta GD ⁽²¹⁾	The mothers in the research reported the need for counseling on general contraceptives in the postnatal period, informed only of the knowledge of traditional methods.
	Rossman B, Asiodu I, Hoban R, Patel AL, Engstrom JL, Medina-Poeliniz C, et al.⁽²²⁾	In the study, the puerperal women report the desire for contraceptives that are easily accessible and without side effects such as the IUD or injectables, showing a significant knowledge about these methods.
	Giacomo PD, Sbarlati A, Bagnasco A, Sasso L ⁽²³⁾	Most women report in the study that they prefer to continue breastfeeding for another six months as a contraceptive method, others prefer hormonal and barrier methods.
	Lathrop E, Telemaque Y, Haddad L, Stephenson R, Goedken P, Cwiak C, et al.⁽²⁴⁾	In the study, more than half of respondents knew about contraceptive methods, but knowledge about modern methods was low.
	Shabiby MM, Karanja JG, Odawa F, Kosgei R, Kibore MW, Kiarie JN, et al.⁽²⁵⁾	The best known contraceptives for this population were injectables, pills, IUDs, condoms and implants. The least known were lactational amenorrhea and the rhythm method.
Benefits of breastfeeding	Lima GKS, Santos AAP, Silva JMO, Comassetto I, Correia SR, Ferreira DCS. ⁽¹⁷⁾	Gaps in the knowledge of adolescent mothers about the benefits of breastfeeding for maternal and child health were observed, which, according to the analysis of their testimonies, were due to the lack of instruction on these aspects.
	Özsoy S, Aksu H, Balkaya NA, Horta GD. ⁽²¹⁾	Most women were unaware of the method of lactation and amenorrhea and its effectiveness.
	Rossman B, Asiodu I, Hoban R, Patel AL, Engstrom JL, Medina- Poeliniz C, et al. ⁽²²⁾	The mothers of premature babies show interest in knowing effective methods that prioritize the baby dependent on the breast pump and thus go in search of other methods other than lactation and amenorrhea.
Contraception in women with HIV	O'shea MS, Rosenberg NE, Hosseinipour MC, Stuart GS, Miller WC, Kaliti SM, et al. ⁽¹⁶⁾	HIV-infected postpartum women obtain little knowledge about long-acting reversible contraception. Clearly, there is a need to improve access to and knowledge of forms of contraception to adequately meet this need population.
	Shabiby MM, Karanja JG, Odawa F, Kosgei R, Kibore MW, Kiarie JN, et al. ⁽²⁵⁾	Of all the methods, sterilization was most familiar to women with HIV. It is observed that it is necessary to develop strategies to improve access and participation of partners and alert about the side effects of contraceptives in this population.
	Credé S, Hoke T, Constant D, Green MS, Moodley J, Harries J ⁽²⁶⁾	The study showed the lack of knowledge of most women with HIV about the choice of method.

Source: The authors.

DISCUSSION

From the synthesis of the articles included in the integrative review, it was analyzed that most studies addressed significant topics for discussion, such as the knowledge of women in different life cycles about contraceptive methods during postpartum, knowledge about the benefit of breastfeeding during this period and also about contraception in HIV-positive women.

It was evidenced that the majority of women who participated in the studies have low knowledge about contraceptive methods in the puerperal period and this knowledge is restricted to traditional methods such as condoms, oral contraceptive pills and injectables^{(16-17,19-20)}. Likewise, a study conducted in South Africa showed that the postpartum women interviewed did not use modern methods, such as implants, out of fear due to lack of knowledge⁽¹⁸⁾.

Rossman⁽²²⁾ indicates that 60% of the women interviewed feel the desire to have easy access and know contraceptive methods that have fewer side effects, but have doubts about the correct form of use. This shows that these mothers have needs for guidance and encouragement from health professionals for the use of methods such as IUDs and injectables.

Regarding the knowledge of adolescent puerperal women based on Dorothea Orem's theory, it was found that most participants presented a deficit in self-care related to lack of knowledge of contraceptives⁽¹⁷⁾. It was noticed the existence of factors that contribute to this deficit, such as lack of sexual orientation, low schooling, inadequate use of contraceptives and ineffective counseling^(27-28).

Another important point was the knowledge of women about the efficacy of the lactation and amenorrhea method (LAM), where there is a fertility inhibitory effect in women who breastfeed in the first six months postpartum exclusively with amenorrhea⁽²⁹⁾. Lima⁽¹⁷⁾, Ozsoy⁽²¹⁾ and Rossman⁽²²⁾ in turn, demonstrate in their studies that there are gaps in the knowledge of the efficacy of breastfeeding as a contraceptive and that the puerperal women show interest in knowing other methods that do not interfere in the feeding of their babies.

Concerning the knowledge of HIV-positive puerperal women on contraception, review studies have found that there is little knowledge in the choice of method and longing for drug interactions due to antiretroviral treatment by these women^(16,25-26). Likewise, a study conducted in Fortaleza with women in a maternity hospital showed that only 19.4% had adequate knowledge about the subject⁽³⁰⁾.

In view of the analysis on the subject, contraceptive care should be offered to all people because it is a sexual right, where they may have the possibility of choosing the best contraception according to the reproductive stage⁽²⁹⁾. In addition, the health professional plays a crucial role in guaranteeing this right by counseling and providing information on the subject to this population.

FINAL CONSIDERATIONS

It was concluded that there is still a lack of knowledge of puerperal women about contraception, and can be observed in women with different age groups, as well as primiparous and multiparous women. Thus, it is necessary, the counseling of women during prenatal care on family planning, and that if possible, that she decide which method she will use after pregnancy, as well as, planning and health education should continue in the puerperium because some women change the method of contraception after the puerperium.

Women who have some knowledge most of the time do not know modern contraceptives, and their understanding of some method is quite superficial, not knowing its adverse effects and in some cases, they did not know the correct way to use, compromising the effectiveness of the method, or even if it does not have enough information, it can cause strangeness for it, not wanting to use the method or even using it in the wrong way.

Among the limitations, the fact that in most studies conducted the researchers interfered in the knowledge of puerperous, because they gave them information about contraceptive methods, or still did not evaluate the knowledge of the puerperous women, other studies gathered a group of women to carry out the study without distinguishing pregnant women from postpartum women, these factors caused the sample to decrease greatly.

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[1] Federal University of Piauí, Teresina, Piauí, Brazil. Orcid: https://orcid.org/0000-0003-4928-8714

[2] Federal University of Piauí, Teresina, Piauí, Brazil. Orcid: https://orcid.org/0000-0003-2561-065X

[3] Federal University of Piauí, Teresina, Piauí, Brazil. Orcid: https://orcid.org/0000-0002-2667-1596

[4] Federal University of Piauí, Postgraduate Program in Nursing, Teresina, Piauí, Brazil. Orcid: https://orcid.org/0000- 0002-1624-3838

[5] Federal University of Piauí, Postgraduate Program in Nursing, Teresina, Piauí, Brazil. Orcid: https://orcid.org/0000- 0001-9706-5369

[6] Federal University of Piauí, Postgraduate Program in Nursing, Teresina, Piauí, Brazil. Orcid: https://orcid.org/0000- 0003-2324-107X

ANÁLISE DA PRODUÇÃO CIENTÍFICA ACERCA DO CONHECIMENTO DAS MULHERES SOBRE A CONTRACEPÇÃO NO PUERPÉRIO