Introduction 

Unwanted pregnancy is a worldwide public health problem that can be explained by discontinuing the use of available contraceptive methods, which for the most part have adverse effects that directly affect womens health. Despite the high preventive efficacy, contraceptive pills were replaced by the contraceptive method by subcutaneous implant in the 1960s; however, it was replaced by the subdermal implant due to reports of difficulty in removing them. This implant stood out for its high efficacy and ease of removal. It is an implant that comes in a single 4 cm stem that releases 68 mg/day of Etonogestrel, valid for 3 years, failure rate less than 0.1% and aims to achieve complete suspension of ovulation throughout the period of use by endometrial atrophy and cervical mucus thickening thus inhibiting sperm penetration through the cervix uterus [1].

However the high cost and side effects caused by the use of implants such as: changes in bleeding patterns, acnes, emotional lability and weight gain are causes of the low diffusion of this method in Brazil. Therefore, the increase in the rate of unwanted pregnancy is due to the misuse of contraceptive methods and the withdrawal or financial difficulty to adhere to the subdermal implant [1]. 

According to the ministry of Health women have rights and needs that go beyond pregnancy and childbirth, require actions that provide improvements in health, and clear guidance on contraceptive methods would benefit to avoid potential health problems. Unwanted pregnancy is often one of the causes that lead women to misuse, overuse abortion pills and clandestine abortion methods in order to terminate their pregnancies [2]. As women seeking these methods are more pronounced in women with low education, which implies a lack of guidance and seeking care, women with better education and higher financial status seek specialized clinics where there are more conditions and hygiene thus reducing the risk of mortality from infections and others [3]. 

Emergency Contraception (EC) has been increasingly used. This contraceptive method, better known as postcoital contraception or by its popular name morning after pill, acts on the body to prevent the often unwanted pregnancy that comes with an unprotected sex act. Its action is effective for a short time after intercourse; its composition employs a concentration of hormones, unlike contraceptives that prevent before happening or during sexual intercourse. The main indications for EC are frequent situations such assexual intercourse without contraceptive use, sexual violence, presumed failure in the routine method or inappropriate use of contraception [3]. 

Due to the many difficulties women encounter in trying to access the emergency pill, a search is initiated that is facilitated by pharmacists and clerks who point out the relatively low cost (to Brazil, R$ 20,00 or about $ 4.98) and non-compliance with the standard required by health surveillance, which requires the presentation of a prescription for the sale of emergency pills, in addition, do not provide information on drug side effects, guidelines on exposure to Sexually Transmitted Infections (STI) transmitted by unprotected sex and an ethical debate is set up regarding this easy access [4]. Given the harm that the indiscriminate use of emergency contraception can cause women, it is necessary to investigate the causes that lead these women to choose this means of contraception. It makes sure that women are receiving sufficient and necessary information for effective and less harmful use. 

Objective
Identify by integrative literature review the reasons for the indiscriminate use of emergency contraception.

Method
Integrative literature review, performed through the databases: Brazilian Nursing Database (BDENF), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE) and Scientific Electronic Libary on Line (SciELO). Five descriptors were defined: contraception, womens health, unintended pregnancy, teenage pregnancy, and non-steroidal abortives that were associated with peers, using the term boolean and. The search took place from October 2018 to October 2019. For the selection of articles, the following inclusion criteria were considered: original research related to the objective of the study, in full, in Portuguese language published between 2013 and 2019. The editorials, dissertations and theses were excluded.

Results 

We found 490 articles between platforms Lilacs, Bdenf and SciELO in Medline platform no articles were found. Sixteen articles were selected. The selected articles were based on the inclusion and exclusion criteria presented in the method. Indiscriminate selling of the pill shows the change in how to avoid pregnancy. It should theoretically be used in emergency cases such as condom breakage or rape. However, it has become a solution to sexual relations, often without a condom (Table 1).

Table 1: Presentation of the descriptors, bases and articles found and selected.

Many factors were identified that motivate the large consumption of the pills. In general, peoples lack of information about their use and the consequences of self-medication are emerging. It is possible to identify among them the predominant factors for the indiscriminate use of abortion pills such as: low family income, low level of education, unwanted pregnancy and lack of information or even incorrect information in health facilities. The results are consistent because the selected surveys as can be seen in Table 2 in method were performed with large samples. Importantly, in the results, abortive pill and postcoital pill are considered the same thing.

Table 2: Presentation of article selection base on year/author, theme, method and conclusion.

Discussion 

The reproductive capacity of adolescents is evidenced by biological factors such as changes in puberty. However, that does not mean that they are prepared to experience these changes. These facts open a window of possibilities for unexpected occurrences, as unprotected sex can lead to STI or unwanted pregnancies. Among these factors, there are also the characteristics of adolescence such as impulsivity, egocentric thinking, age of first sexual intercourse, lack of information about contraception, whether or not attending school, the number of partners and the belief that contraceptives can get fat and decrease pleasure [5]. 

During adolescence, a pregnancy imposes limits on future opportunities, significantly affecting adolescent development and has a direct link with poverty and low education even though there is a network that provides clarifications related to sexuality. These links in the network are very important in health promotion and prevention, but talking about sex or something related are still taboos that need to be broken. The promotion of self-care by free choice to promote their health and well-being and to adopt promotion and prevention measures, controlling risk factors and acquiring healthy habits are very important tools in the role of the united basic the health [6,7]. 

A study conducted in Recife (Brazil) shows that the availability of Emergency Contraception is in accordance with state and municipal strategy, but there is no effective offer made. One of the possibilities for this reality is the predominance of the Catholic religion in the region, which considers it an abortifacient drug, influencing women in the decision about its use. To investigate the level of information offered to women, another study conducted in Scotland found that while information on this method is provided in pharmacies, only a minority adopt a regular contraceptive method after using Emergency Contraception. 

This fact is directly linked to family planning, because in yet another study on the use of contraceptive methods and factors related to pregnancy planning among puerperal women; it was evident that most participants did not plan the last pregnancy, even those who had not a low level of education or low income [8,9]. The adolescent population shows a vulnerability to the use of this pill. More than 10% of those born worldwide are teenagers between 15 and 19 years old. Each year in the 28 countries of the Organization for Economic Cooperation and Development (OECD), at least 1.25 million become pregnant. Of these, about half a million seek abortion.

One study identified a pattern of risky behavior for sexual and reproductive health, including unplanned pregnancy. It becomes a major sexual and reproductive health problem when it is also unwanted. In this phase, the adolescent faces problems during the insertion in the sexual life due to the fear of losing their autonomy, but mainly related to the family sphere. Parental dependence and lack of feeling sharing and sexual orientation [10]. 

Teenage pregnancy is an experience that has numerous disadvantages than it would in an adult. Changing paradigms, changes in the physical body, the way you think and see the world, lose educational opportunities, less work opportunities, and psychological conflicts. In a study conducted on the first experience of teenage mothers, it shows that when pregnancy is not something planned and expected, they go into a state of emotional shock when faced with the news. One of the points mentioned as difficulty would be the difficulty of not being able to leave home as before. The fun and time that was once dedicated to herself from then on would be for baby care. Thus evidencing in this speech the concern with herself and the baby [11]. 

In the same study cited above, there is the surprise of primary mother adolescents receiving family support. As mentioned in the same, in the past, the traditional families mostly devoted a differentiated support to male children. While females married early and were closely linked to the home environment. Historically the woman brings this mark in the social and family relationship. Therefore, a teenage pregnancy reflects for them as a loss of their freedom and autonomy, as well as the difficulties already mentioned. It is possible to conclude this after mentioning that the adult mothers who testified in this study, in addition to having an expected pregnancy, already had the support of family and those involved. As indeed, for these the support was intense and the news of the pregnancy was without conflicts and tensions [11]. 

Increasing the coverage of family health units along with professional training may improve health care qualifications, as the percentage of adolescent parturients has increased over the years. (34.6% from 2000 to 2005). The main risk for these adolescents, besides being biological, can be associated with social situation, lack of information and lack of emotional competence. In another study, it states that epidemiological research is important for the elaboration of public policies, for the definition of programs for this public. The biggest concern is the sexual and reproductive health of adolescents that exposes them to the risk of unwanted pregnancy and sexually transmitted diseases [12,13]. Despite the increase in contraceptive distribution in the Unified Health System, very little is said about adverse effects, correct use and drug interaction, with this, many users end up giving up the method. However, the guarantee of the provision of assistance in reproductive planning is established, and the state is responsible for promoting full access and the health management body to provide assistance in full. 

In the study where information and use of contraceptive methods compared among adolescents, showed a higher percentage of responses associated with the use or infrequent contraceptive methods (85% indicated to use sometimes and 8% never used). When asked about having already received information about contraception 96% of pregnant women and 98% of non-pregnant women answered yes. However, the quality of the information received by these young women is questioned, since in the group of pregnant women the use of contraceptives is frequent [5,14,15]. 

The sexual and reproductive behavior of the human being is related to the educational level of the same, those who are more dedicated to the studies make use of contraceptive methods avoiding the unwanted pregnancy and/or STI. The use of contraceptive methods is directly related to the level of knowledge. Condoms are more commonly used by students in the early grades, while those at the end of the course opt more for oral contraceptives claiming a more stable love relationship. Through a study carried out shows that most adolescents did not complete elementary school or high school and only a small part of these adolescents continued their studies, through these studies indicates that low education is directly related to teenage pregnancy [16-18]. 

Most women have some knowledge about contraceptive methods, but do not negate the lack of information on these methods, so it is necessary a greater professional and user interaction to increase freedom of choice, increase confidence and the knowledge between professional and client since nurses play a fundamental role in the Family Health Strategy and family planning. However, undergraduates in health care, with an average age of 20.5 years, despite the knowledge of contraceptive methods, inform male condoms as the main preventive method, but with the use of alcohol and other drugs, they increase their exposure to pregnancy and pregnancy. STI due to unpredictable sex [19,20]. 

The health professional who prescribes contraception or emergency contraception for an adolescent does not violate the law and does not violate ethical principles, but it is the health professionals duty to pay attention to the sexual and reproductive health of adolescents. And the resource for proper counseling is family planning, which is an integral part of womens care [21]. 

The family health strategy added to family planning presents a set of actions outlined by the Ministry of Health that aims to guarantee the couples right to the planned conception and or contraception of their children. Rights guaranteed from Law n^°. 9,263 of January 12, 1996 and provides resources for sex education, quality reproductive health, contraceptive methods, and socio-educational programs that practitioners should use to raise awareness of those in need of information to avoid medicalization and unpleasant consequences to health [22]. 

According to the ministry of healths team of experts, the most commonly used emergency contraception pills are 0.75 or 1.5 mg levonogestrel, marketed as: Diad; Dopo; H time; Neodia Pilem; Postinor; Pozato and Prevention. However, such drugs have no scientific studies to prove their effectiveness. They are inexpensive and a study of the compositions and possible side effects is suggested before use in emergency contraception [23]. Emergency contraception is a controversial subject full of ethical, political and ideological controversies, relating fears from the beginning of human life to possible changes in sexual behavior but needs to be debated for the awareness of professionals and society [24]. 

Conclusion 

The main reason for the misuse of abortion pills has still been the unwanted pregnancy, both by adolescents and women in adulthood, due to lack of information, guidance and even carelessness. Then begins the desperate search for the pills, which would at first solve the problem caused by themselves, without imagining the grievance and complications caused by the misuse of these medications. 

Indiscriminate use of abortion pills is also associated with women with low income and low education. Many women do not use contraception, increasing pregnancy rates and the incidence of STI. Thus, with little knowledge and lack of information, facilitates the excessive use of abortion pills and even illegal means such as seeking clandestine clinics to terminate pregnancy, where there is no hygiene, increasing the risk of infections and even leading to death.

References    

1.  Moraes MST, Oliveira RC, Santos JM, Lucena Junior RP, Queiroz JRC, et al. Adverse effects on contraceptive implant users (2015) Femina 43.
2.  Protocols of Primary Care: Womens Health. Ministry of Health, Syrian-Lebanese Institute of Education and Research (2016) Ministry of Health, Brazil.
3. Santos ACA, Rocha RDL, Nery IS and Silva JCP. Goodbye Hormones: Conceptions about body and contraception from the perspective of young women (2018) University of São Paulo, Brazil.
4. Brandão ER, Cabral CS, Ventura M, Oiava SP, Bastos LL, et al. Hormone bomb: risks of emergency contraception from the perspective of pharmacy attendants in Rio de Janeiro, Brazil (2016) Cad Saúde Pública Rio de Janeiro 32: e00136615. https://doi.org/10.1590/0102-311x00136615
5. Patias ND and Dias ACG. First sexual intercourse, information and contraceptive use: a comparison between adolescents (2014) Psico-USF, Brag Pauli 19: 13-22.
6. Costa GPO, Guerra AQS and Araújo ACPF. Knowledge, attitudes, and practices on previous use of contraceptive methods among pregnant teenagers (2016) J res fundam care 8: 3597-3608.
7. Lima GKS, Santos AAP, Silva JMO, Comassetto I, Correia SR, et al. Self-care of adolescents in the puerperal period: application of the orem theory (2017) J of Nurs 11: 4217-25.
8. Spinelli MBAS, Souza AI, Vanderlei LCM and Vidal SA. Emergency contraception supply on primary health care in Recife, Northeastern Brazil (2014) S0061úde Soc São Paulo 1: 227-237. http://dx.doi.org/10.1590/S0104-12902014000100018
9. Alves MO, Perreira BDM, Dias FA, Mendes LC, Elias TC, et al. Use of contraceptive methods and factors related to pregnancy planning among puerperas (2016) Rev Enferm UFSM 6: 424-433.
10. Domingos SRF, Merighi MAB, Jesus MC Pand Oliveira DM. The experience of women with abortion during adolescence as demanded by their mothers (2013) Rev Latino-Am Enferm 21: 899-905. http://dx.doi.org/10.1590/S0104-11692013000400010
11. Zenettini A, Souza JB and Aguiar DM. The interfaces of adolescent and adult mothers first experience (2017) Rev Enfer Cent-Oest Mine 7: e1987. https://doi.org/10.19175/recom.v7i0.1987
12. Barbaro MC, Lettiere A and Nakano AMS. Prenatal care for adolescents and the attributes of primary health care (2014) Rev Latino-Am Enferm 22: 1-7. http://dx.doi.org/10.1590/0104-1169.3035.2390
13.  Gondim PS, Souto NF, Moreira CB, Cruz MEC, Caetano FHP, et al. Accessibility of adolescents to sources of information on sexual and reproductive health (2015) J Hum Grow Deve 25: 50-53. http://dx.doi.org/10.7322/jhgd.96767
14. Marin C, Albuquerque AAB and Fontes KB. Knowledge of women workers in the clothing industry about contraceptive (2013) Arq Cienc Saúde UNIPAR 17: 159-162. https://doi.org/10.25110/arqsaude.v17i3.2013.5065
15. Medeiros TFR, Santos SMP, Xavier AG, Gonçalves RL, Mariz SR, et al. Womens experience with contraception from the perspective of gender (2016) Rev Gaúcha Enferm 37: e57350.
16. Carmo SS, Livramento DE, Paulino Neto HF and Zeferino MGM. Quantitative analysis regarding pregnancy in adolescence in a municipality in minas gerais (2014) Cogi Enfer 19: 740-746. https://doi.org/10.1590/1983-1447.2016.02.57350x
17. Sousa SC, Leão DCMR, Vieira BDG, Alves VH, Rodrigues DP, et al. The puerperal woman hospitalized facing the prevention of pregnancy: possibilities and limits of nursing (2016) Rev enferm UFPE 10: 3560-3566.
18. Pereira ALF, Penna LHG, Pires EC and Amado DC. Sexual and birth control health practices among female undergraduates: a descriptive study (2014) Braz J Nurs 13: 25-35. https://doi.org/10.5935/1676-4285.20144066
19. Lima PVC, Rocha RDL, Nery IS and Silva JCP. Use of contraceptive methods by users of a basic health unit (2015) Rev enferm UFPI 4: 11-18.
20. Sarmento MSRA, Sales JCS, Silva Junior FJGS and Parente ACM. Sexual behaviors and the use of contraceptive methods among undergraduate female students of the health area (2018) Nurs J Min Gera 22: e-1112. http://www.dx.doi.org/10.5935/1415-2762.20180040
21. Ministry of Health. Emergency contraception: questions and answers for health professionals, 2010 Brazil.
22. Lacerda JOS, Portela FS and Marques MS. The indiscriminate use of emergency contraception: a systematic review of the literature (2019) Rev Mult Psic 13: 379-386.
23. Pinheito P. Next pill leaves: How to take, effects and rate of effectiveness.
24. Wannmacher L. Emergency contraception: evidence versus prejudice, Rational drug use: selected topics (2005) Brasilia, 2: 1-6.

^*Corresponding author

Bruno Vilas Boas Dias, Department of Nursing, Padre Anchieta University Center, Campo Limpo Paulista University Center, Brazil, Tel: +55114527-3444, E-mail: bruno.dias@anchieta.br

Citation

Dias BVB, Silva JAD, Da Cruz LV and Antognetti SDS. The indiscriminate use of an emergency contraceptive pill in the light of the integrated literature review (2019) Nursing and Health Care 4: 57-61.

Keywords

Unwanted pregnancy, Emergency contraception, Asexual intercourse, Postcoital contraception.