1. Introduction
Family planning (FP) is a public health policy tool that directly influences the human development index (HDI) of a nation. P.F is understood as the set of actions that aim to contribute to the health of women, children, fathers, families and society, allowing women and men to choose what to do with their lives, whether or not to have children, when to have them, the number of children, the spacing between the birth of children and the type of education and education, comfort, quality of life and social and cultural conditions that their children will have.
Family planning is an instrument with sufficient scientific evidence as to the cost-benefit results in improving living conditions, reducing unwanted and early pregnancies, reducing the induced mortality rate and the direct causes of maternal mortality in countries, because it respects inter-genetic intervals, defines the desired number of children and more [1] .
Assistance to family planning is currently offered in all countries of the world, in each of the countries contextualized according to their economic, social, cultural conditions, etc., in Angola, this assistance is provided in health units of different levels of care (primary, secondary and tertiary), by multidisciplinary health teams, it is a model of public health policy that brings the proposal of teamwork, where they are linked: health professionals, the community, valuing and encouraging community participation in the condition of Subject of health [2] .
The family is the nucleus of society, and attention in family planning must begin there where the families are, it is a continuous process of thinking about the future of a community/nation, which implies permanent decision making within a context that suffers constant influences [3] [4] .
When intervening in the community to achieve goals and meet objectives within public health policies on family planning, we must take the following steps:
1) Planning,
2) Organization-development,
3) Implementation-direction,
4) Control-evaluation.
When assessing the feasibility and feasibility of implementing policies aimed at improving social indicators, we must take into account the existence of the problem, gather information about it and define the nature of the problem [3] [5] (Figure 1).
Courtesy of Tavares, HP & Tavares, SBMPT (2023)
After the existence of a given problem we must evaluate the modality of resolution of the problem, but that this resolution will depend on the commitment and resources available, hence always present the possible situation of resolution.
The performance of health professionals in assisting populations with regard to family planning necessarily involves four types of activities:
1) Educational activities,
2) Counseling,
3) Clinical activities,
4) Follow-up appointments.
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Figure 1. Model of diagnosis and intervention in communities.
The above steps when integrated, the favorable outcome is more than 75% chance of success [2] .
Educational activities: educational activities should be developed with the aim of providing the population with the necessary knowledge to choose personal, family life, and subsequently the use of the most appropriate contraceptive method, as well as creating conditions for reflection on issues related to the practice of contraception/conception, including sexuality [6] .
Counselling: is a process of active dialogue, individualized or not, focused on the individual and/or couple. It presupposes the ability to establish a relationship of trust and empathy, between the interlocutors (health professional and user), making the recipient the subject of their own health and transformation [7] .
Clinical activities: Clinical activities should be carried out taking into account that any and all contact that the woman and/or the couple will have with the health services should be used for the benefit of the promotion, protection and recovery of her or their health. The first consultation(s) should be made after the first (educational) activity including: anamnesis; general and gynecological physical examination, with special attention to the orientation of breast self-examination (depending on age and/or family history) and seeking to know the date of the last Pap smear to assess the need for collection or referral for such, analysis of the choice and prescription of the contraceptive method [8] .
Follow-up consultations: Subsequent consultations or return consultations aim at a periodic and continuous care to reassess the relationship created between the method in use, as well as prevent, identify and treat possible intercurrences, the interval to this the user, depends on the diagnosis of hidden diseases, asymptomatic, symptomatic or absence of disease [9] .
The assistance to the P.F has the purpose of ensuring increasingly qualitative health care, incorporating collective actions of a health promotional and preventive nature of diseases. In this regard, it is essential to establish intersectoral partnerships with education (instructing and training), social action, other governmental bodies and civil society [2] [10] .
Among the objectives of the P.F we highlight the following:
a) Promote healthy behaviors towards sexuality;
b) Inform and advise on sexual and reproductive health;
c) Reduce the incidence of sexually transmitted infections and their consequences, including infertility;
d) Reduce maternal, perinatal and infant mortality and morbidity;
e) Enable couples to decide how many children they want, if they want them and when they want them, i.e. to plan their family.
f) Prepare for and promote responsible motherhood and fatherhood;
g) Improve the health and well-being of the family and the individuals concerned.
FP is a practice far above what is usually understood, it is wrongly understood that FP has only to do with contraception, no, it is much more than contraception, it is an attitude that begins in the social aspects of the family/individual, research, health promotion, disease prevention, diagnosis and treatment of family/individual diseases (vertical and transversal) at the end conception or contraception according to the previous phases.
Each citizen is and must necessarily feel a partner of the government where he/she lives, fulfilling duties to benefit from rights, thus actively participating in improving indicators and increasing Gross Domestic Production (GDP).
With regard to the social aspects on which the citizen must focus in terms of family planning, we have made it relevant to consider: age, biotype, individual economic condition, having some degree, being employed or not, having a house to live in (own or rent), cultural and traditional habits, etc.
The elements highlighted above, should be taken into consideration because they constitute the framework to avoid perpetuation of poverty, helps to promote health and improve the quality of life. Citizens, should before any decision for the P.F, have a socially and biologically acceptable age to have some love relationship, where the recommended is that it is above 19 years, where it is a considerable young age with the beginning of adulthood (WHO, 1986), an age to study and professionalize, in order to allow, professionalize, get employed or self employ (entrepreneurship), thus guaranteeing income for individual and family support increasing the chances of renting or owning a home [11] . Living beings, population where humans are part of the group, are all the time improving their characteristics over the generations, as explained in geneticist theories. As the living beings cross, they end up bringing new characteristics in the populations, commonly, better genotypic and phenotypic characteristics, as long as there is no interference of something that causes some error during the creation of the new being, by these theories, today we have living beings (animal, vegetable, fungi, protist and Monera) better than yesterday [12] .
An element that is of greater relevance in developing countries are cultural and traditional habits, it is always good to know these two qualitative variables, because we must take into account whether we accept them or not when in a given family they exist, because by accepting the partner, we are also accepting such customs.
Regarding the aspect linked to the binomial health disease, people should at the time of dialog, share their states of health and disease, address the diseases of hereditary character in order to assess whether it is possible during the crossing, or if they can generate offspring, this is a condition that makes, couples are aware of the possibility of having children with or without genetic defects, because when having children with genetic defects, the need for attention to them increases, more resources for the disease(s), not allowing the couple to enjoy life and causing the Government to spend more resources on special treatments and special schools. Not taking this aspect into consideration, it is hardly possible to be happy.
Therefore, the recommendation after the dialogue between the couple, is to go to the nearest health unit, and carry out tests for these diseases (vertical transmission), among them: (Hemophilia, drepanocytosis, tumor markers etc.) [1] . After knowing the results of these elements, search for infectious diseases (Transversal transmission) such as: HIV (Acquired Immunodeficiency Virus), Hepatitis B and C, Syphilis, Toxoplasmosis, Rubella, Cytomegaloviruis, Human Papilloma Virus, these tests must be requested by a health professional. After performing these tests, in diseases of vertical transmission, if there is isolation/identification of one element or more, it gives us two possibilities;
1 - Assess whether it is treatable; if it is treatable, it must be treated.
2 - If it is not treatable, there are two possibilities.
2.1 - Continue together (married) without generating descendants.
2.2 - Separate, look for another partner and start the process again in the new relationship. With these attitudes, we will be improving the profile of the population and allowing government resources to be more comprehensive and leading to a simpler and happier life.
Here the decision to opt for conception or anti-conception depends on what has been clarified in the previous steps (social aspects and the health-disease process), remembering that to get here the couple will have to have passed the social issues and be healthy (Figure 2).
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Figure 2. Stratification of family planning.
Courtesy of Tavares, HP & Tavares, SBMPT (2023)
Contraceptive methods are ways/attitudes, medicines, objects and surgeries, used by people to avoid pregnancy, there are female and male methods [13] .
The use of contraceptive methods allows the woman to have greater control over the decision to be a mother [14] .
Contraceptive methods come in two forms:
1 - Non-hormonal or non-medicated: being those that do not have any hormone, which can be reversible ranging from natural, behavioral and barrier and we have the irreversible ones that are related to surgeries whether they are tubal ligation and vasectomy.
2 - Hormonal methods that are reversible, characterized by mini pills, combined pills and emergency pills.
This vision of the methods of preventing unwanted and/or unplanned pregnancies is mirrored in the figure below.
Courtesy of Tavares, HP & Tavares, SBMPT (2023) (Figure 3)
Although the use of contraceptive methods is still low, but it has been increasing little by little, a research developed by Paniz (2005), Tavares (2016), show little female population using contraceptive methods, the same is published by Schor (2000) and collaborators when they studied the knowledge and use of contraceptive methods in women aged 10 to 49 years living in the southern region of the Municipality of São Paulo, Brazil [15] [16] [17] [18] [19] .
Among the most widely used hormonal contraceptives are oral pills [20] .
Even with the achievements of the female population in relation to sexual and reproductive rights, especially in access to contraceptive methods, there are still areas where there are difficulties in accessing health services, as well as failures in the guidelines that establish the best way for women to perform family planning, easily accessible and free of complications for their health [21] [22] .
There is no best contraceptive method, what exists is the most suitable method
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Figure 3. Classification of contraceptive methods.
for a given couple. The care offered in P.F. consultations in contraception presupposes the offer of all methods and contraceptive alternatives approved by the Ministry of Health of any country, as well as knowledge of their indications, contraindications and implications of use, guaranteeing the woman, the man, the couple and the family, elements necessary for the free and conscious choice of the method that best suits them or suits them. However, proper clinical and gynecological follow-up of the user, regardless of the method chosen, should be part of the program.
When deciding which contraceptive method to use, a number of aspects should be taken into account: The choice of the woman, the man or the couple, Characteristics of the methods, Individual and situational factors related to the users of the method [23] .
The existing contraceptive methods when offered for use to a couple, we must always take into account some aspects such as: Effectiveness/efficiency, Side effects, Acceptability, Availability, Ease of use, Reversibility, Protection from Sexually Transmitted Diseases (STDs) and HIV infection [23] .
Effectiveness/efficiency: All contraceptive methods have a failure rate, varying from method to method (0.1% - 26%), being higher in behavioral and or natural and spermicide methods. Thus, there are two failure rates for each method: one showing the overall failure rate, and the other linked only to users (correct and consistent use) [24] [25] [26] .
Side effects: the absence of any adverse side effects would be an ideal condition for a couple, scientific research continues to achieve this. In addition, the health professional must be trained to prevent and treat such effects, as well as to assess the risks that a given method may bring, hence the continuous training in health [24] [25] [26] .
Acceptability: the acceptance of the method, the degree of confidence in it, the motivation for its use and good guidance from the health professional are important elements for the success of the method to be chosen [24] [25] [26] .
Availability: free access to contraceptive methods is a fundamental condition for the choice of method to be made freely, without restrictions, the more methods available, the better for users and the more options will be provided [27] .
Ease: the use of the method should be proportional to the degree of knowledge of users, thus facilitating its consumption and efficiency. It is true that most of the difficulties related to the use of the method can be solved with adequate support from the health professional [24] [25] [26] .
Reversibility: ideally, contraceptive methods should be completely and immediately reversible, so that once use is discontinued, there is full recovery of fertility corresponding to the user’s age group and needs [24] [25] [26] .
Protection from Sexually Transmitted Diseases (STD) and HIV Infection: The occurrence of cases of sexually transmitted infection among them by HIV has consequences for the exercise of sexuality and reproduction, it is urgent to encourage the practice of double protection, that is, the simultaneous prevention of sexually transmitted diseases, including HIV/AIDS infection, and unwanted pregnancy, it is of fundamental importance that health professionals create a relationship of empathy by dialoguing with the couple about STD and AIDS [24] [25] [26] .
Individual factors related to the use and choice of contraceptive method:
a) economic conditions;
b) Health status;
c) Personality characteristics of the woman and/or man;
d) Stage of life;
e) Pattern of sexual behavior;
f) Reproductive aspirations;
g) Other factors, (fear, doubts and shame).
Clinical eligibility criteria: The most commonly used clinical eligibility criteria for prescribing contraceptive methods are based on those developed by the World Health Organization [27] . They should be used to guide the user through the process of choosing a contraceptive method. Four categories have been classified that establish the convenience or restriction of using a contraceptive method, described below:
Category 1: The method can be used without restriction.
Category 2: The method may be used with restrictions. The method in question can be used with some caution. These are situations in which the advantages of using the method generally outweigh the risks.
Category 3: Means that the method is not the first choice and, if used, should be monitored more closely.
Category 4: The risks arising from its use generally outweigh the benefits of using the method. When there is a category 3 condition for a method, it should be the method of last choice and, if chosen, close monitoring of the user is required. The method should not be used as it presents an unacceptable risk [28] .
Febrasgo’s 2009 Manuel of contraceptive methods reflects that there are several classifications of contraceptive methods, but mentions the following classification: Two main groups are recognized: I - Reversible II - Definitive [29] .
Reversible methods are: behavioral, barrier, intrauterine devices, hormonal and emergency [30] . The definitive methods are surgical: female surgical sterilization and male surgical sterilization [31] [32] .
1 - Reversible methods: reversible, are all those considered temporary, and which can be interrupted at any time, whether for personal causes, and or Health / Illness. They can be stratified as shown below:
1.1 - Behavioral methods
Also known as natural methods of contraception. They are the methods based on the recognition of the fertile period.
a) Ogino-Knaus method (Table): Calendar method. The basis of this method is the knowledge of the physiology of the woman’s menstrual cycle, thus determining the fertile period and avoiding having unprotected sex in this time interval.
b) Cervical mucus method (Billings): The rationale behind this method is the knowledge that cervical mucus undergoes physico-chemical changes related to the type of hormonal stimulation to which it is subjected. The greater the oestrogenic stimulation, the more the mucus becomes abundant, watery, transparent and stringy, at which point it indicates ovulation in progress.
c) Basal temperature curve method: This method is based on the change in body temperature that occurs with ovulation due to increased progesterone. Among other properties, progesterone raises body temperature by a few tenths of a degree.
d) Symptothermal method (basal body temperature + cervical secretions + other signs of fertility) consists of using multiple markers of the fertile period. To identify the beginning of the fertile period: calendar calculation and mucus analysis. To identify the end of the fertile period: observe mucus variations and identify basal temperature decalage.
e) Intercourse without ejaculation in the vagina: Consists in the use of sexual practices other than vaginal intercourse, so that ejaculation is not intravaginal.
1.2 - Barrier Methods
These consist of the use of devices that prevent the sperm from ascending into the female genital tract.
a) Condom (male condom, condom, venues flytrap): It is a wrapping for the penis, already used in ancient Egypt. Female Condom: It is a cylindrical pouch made of ino (polyurethane) plastic, transparent and soft, of the same length as the male condom, but with two flexible rings, one at each end, one of which is occluded by a membrane.
b) Spermicides: These are chemical substances that, when introduced into the vagina, compromise the vitality of spermatozoa, thus preventing fertilization.
c) Diaphragm: The diaphragm is a dome-shaped silicone membrane, therefore concave-convex, surrounded by a flexible ring that has the purpose of giving it shape memory, is inserted into the vaginal cavity.
d) Cervical cap: It differs from the diaphragm only in size and in the place where it is placed, and must cover the cervix.
e) Intrauterine devices: The intrauterine device (IUD) is a contraceptive method consisting of a small, flexible device that is placed inside the uterus, which exerts actions that ultimately prevent pregnancy.
1.3 - Hormonal contraception: Hormonal contraception is the use of drugs, classified as hormones, in a dose and manner suitable to prevent the occurrence of an unwanted or unplanned pregnancy, without any restriction on sexual intercourse. Hormonal contraception can be classified in several ways [33] [34] [35] .
1) Single-phase combined oral contraceptives:
a) (bi)phasic combined oral contraceptives;
b) triphasic oral contraceptives;
c) progestogen-only oral contraceptives;
2) Injectable-combined, monthly:
a) progestogen-only, quarterly;
3) Implants;
4) Vaginal rings;
5) IUD with progestogen;
6) Skin patches (Patch) [36] .
Injectable hormonal contraceptives Hormones for contraceptive purposes can be presented in injectable form. Their main quality is that they do not have a first pass through the liver. There are two basic types of formulations: combined injectables (monthly) and progestogen-only injectables (quarterly). Combined injectables The combined injectables available are:
a. Perlutan® and Preg-Less® - oestradiolenanthate - 10 mg + algestoneacetophenide (dihydroxyprogesterone) - 150 mg
b. Mesigyna® and Noregyna® - Estradiol valerate - 5 mg + norethisterone enanthate - 50 mg
c. Ciclofemina® - Estradiol cypionate – 5 mg + medroxyprogesterone acetate – 25 mg
Progestogen-only injectables: The existing formulation of this contraceptive is depot medroxyprogesterone acetate (DPA). This product comes in 50 mg, 150 mg and 500 mg ampoules. The latter is used in endometrial oncology [37] .
Implants: These are small capsules or rods of plastic material, permeable, which contain a hormone to be released gradually, when placed in the subcutaneous cellular tissue [38] .
Vaginal pills: These are monophasic type pills, containing 50 µg ethinylestradiol and 250 µg levonorgestrel, are used in the vagina, daily, instead of orally.
Vaginal ring is marketed under the name NuvaRing®. Consisting of a flexible ring, it contains etonogestrel and ethinylestradiol. Placed in the vagina, it releases an average of 120 µg of etonogestrel and 15 µg of ethinylestradiol daily.
Hormone skin patches Contraceptive skin patches (Evra®) are small seals containing 750 µg ethinylestradiol and 6.0 mg (6,000 µg) norelgestromin. Each patch stuck to the skin releases 20 µg of ethinylestradiol and 150 µg of norelgestromin per day, which are absorbed and go directly into the systemic circulation [39] .
Emergency contraception: is a hormonal pill used up to 72 hours after intercourse, whether scheduled or not, with the sole purpose of preventing unwanted pregnancy [40] [41] [42] .
Hormonal contraceptives in addition to the effects of preventing unwanted pregnancy, also serve as drugs to regulate menstrual cycle, treat polycystic ovary syndrome, endometriosis, adenomyosis, hirsutism etc. [43] .
2 - Definitive (surgical) methods Definitive, or surgical, contraceptive methods are procedures that result in sterilization, whether male or female. In women it is performed by tubal ligation and in men by vasectomy
Conception
It is recommended that the couple prepare for motherhood, in particular the maternal organism [44] , hence the need to comply with the seven steps which are:
1) Seek medical attention. ...
2) Take folic acid. ...
3) Control your weight. ...
4) Stay away from harmful habits. ...
5) Aim for a healthy diet. ...
6) Exercise. ...
7) Take care of your emotional health.
2. Material and Method
This study was conducted from a literature review, using techniques that synthesize the results of this research on Family Planning.
The selective and exploratory reading consisted of reading the bibliographic material of interest in the present research.
Procedures for data collection
For data collection, the integrated search system of the Virtual Health Library (VHL) database was used, which included the search in the MEDLINE databases, Latin American and Caribbean Literature in Health Sciences (LILACS), INDEX PSICOLOGY, GOOGLE ACADÉMICO, Virtual Public Health Field (CVSP), LIS (Health Information Locator), with the objective of finding publications of scientific articles related to the study theme from 2000 to 2023. This cut was chosen to increase the options of studies. The words used for the search were: contraceptives AND family planning. Of the articles found, initially there were 5119 results in the databases adopted.
After performing the full text filter, and adopting the inclusion criteria, 128 publications were identified. Ninety articles were excluded due to repetition (duplication in the database), totaling 38 articles, which were available as full texts, which were included in the study analysis (Figure 4).
3. Presentation and Discussion of Results
Family planning should be a practice as it interferes with the development of a nation, because it well used with the participation of all, in a public health policy where the citizen is the subject of it, the health indicators and the economy of the same nation improves significantly [1] , emphasize family planning as a tool used to improve the lives of populations.
Pathfinder (2008) concludes that this is possible, where the subject of health is the population, Educating, counseling, assisting and following up in consultations is a set of integrated activities that provide a high success rate in the implementation of family planning, [2] [6] [7] [8] .
Despite the wide role of health professionals in family planning actions, teams
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Figure 4. Detailed flow diagram of the systematic selection of articles included in the study.
must create care routines, which is an indispensable requirement for legal practice [44] .
What is recommended as a partner of any government, is to guide a conduct where we always think about health promotion, disease prevention, and always be happy, form a family, maintaining healthy pleasures without hurting others, sharing good and pleasurable things [4] .
Researchers emphasize that various health professionals can inform/train about family planning and offer contraceptive methods. In several countries, in addition to doctors, nurses, nursing assistants and technicians, health workers, psychologists, social educators, community members and experienced users of contraceptive methods usually offer family planning services, all in order to increase coverage [45] .
To this end, in Angola, health facilities offer continuous training to increase the quality of care on an ongoing basis [1] .
In developing countries, there are difficulties regarding the number of children a couple has, and there is a direct relationship with the use of contraceptive methods (existing, available), population coverage and in some cases cultural and traditional aspects to prevent an unplanned pregnancy. An unplanned pregnancy can have serious consequences for the social problems already existing in any country [16] [46] .
In the view of many authors, the combined pill, the progestogen-only pill, the male condom, spermaticides, behavioral methods and lactation amenorrhea can be offered by all trained health professionals, so this practice should be more widespread every day in order to improve social indicators [47] .
With individuals of childbearing age as priority targets for family planning consultations, early initiation of follow-up is favorable and recommended. The precocity of these consultations, are understood through the theory of Peplau (1991), in which the interpersonal relationship between the health professional and the user, enhances personal growth [48] .
In this way, it is also possible to build for a relationship of trust with young people, through the continuity of follow-up, to obtain better results in sexual and reproductive health [16] .
Choosing not to conceive or to conceive, depends a lot on the objectives of the people or couples, if they are socially fulfilled and healthy, they will prepare the body for maternity (Physical exercise, diet adjusted for the purpose, vitamins, minerals), if they are not yet socially fulfilled, then they will opt for contraception, in this regard, there are non-hormonal and hormonal methods, they should always opt for a method that is considerable ideal for the couple [49] .
Regarding the contraceptive methods mentioned in all the articles researched, aspects within family planning, it states that their “counseling should begin with the purpose (of the couple’s preferred method), comparing it with other similar, existing and available methods. If there are no medical reasons preventing its use, the method provided should be the one chosen by the user. Where there are no doctors or not enough doctors, Nurses should exercise their activities without restriction in P.F., as they are skilled and trained professionals [50] .
The specialist nurse must provide “contraceptive methods and supervise their use”, and the nurse “designs, plans, coordinates, supervises, implements and evaluates interventions for health protection and prevention of sexually transmitted infections”. The nurse should not “impose his/her own criteria and values in the context of conscience and philosophy of life”, but should support the person(s), help him/her to understand him/herself, and, if he/she considers that he/she is sensitized to the acts by providing such care. However, you should ensure that you provide the care that users need, referring them to other health professionals if necessary, always recognizing your technical and conceptual skills [50] .
It is the responsibility of health professionals to guide the means of conception and contraception, through educational, clinical and counseling activities, so that choices are conscious and so that all (Users and Health Professionals), see and feel integrated in the common good of a nation. These activities should be developed in an integrative way, thus articulating the relationship between professionals and users, systematically and continuously stimulating the participation of men and women in the same activities, according to the level of responsibility and need of each side, not forgetting family participation and the interests of the nation in favor of social development [51] .
Good FP practices, implemented in health facilities, especially in basic units, promote health and reduce maternal and infant morbidity and mortality [52] .
4. Conclusions
Family planning is a set of activities that fundamentally involve three stages: 1 - Social aspects, 2 - Health-disease binomial and 3 - Anticonception ↔ Conception.
Following the above, is the ideal way to realize dreams, creating conditions to have a better life than the one we had before, with decent conditions to live, as a family (husband, wife and children?), avoiding perpetuating poverty, allowing a socially acceptable education for children, a better family education and schools, schools with good references, thus allowing the generation of family resources and the creation of family enterprises, with acceptable per capita income, being a worthy partner of the Government, paying taxes and improving social indicators.
The P.F allows a regulation within human rights, prevention of sexually transmitted diseases, and improves morbidity indicators, maternal mortality, perinatal, infant.
Furthermore, it allows for a healthy maternity, deciding whether or not to have children, if the couple has to determine the number, thus improving the health and well-being of the family.
There are several contraceptive methods, but the ideal/best method for the couple should always be chosen in order to avoid any inconvenience [49] .
Family planning done well in all its aspects considerably reduces maternal and infant morbidity and mortality [52] .