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By Kerry Wright Aradhya, Senior Science Writer, William Finger, Associate Director, Youth Information, and Ed Scholl, Director, Public Health Programs, Family Health International, Research Triangle Park, NC, USA With the risk of teenage pregnancies on the rise, sexually active youth in Africa need safe, effective, and reliable contraception now more than they ever did before. As the HIV/AIDS epidemic continues to grow, young people must also find a way to protect themselves against HIV and other sexually transmitted infections (STIs). Healthcare providers should explore the reproductive health needs of young clients when they help them choose a contraceptive method. Providers must also consider the range of available options, the effectiveness of the methods, and their medical appropriateness. Need for contraception The age at which young women begin menstruating is steadily decreasing, while the age at which they marry is slowly increasing. The result is a widening gap between the time they are first sexually active and the time when they wish to have children. Even in countries where youth are waiting longer to begin having sex, the time between sexual initiation and marriage is growing.1,2 Regardless of marital status, preventing unintended pregnancies can prevent unsafe abortions and protect a woman's health. More than half of the women in sub-Saharan Africa deliver their first child before the age of 20.3 Yet, pregnant adolescents have a higher risk than older women of pregnancy-induced hypertension, anemia, and prolonged or obstructed labour.4 Compared to women in their twenties, adolescents are two to five times as likely to die during childbirth.5 For every young mother that dies, an estimated 30 more experience complications such as vaginal tears, fistulae, or excessive bleeding.6 As the risks of unintended pregnancies have risen among youth, their exposure to STIs has also increased. Many young people today are as concerned about STIs -- especially life-threatening HIV -- as they are about an unintended pregnancy. In many countries, about half of the new HIV infections are among youth, particularly young women. About a third of all other new STIs occur among youth.7,8 Multiple options Many young people in Africa still have a difficult time accessing contraception (see Making family planning services more "youth-friendly"). This is unfortunate because the more contraceptive options that are available, the more likely it is that a young client will use a method that suits her or his needs. Throughout most of Africa, shorter-acting methods are the most accessible and, consequently, the most popular contraceptive methods among youth. Condoms, oral contraceptives, and to a lesser extent injectables are the most common. Pills and injectables are both hormonal, and each comes in either a progestin-only form or a combined form containing both estrogen and progestin. Although young people usually choose shorter-acting methods, long-acting reversible methods such as contraceptive implants and intrauterine devices (IUDs) are suitable options for some young people. They may be especially good options for young women who wish to delay childbearing for an extended period of time or who already have a child but want to wait before having another. Progestin-only implants are registered in Africa for three to five years of use, depending on the type of implant. Copper IUDs, which do not contain hormones, are labeled for up to 10 years of use (although studies have shown them to be effective at preventing pregnancy for up to 12 years). While not recommended as a routine form of contraception, emergency contraceptive pills (ECPs) can prevent an unintended pregnancy in the event of unprotected sex. ECPs play an important backup role for users of condoms and pills. Given the incidence of rape, incest, and coerced sex among young people in Africa, even youth who are not sexually active should be aware that ECPs exist and should know where they can obtain them. Contraceptive effectiveness When used correctly and consistently, all modern methods of contraception are highly effective at preventing pregnancy. However, some methods are more effective than others during 'typical' use -- which often includes incidents where a person forgets to use a method or uses it incorrectly. In general, injectables are more effective than pills, and pills are more effective than condoms. Implants and IUDs are the most effective. During one year of use, fewer than 1 in 100 young women who use implants or IUDs will become pregnant. Some people consider oral contraceptives the best contraceptive option for sexually active girls. However, adolescent users frequently miss pills, which can increase their risks of unintended pregnancies. Methods that do not require adherence to a daily regimen, such as injectables or implants, have been associated with a declining rate of teen pregnancy in the United States. Many teens might prefer these methods, if they are available and if good counselling and follow-up can be provided.9 Dual protection Some sexually active youth engage in high-risk behaviours such as having multiple sexual partners or changing partners often. Because these behaviours put them at risk of STIs as well as unintended pregnancy, they need 'dual protection'. Some contraceptive methods, including hormonal methods and IUDs, offer very effective protection against pregnancy but offer no protection against STIs. Clearly, the most effective way to prevent both pregnancy and STIs is sexual abstinence. But, for sexually active youth, three additional strategies can be used. If used consistently and correctly, condoms are highly effective at preventing the transmission of HIV and other STIs. Therefore, one option is for a young couple to use two methods -- a primary method for preventing pregnancy, plus condoms to prevent STIs. Another option is to rely solely on condoms. Condoms alone can be very effective at preventing both pregnancy and STIs, but only if they are used correctly during every act of sexual intercourse. Here, ECPs should be used as backup to prevent pregnancy in case a condom is not used, or if it breaks or slips. Finally, young women and men can use a primary method for preventing pregnancy, plus reduce or eliminate their risks for HIV and other STIs by being in a mutually monogamous relationship with an uninfected partner or in a monogamous relationship in which both partners are frequently tested for STIs. Medical appropriateness Another key factor in helping young people choose a contraceptive method is its medical appropriateness. According to the World Health Organization's (WHO's) Medical Eligibility Criteria for Contraceptive Use, healthcare providers should not restrict the use of any contraceptive method based on age alone. When making recommendations for contraceptive eligibility, the WHO places each of a client's characteristics or 'conditions' (such as age) into one of four categories. In general, a particular contraceptive method can be used if the client's condition falls into category 1 or 2. 'Young age' falls into category 1 for most methods, which means the methods can be used under any circumstances. It falls under category 2 for IUDs and progestin-only injectables (see Table 1). IUDs may not be the most appropriate choice for some women who are less than 20 years old. This is because young women who have not given birth are at a slightly increased risk of expelling the device. Also, young women may be more likely than older women to engage in sexual behaviours that put them at risk of a possible STI at the time of insertion. Progestin-only injectables, such as depot medroxyprogesterone acetate, may not be the best choice for women younger than 18 years because of the theoretical risk that large dosages of progestin may interfere with bone development in growing girls. Nevertheless, the advantages of both methods are thought to outweigh the theoretical or proven risks, so they can generally be used by youth of any age. Although age should not be used to restrict the use of any method, the WHO does not recommend sterilisation for young people. (The WHO uses a different classification system for sterilisation.) Young people who have been sterilised are often dissatisfied or remorseful. Up to 20% of young sterilised women later regret their decision.10 Table 1: Medical eligibility based on young age
Interaction with clients All of these issues should be carefully considered when helping a young client identify the best contraceptive options. The goal of counselling should be to provide enough information and guidance so that a client can make informed, voluntary decisions. Comprehensive counselling should help youth to (1) identify their reproductive intentions and assess their risks of pregnancy and STIs, (2) determine whether they need to use contraception, and (3) decide which method or combination of methods is the most appropriate for their needs.11 Counselling is also an opportunity to reach a variety of youth -- even those who are not yet sexually active -- with other important messages about their reproductive health (see Targeted messages for youth). References
Contraceptive Options for Young Adults is a set of 24 slides with presenter notes, appearing in an interactive format for either presenters or self-study. Specific to the needs of youth, these Adolescent Cue Cards are colourful and user-friendly job aids that offer providers helpful information and tips on eight different contraceptive methods.
Making family planning services more 'youth friendly' By Kathleen Henry Shears, Senior Science Writer, Family Health International, Research Triangle Park, NC, USA In spite of the dire need for preventive reproductive health services, many sexually active youth do not seek these services at family planning clinics or other health facilities. Often young people go to clinics only when they are ill or have a problem, such as an unintended pregnancy or symptoms of a sexually transmitted infection. Youth in many different countries cite similar reasons for not seeking assistance with family planning or other reproductive health services. Misconceptions about the side effects of contraceptives and fears that the services will not be confidential are common. Sometimes young people avoid going to a clinic because they are afraid of being seen by someone they know. Some youth may be deterred by inconvenient hours, the cost of services, or policies based on a client's age. A clinical environment that young people perceive as unwelcoming is just one of the barriers to accessing reproductive health services, but research suggests that it is an important one. In Uganda, for example, young women expressed fears that they would be treated disrespectfully by health workers or be refused family planning services because of their age.1 Teenage girls in South Africa reported that when they did go to a health clinic to ask for contraceptives, the nurses lectured them about being too young for sex and made them feel ashamed.2 And when young people in a Senegalese study pretended to be clients, their requests for contraceptives were denied.3 Welcoming young clients Some family planning programmes are working to make their services more accessible and helpful to young people. How far they can go to meet the needs of youth depends on the available resources. But these programmes have found that even small, relatively inexpensive changes can help youth feel welcome at health clinics. Providers and programme managers can make staff members aware that young clients should be treated with respect and that the privacy of every client should be protected. They can develop a list of services for youth in their communities and refer youth to those services when necessary. They can also revise clinic policies that limit access to services. Training that explores providers' values and attitudes is at the heart of most efforts to improve services to young people. This is because a healthcare provider's personal views about adolescent sexuality can affect the quality of the care he or she provides. Providers often feel uncomfortable talking to a young person about reproductive health. They may disapprove of young people having sex, or they may not be knowledgeable about contraceptive options for youth. Although youth sexuality is a sensitive issue, training can help providers overcome their discomfort with counselling young people about reproductive health. A study among nurses and midwives in Kenya and Zambia found that providers who had received continuing education on adolescent reproductive health were more open to providing family planning to young people.4 Like all providers, those who serve young clients should be trained in counselling techniques and should have the most current information about contraceptives. But training also should address how teenagers' needs differ from those of adults and how to communicate with youth in a respectful, nonjudgmental way. Involving young people in planning and implementing services is another important way to make those services more attractive to youth. Some programmes do this through a youth advisory board. Others solicit young people's ideas through suggestion boxes. Youth can also help design educational materials that are appealing and relevant to their peers. Programmes that have greater resources for improving youth services might consider providing separate services for teenagers and adults, either at different facilities or in different rooms. These programmes might also offer services during hours that are more convenient for young people, such as after school or on weekends. Reducing prices for young clients removes a major barrier to access. Programmes can reach youth who avoid or do not know about the health services available to them through schools, events, peer educators, and the media. Community support critical There is some evidence that making clinics more youth friendly increases young people's use of reproductive health services. After family planning associations in three South American countries trained staff and opened youth centres, the average number of services provided to young people each month increased dramatically: from 895 to 1353 in Peru; from 72 to 426 in Brazil; and from 35 to 87 in Ecuador.5 On the other hand, other studies in Brazil and Zimbabwe failed to show that efforts to improve services for youth increased the use of those services.6,7 An evaluation of three projects to make reproductive health services in Zambia more youth friendly found that young clients' use of services increased at some clinics. But the results suggest that the community's acceptance of reproductive health services for young people may have a greater impact on use than the clinical environment itself. This reveals a need for outreach programmes to educate parents, teachers, and other community members.8 References
This article was reproduced with permission of the Mera journal, the leading publication of continuing medical education for health professionals in the English-speaking countries of Africa (info@fsg.co.uk, www.fsg.co.uk). |
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