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Reproductive Health |
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Meeting the Needs of Young Clients:
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As a service provider or program manager, you can play a vital role in helping young people prevent too-early pregnancies. You can
As you begin to work with adolescents, you may find your goals are different from the young people you serve. You may want to encourage adolescents to delay sexual activity, but young people may already be sexually active when they come to visit you. You may want couples to consider birth spacing, but young women and men may not want to use contraception until they have reached their desired family size. However, it is important to guard against letting personal biases influence professional behavior. You need to support and encourage young people to make their own decisions and good choices for their future, based on their knowledge and reproductive goals. When counseling youth about reproductive health, you should explain that adolescent pregnancy carries special health risks. Even when a pregnancy is wanted and planned, the risks are higher for adolescent mothers and their infants. You can explain that there are both health and socioeconomic reasons to delay childbearing until a woman is in her twenties. Why Delay Childbearing?Several studies have shown that the outcomes for adolescents who receive good prenatal care are no different from those of older women. However, prenatal care may not be available, and even if it is available, adolescents are less likely to get prenatal care, or they seek treatment later in their pregnancies. They may not recognize the signs of pregnancy, may want to hide a pregnancy, may not realize care is available or may not be able to afford care. There are several reasons, both medical and socioeconomic, to delay childbearing. Medical reasons to delay childbearing A young woman under age 16 has not reached physical maturity. If her pelvis is too small, she may suffer prolonged labor or obstructed delivery, which can result in hemorrhage, infection, fistulaor* death of mother or infant. Young women, especially those under age 15, are more likely than women ages 20 and older to experience premature labor, spontaneous abortion and stillbirths. First births are typically more risky than subsequent births. Women giving birth for the first time have a higher probability of developing hypertensive disorders, including preeclampsia and eclampsia, conditions marked by protein in the urine, high blood pressure and edema. Infant death rates are typically higher for adolescent mothers than for older women. Socioeconomic reasons to delay childbearing Delaying childbearing can give young women the opportunity to pursue formal education and work outside the home. Men who delay the start of their families can pursue educations and jobs without the pressure of providing for a family. Delayed pregnancy can mean smaller families and can offer economic benefits for the couple. * A fistula is an abnormal passage created between two internal organs or between an internal organ and a body surface. In prolonged or obstructed labor, fistulas may occur between the vagina and rectum or urethra, leading to incontinence and other health problems. Contraceptive MethodsAdolescents can safely use any contraceptive method. However, while all methods are medically safe for young people, some may be more appropriate than others. Sterilization is not recommended for young people because it is permanent and because the younger the client, the stronger the likelihood of regret. The following charts offer information on contraceptive methods and their use by adolescents. As always, you should help the young woman or man consider all contraceptive options, but the final decision rests with the client. For more guidance on how to help young people make informed choices about contraception, see Chapter 6, "Counseling Young People about Reproductive Health."
* Percentage of women typically experiencing pregnancy in first year of use (U.S. data). Contraceptive Methods: Other IssuesThere are several other issues when dealing with contraception for adolescents that will be discussed now. These include: Abstinence What to do about missed pills Dual protection Emergency contraceptive pills (ECPs) Postpartum and postabortion contraception Abstinence Saying no to sex can be difficult for many young people. There may be pressure from peers who claim "everyone" is having sex, or pressure from partners who argue that sex is the best way to prove love and affection, or pressure from older friends and relatives who say having sex is a way to show that you are an adult. Adolescents may not feel they have many choices, but as a provider, you can explain to young people that they can say no to sex if they are not ready. You can help them develop "refusal skills" by counseling them about abstinence or delaying sexual activity. One way to do this is to help them imagine situations in which they might find themselves and help them practice saying no. Following are some examples of how to empower youth to say no if they are not ready for sex.
What to Do about Missed Pills If a young woman forgets to take combined oral contraceptives (COCs), you can explain that there are steps she can take to reduce her risk of pregnancy, outlined by the diagram below.*
* Adapted from Hatcher RA, Rinehart W, Blackburn R, et al. The Essentials of Contraceptive Technology. Baltimore: Johns Hopkins School of Public Health, Population Information Program, 1997. Dual Protection Because many young people face the double risk of unplanned pregnancy and STIs, dual protection may be recommended. Dual protection is defined as the simultaneous prevention of STIs and unwanted pregnancy. For example, a couple may use condoms to protect against STIs and oral contraceptives to protect against pregnancy. Or they may use condoms as their primary means of pregnancy and STI prevention, with emergency contraception as a backup against pregnancy if the condom breaks or slips. Practicing abstinence is also an option. While dual protection offers obvious benefits, its use can be problematic for adolescents. This is because both abstinence and consistent use of condoms require high motivation, and members of this age group may have difficulty using two methods consistently and correctly. Negotiating condom use You can help adolescents learn to negotiate condom use by: Encouraging young people to talk about contraception and STI protection before they have sex. Encouraging young men to take responsibility for protecting themselves and their partners by preventing an unplanned pregnancy or STI. Helping young women recognize that they can ask a young man to wear a condom. Helping young people overcome embarrassment in talking about condoms. One strategy that is effective in helping young people negotiate condom use is role-playing. The following role-play offers suggestions for responses when one partner is reluctant to use a condom. In a one-on-one counseling session, you and your young client can pretend to be a couple discussing condom use. In a larger group setting during an education session, for example you may ask two young people to volunteer to participate.
* Adapted from materials from the Planned Parenthood Federation of America and the California Office of AIDS. Emergency Contraceptive Pills: A Special ConsiderationEmergency contraceptive pills should be available to adolescents who have unprotected sex. The earlier ECPs are administered after unprotected sex, the greater the chances that they will be effective. You can provide ECPs in advance to young people. However, you should counsel clients that ECPs are for emergencies only. They should not be substituted for a regular contraceptive method. What are ECPs? ECPs are the use of oral contraceptives within 72 hours after sexual intercourse to prevent pregnancy. It is especially important that adolescents know this method is available for them, since they may not plan to have intercourse or may not use regular methods effectively. ECPs can also be used for victims of rape or other coercive sex acts. What types of ECPs are available? Certain types of combined oral contraceptive pills or progestin-only pills can be used as ECPs. In some places, pills packaged specifically for emergency contraceptive use are available. Where they are not, regular pills can be used, as long as the COCs contain ethinyl estradiol and levonorgestrel, and the POPs contain levonorgestrel. How do ECPs work? Depending on when they are taken during the menstrual cycle, ECPs can: Delay or inhibit ovulation. Have effects after ovulation. ECPs do not interrupt or harm an established pregnancy, and do not cause abortion. Who can use ECPs? Any young woman can use ECPs, even those who cannot regularly use oral contraceptives because of migraine headaches, severe heart and blood vessel disease or acute liver disease. If a woman is already pregnant, ECPs will not be effective. ECPs will not harm the pregnancy. Are there any side effects of ECPs? Yes. They include:
Side effects can be unpleasant but typically do not last more than 24 hours after the second dose is taken. Nausea and vomiting are more common with COCs than with POPs. Antiemetic drugs can help minimize these side effects. What should I tell clients about how to take ECPs? Two ECP regimens have proven effective. One contains only levonorgestrel (POPs), and the other contains both levonorgestrel and ethinyl estradiol (COCs). The levonorgestrel regimen has been proven to be more effective. You should determine which pills are most readily available in your community and tell your clients about that particular regimen. Progestin-only pills: One dose equals 0.75 mg of levonorgestrel. Tell clients to take one dose within 72 hours after unprotected sexual intercourse, then take another dose 12 hours later. This means that for pills packaged especially for use as emergency contraception, clients will take a total of two pills. For POPs that are not packaged for emergency contraception, the client may have to take as many as 20 pills for each dose. Combined oral contraceptives (Yuzpe Method): One dose equals at least 0.1 mg ethinyl estradiol and 0.5 mg of levonorgestrel. Tell clients to take one dose within 72 hours after unprotected intercourse and another dose 12 hours later. The number of pills taken varies, depending upon the amount of hormones in the pills. You should advise clients on how many pills to take, depending on the formulation used. What should I know about ECPs? The correct dosage for clients and how to take them. How ECPs work. Their effectiveness. Which pill brands to use. Their side effects. Where they are available in my area. Also, you should know: If vomiting occurs within two hours of taking pills, some experts recommend repeating that dose. ECPs do not cause abortion. ECPs can be provided in advance for use when needed. It is not essential in some countries for a young woman to visit the doctor to obtain ECPs. She can obtain pills from the pharmacy, although a doctor's permission may be required. What should I tell young people who want to use ECPs? Explain the correct use of ECPs. Explain their effectiveness. The sooner ECPs are taken after unprotected intercourse, the greater their effectiveness. Discuss side effects. Explain that ECPs will not cause menstrual bleeding to start immediately. Menses may start a few days earlier or later than usual. Explain that ECPs will not be effective if the young woman is already pregnant. ECPs will not harm an existing pregnancy. ECPs should not be used as a regular contraceptive method because long-term safety data on their frequent use are not yet available. Young women and men who are sexually active should use a regular contraceptive method. The client should return to you if she has additional concerns, if her menstrual period is more than a week late or if she needs information about contraception. Explain that ECPs provide no protection against STIs/HIV. Questions to Ask Adolescents about the Use of ECPs To make sure young people understand ECP use, you can ask the following questions. When providing ECPs in advance: What contraceptive method are you currently using? Are you having problems using this method effectively? Why? What kinds of problems are you having? How soon after unprotected intercourse will you start taking your ECPs? How many pills will you take? How often will you take ECPs? What side effects can you expect? What will you do if you experience side effects? When should you come back to the clinic if your menstrual period does not start? When providing ECPs after unprotected intercourse: Why do you think you need emergency contraception? If you take your first dose now, when will you take your second dose? How many pills will you take? How often will you take ECPs? What side effects can you expect? What will you do if you experience side effects? What is your regular method of contraception? Do you want to continue to use this method? Would you like to try another method? If you do not have a regular contraceptive method, would you like to choose a method? When should you come back to the clinic if your menstrual period does not start? Postpartum and Postabortion ContraceptionAdolescents who are pregnant need information about how to have a healthy pregnancy and safe delivery. They also need information about contraception to prevent future unplanned pregnancies or to space births to improve infant and maternal health. Although they may have contact with a health provider during delivery or abortion, they may not be offered contraceptive methods as part of follow-up care.
While young postpartum clients need information about contraception, the needs of the postabortion woman are more immediate since fertility can return in as little as two weeks. For the postpartum woman, ovulation can occur as early as four weeks after delivery if she is not breastfeeding or be delayed for as long as six months (and possibly longer) if she is breastfeeding. Methods that contain estrogen are not recommended for breastfeeding women, since estrogen can reduce breastmilk production. The following charts outline guidelines for postpartum and postabortion contraception.* * Sterilization is not included on the charts because it is not recommended for adolescents. (Please click on thumbnails below to view detailed graphics) When to Begin Contraception after Childbirth (Breastfeeding)
IUDs should be inserted within 48 hours or else delayed 4-6 weeks. When to Begin Contraception after Childbirth (Not Breastfeeding)
IUDs should be inserted within 48 hours or else delayed 4-6 weeks. When to Begin Contraception after Abortion without Complications (First Trimester) When to Begin Contraception after Abortion without Complications (Second Trimester)
When to Begin Contraception after Abortion with Complications (Infection or Bleeding/Anemia)
When to Begin Contraception after Abortion with Complications (Injury to Reproductive Tract)
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