Do Youth-Friendly Services Make a Difference?

Reproductive health facilities in the developing world serve fewer adolescents than people in their 20's and older. While there are usually health services in place to provide married women under 20 with the prenatal and maternity care they need, consideration is rarely given to their age-related, physical, or emotional needs. Also, contraceptive services are often discouraged until after a young married woman has had a first or even a second birth. Health providers are especially reluctant to serve young unmarried people. This reluctance often reflects social attitudes and cultural perceptions that adolescent sexual activity is inappropriate. Yet, as more unmarried young women become pregnant, some new efforts to meet their special need for prenatal and maternity care are being tested and evaluated.

Because the health needs of pregnant adolescents and young women can be easily and immediately identified, special programs for this group have been developed earlier than health programs to serve young women who are not pregnant. Some evaluations of these efforts illustrate positive outcomes:

• In Mexico, a hospital-based program implemented by the Asociación Mexicana de Educación Sexual (AMES), offered family planning information and counseling at both prenatal and postpartum sessions for women under 20 who were delivering a baby at a public hospital. Education and services were also offered through a special adolescent clinic located in the hospital. After an evaluation found that counseling and education sessions were not effective during the immediate postpartum period, this approach was changed. A second evaluation of the project showed that young adults who had attended a prenatal educational session received more prenatal check-ups, and were more likely to space their subsequent births than young women who had not attended that session (86% vs. 64%).^1,6

• Another Mexican hospital-based program, the Educational Program for Adolescent Mothers (PREA), was conducted by the Centro de Orientación para Adolescentes (CORA—Adolescent Guidance Center). Participants attended postpartum and one or more subsequent sessions in which family planning was discussed. Evaluation showed that PREA participants breastfed their infants longer and had a higher rate of contraceptive use than a control group.⁵

• In Chile, multidisciplinary teams have been working to improve birth outcomes and postpartum practices among high-risk young women in government hospitals and clinics. Medical records reveal several positive results: reduced rates of infant mortality, higher rates of continued breastfeeding, and reduced rates of second pregnancy. ⁴

• A Brazilian hospital-based program offered adolescents who were in the postpartum or postabortion period special out-patient services. These included counseling, education, and contraceptive services. Evaluation showed that 50% of the young women who received services or educational talks returned to the out-patient clinic for follow-up. Furthermore, in one participating hospital the ratio of abortions to births declined from 18 to 13 percent after five years of project operation. ⁹

• In the United States, a comprehensive program for pregnant women under the age of 18 was offered in a university medical school. The program used nurses, social workers, a nutritionist, obstetricians, and a psychiatrist. Caseload management was carried out by nurse-midwives. Evaluators concluded that this approach resulted in a significantly lower incidence of low-birth-weight babies, even among a socio-economic population of adolescents who were considered to be at high risk. ⁷  

Some specialized nutritional services have also resulted in improved outcomes for young women:

• A survey in Nigeria found that pregnant adolescents who had received antimalarial drugs and iron and folic acid supplements during the second half of pregnancy had a reduced incidence of cephalopelvic disproportion. ²

• In the United States, a group of pregnant adolescents who had received calorie, protein, vitamin, and mineral supplements gave birth to infants with a significantly higher mean weight than a group that had received no supplements; larger beneficial effects were observed among girls under 16. ⁸

There are mixed conclusions from US studies that have assessed the impact of specialized youth services to improve contraceptive use and help young women delay pregnancy.

• In a US study, six family planning clinics introduced a special protocol that addressed adolescents' psychological and social concerns. Elements of the service included: one-to-one counseling; delaying the pelvic exam (which many teenagers often fear); special staff training; trained teenage counselors; involvement of male partners; encouragement of parental involvement; additional time for discussion; more frequent follow-up visits; and other refinements. The intervention resulted in higher rates of contraceptive continuation and lower pregnancy rates (within one year) among clients in the experimental group than in the control group. ¹⁰

• A US study looked at the effect of an ambitious effort to expand family planning services directed at teenagers in the area near the clinic. Among the added strategies were expanded afternoon and evening hours, walk-in hours, decreased waiting time, and outreach efforts directed at teenagers and their parents. The study showed disappointing results. The project was found to have no measurable impact on the reproductive behavior, attitudes, or knowledge of the target population. These findings suggest that while the clients who come to a clinic may be well served, improving and increasing the availability of services will not necessarily increase the demand for services or affect the reproductive health of the larger population living nearby. ³

• Restrictive or unclear public policies.

• Provider attitudes. Many providers (including community-based distribution agents and pharmacy employees) are often unaccepting of adolescent sexual behavior and disapprove of family planning services for young people.

• Ambivalent and moralistic community attitudes. These can often be partially addressed by means of public education activities.

• No tradition of adolescents routinely using services and adolescent discomfort with using clinical services. Both these problems can be addressed by making clinic services friendlier and by taking outreach services to adolescents in the kinds of places they spend time at in their everyday lives.

• Lack of evaluation data about specific elements of service provision. Answers are particularly needed to the following questions:

  • What elements of a clinic service (e.g., atmosphere, assurance of privacy, drop-in scheduling, hours, costs) are most important for young adults?
  • What services (and service providers) are most vital to attract young people and to meet young adults' reproductive health needs?
  • For young adult women coming for prenatal, postnatal, and postabortion care, what are the most effective ways to encourage teenagers to adopt and use a contraceptive method following delivery or pregnancy termination? What timing, format, and frequency of contraceptive information services are most effective in leading to adoption of contraceptive methods?
  • How can young adults be encouraged to go to clinics for STD screening and treatment?

References

1. Corona E, Gribble JN, Ehrenfeld N, et al. A Study to Evaluate the Quality of Care in a Comprehensive Model of Service Delivery to Adolescent Mothers in a Mexico City Hospital. Asociación Mexicana de Educación Sexual (AMES), 1988.
2. Harrison KA, Fleming AF, Briggs ND, et al. Growth During Pregnancy in Nigerian Teenage Primigravidae. British Journal of Obstetrics and Gynecology 5(suppl.): 32-39 (1985).
3. Hughes ME., Furstenberg FF, Teitler JD. The Impact of an Increase in Family Planning Services on the Teenage Population of Philadelphia. Family Planning Perspectives 27(2): (1995).
4. Maddaleno M. Promoting Comprehensive Health Services for Adolescents in East Metropolitan Santiago de Chile. Final Report. Departments of Pediatrics and Psychiatry, University of Chile, 1994.
5. Martin A, Schenkel P, Vernon R, et al. A Sustainable Educational Program for Postpartum Adolescent Mothers, Mexico. Paper presented at the 19^th annual NCIH International Health Conference. Arlington, Virginia, June 14-17, 1992. 
6. Pathfinder International, Evaluation Unit. Adolescent Project Evaluation. (Draft). 1995.
7. Piechnik S, Corbett MA. Reducing Low Birth Weight among Socioeconomically High-Risk Adolescent Pregnancies. Journal of Nurse-Midwifery 30(2): (1985).
8. Rosso P, Lederman SA. Nutrition in the Pregnant Adolescent. In: Winick M, ed. Adolescent Nutrition. New York: John Wiley & Sons, 1982.
9. Shepard BL, García-Núnez J, Miller JT, et al. [Pathfinder International] Adolescent Program Approaches in Latin America and the Caribbean: An Overview of Implementation and Evaluation Issues. Discussion Draft prepared for the International Conference on Adolescent Fertility in Latin America and the Caribbean. Oaxaca, Mexico, Nov. 1989.
10. Winter L, Breckenmaker LC. Tailoring Family Planning Services to the Special Needs of Adolescents. Family Planning Perspectives 23(1): (1991).

The In Focus series summarizes for professionals working in developing countries some of the program experience and limited research available on young adult reproductive health concerns. This issue was prepared by Judith Senderowitz and was reviewed by the FOCUS Editorial Board, some outside experts and the staff of the FOCUS program.