Greetings,
This message starts Week 3 of the Youth Forum on Pregnancy Prevention in a Time of AIDS. I'd like to first, though, thank Lynn Collins from UNFPA for being our guest panelist last week and for her very insightful comments and answers to questions.
This week we focus on the theme of access barriers that youth face in obtaining reproductive health services. This theme has already come up in some of the postings received during the first two weeks. It is obvious that many participants are well aware of barriers that exist, whether they are medical, procedural, political, cultural or economic barriers. Sometimes barriers go unnoticed, because they have traditionally existed — such as long-standing social norms — or because they are confused with cautious medical practices. Better understanding these barriers, and getting feedback from participants on lessons learned in overcoming them, is the goal of this week's forum.
We have the privilege this week of having Dr. James D. Shelton, MD, MPH, as our guest panelist. After his medical training, Dr. Shelton worked at the Epidemic Intelligence Service (EIS) at the Centers for Disease Control (CDC) and came to the Office of Population at USAID in 1977. He has served as Chief of its Research Division and Acting Deputy Director of the Office. He is currently the Senior Medical Scientist in the Office of Population and Reproductive Health and engages in a wide variety of technical, programmatic and management issues. One of his main passions is the Maximizing Access and Quality (MAQ) initiative — a collaborative initiative between USAID and its Cooperating Agencies (CAs) — designed to improve family planning/reproductive health service delivery throughout the developing world. He also authors "Contraceptive Pearls", a periodic e-mail to colleagues around the world on contraceptive issues.
I look forward to this third week of discussions on such an important topic for youth reproductive health.
Best regards,
Ed Scholl, Forum Moderator
On behalf of YouthNet, The INFO Project, and the Implementing Best Practices in Reproductive Health Initiative/World Health Organization
*********************************************************
Thanks to Youthnet, INFO and WHO for this opportunity to talk about access barriers for youth. I'm going to focus on barriers to access to contraception for sexually active youth, but it would be interesting to hear other experience regarding access barriers for other services as well. The key point is that on a medical basis, young age should not be a barrier to access for any method of contraception.
Access barriers in general: Access barriers include the standard medical barriers (inappropriate contraindications, age-parity restrictions on methods, inappropriate exams and lab tests, provider bias toward certain methods, restrictions on when to begin methods, restrictions on amount of supplies given, and who is allowed to provide certain methods.)
Access barriers also include a wide variety of other factors including: physical location and hours of service sites, availability and attitudes of providers, availability of supplies, laws and regulations, socio-cultural factors such as women's autonomy and norms about family planning, safety and appeal of the physical environment, linkages with other services, perceived quality and cost.
Access barriers specifically important for youth include:
- Service sites that are not designed to be inviting for youth
- Providers reluctant to serve youth
- Laws and policies restrictive for youth
- Medical eligibility restrictions on which methods youth may have
- Attitudes toward married youth that they should, or that assume they should want to, have children right away and in rapid succession.
Such access barriers may often be even more of a problem for youth because they may lack experience and self efficacy in seeking services for the first time, may fear judgment or discovery, and lack funds for transportation or services.
WHO guidance: Fortunately WHO has taken evidence-based positions on medical eligibility and practice recommendations that should help improve access for youth. See:
For those who may not be familiar with the WHO classification system, see information below:
*******************************************************
WHO's Evidence-based Approach to Medical Contraceptive Eligibility
Category 1 - Use the method under any circumstances, when clinical judgement is available or with limited clinical judgement.
Category 2 - Generally use the method, either when clinical judgement is available or with limited clinical judgement.
Category 3 - When clinical judgment is available, use of the method is not usually recommended unless other, more appropriate methods are not available or acceptable. With limited clinical judgement, do not use the method.
Category 4 - Do not use the method either with clinical judgement or with limited clinical judgement.
*******************************************************
Importantly, under the system, a 1 or a 2 simplifies to a "yes" for eligibility. Notably, all contraceptive methods are a 1 or 2 for youth. In fact they are all 1, with the exceptions described below.
For progestin-only injectables such as Depo-Provera, age less than 18 is Category 2 with the following comment: "For women under 18 years of age, there are theoretical concerns regarding the hypo-estrogenic effects of DMPA use, including whether these women will achieve their appropriate peak bone mass." More recent evidence has heightened concern about this issue. In fact, the manufacturer's labeling now recommends use beyond 2 years only if other methods are inadequate. WHO is currently looking at the evidence. However, my own view is that the effects of DMPA are similar to the effects of lactation, and while important to consider, do not rise to the level of restricting access.
For IUDs, age less than 20 is a Category 2 with this comment: "There is concern both about the risk of expulsion due to nulliparity and risk of STIs due to sexual behavior in younger age groups." I believe the purpose of the '2' here is just to bring these issues into counseling as appropriate. The increase in expulsion risk with nulliparity is not that much, and not all young women are nulliparous anyway. STI risk is addressed elsewhere and only "very high individual risk" of gonorrhea or chlamydia raises IUD insertion to Category 3.
Bottom line: Under WHO guidance, young age is not a restriction for contraceptive method use and should not be an access barrier.
I look forward to your thoughts, experiences and questions.
Jim Shelton
return to forum main page
