Counselling of adolescent women on contraceptive methods - PowerPoint Presentation

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Counselling of adolescent women on contraceptive methods

Educational Slide KitModule 1: Rates of unintended pregnancy and factors impacting on adolescent women’s use of contraception

G.MKT.WH.FC.07.2016.0862

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Module content

The biological and psychosocial changes taking place in adolescenceDrivers of sexual behaviourUnintended pregnancy: prevalence and consequencesContraceptive use in adolescenceBarriers influencing access to and use of contraception

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Some biological and psychosocial changes of adolescence are relevant to contraceptive needs

1

Biological

changes

H

ypothalamic-pituitary-ovarian (HPO) axis develops into fully ovulatory cycles, often leading to

bleeding irregularities

and hyperandrogenic conditionsPrimary dysmenorrheaPolycystic ovary syndrome (PCOS) can present and impact on present and future health

1. Bitzer J. Best Pract Res Clin Endocrinol Metab 2013;27:77–89.

Psychosocial changes

Start their sexual life

Experience mood swings, abrupt changes of behaviour, spontaneous behaviour Body image concerns Increased risk of eating disorders as well as drug and/or alcohol abuse

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Adolescents

are more likely to engage in behaviours that increase risk of unintended pregnancy1 Alcohol, drug abuse and smoking can increase sexual or reproductive health risks2 Other contributing factors include:

Lack

of sex education and knowledge regarding prevention of

pregnancy

3

Delay

in access or lack of access to

contraception3,4Incorrect, inconsistent or lack of use of contraception4,5Inability to initiate the discussion with a partner about use of contraception6Body image concerns and eating disorders741. Jackson CA, et al. J Public Health 2012;34(S1):i31–i40; 2. Porter C. Gynaecology Forum 2013;18(3):8–10; 3. World Health Organization. Fact Sheet no. 364; 4. Meyrick J. J Fam Planning Reprod Health Care 2001;27:33–36; 5. Trussell J. Contraception 2011;83:397−404; 6. Manlove J, et al. Perspect Sexual Reprod Health 2004;36(6):265–275; 7. Bitzer J. Best Pract Res Clin Endocrinol Metab 2013;27:77–89.

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By the late teenage years, approximately 60%

of adolescent women will have had sexual intercourse1The earlier that adolescents have sex, the less likely they are to use contraception2

Percentage of women aged 20–24 years reporting first intercourse in their teenage years

1. Apter

D, et al.

Gynaecol

Forum 2013;18(3):1–

32;

2. Leikko R, et al. J Social Med, In press 2016.

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Although birth and abortion rates amongst adolescents

are declining, they remain high1,2 Birth and abortion rates per 1000 15–19 year olds

1

1. Sedgh

G, et al

.

J Adolesc Health 2015;56:223-

230; 2. World Health Organization. Fact Sheet no. 364, 2014.

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The majority of pregnancies in women

aged 15-19 are unintended1,2An estimated 16 million women aged 15-19 years worldwide give birth annually1Many of these are unintended:

1

e

ither unwanted

or mistimed

2

In the US, approximately 82% of teenage pregnancies are unintended

3In developing countries like sub-Saharan Africa, the proportion of unintended pregnancy is lower – approximately 35%3 1. World Health Organization. Fact Sheet no. 364.; 2. ESC and FIGO. Unintended Pregnancies: Scope of the Global Epidemic. 3. Sedgh G, et al. J Adolesc Health 2015;56:223-230.

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Ambivalence towards pregnancy can affect motivation to use contraception1

Women who have ambivalent views about pregnancy are more likely to lack the motivation to prevent it1They may be more likely to use less effective methods or use them inconsistently or incorrectly1

Amongst adolescents, ambivalence towards pregnancy is a predictive factor for the occurrence of pregnancy

2

1. Speizer IS,

et al. Reprod

Health 2009;6:19-

28; 2. Kornides

ML, et al. J Midwifery Womens Health. 2015 Mar-Apr;60(2):158-68.

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Unintended pregnancy in adolescence has far-reaching consequences

There are major consequences for the women involved, their families, their communities and the economy1-3 Adverse impact on maternal pre- and post-natal health and

behaviour

4-7

Poorer

health and developmental outcomes for the

childre

n

5,7-9Failure to achieve educational or career goals and an inability to support themselves financially5,101. World Health Organization. Adolescent Pregnancy Fact Sheet no. 364, updated Sept 2014. Available at: http://www.who.int/mediacentre/factsheets/fs364/en/.; 2. Klein JD. Pediatrics 2005;116(1):281–6; 3. Ruedinger E, Cox JE. Curr Opin Pediatr 2012;24(4):446–52; 4. Cheng D, et al. Contraception 2009;79(3):194–8; 5. Dalby J, al. Prim Care Clin Office Pract 41 (2014) 607–629; 6. Dye TD, et al. Am J Public Health 1997;87(10):1709−11; 7. Logan C et al. In: Child Trends, and the National Campaign to Prevent Teen and Unplanned Pregnancy. Washington, DC; 2007; 8. Fraser AM, et al. New Eng J Med 1995;332(17):1113–1118; 9. Chen XK, et al. Int J Epidemiol 2007;36(2):268–73; 10. Committee on Adolescent Health Care. Obstet Gynecol. 2017 May;129(5):e142-e149.

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Adolescents use a

wide variety of contraceptive methods11. Bajos N, et al. In: Reproductive health behaviour of young Europeans, Population studies No. 42, Strasbourg, Council of Europe Publishing; 2003; 42(1):13–76.

100

90

80

70

60

50

40

30

20

10

0

Percentage

Netherlands

(1993)

Czech

Republic

(1993)

Portugal

(1997)

Spain

(1993)

Romania

(1999)

Armenia

(2000)

Turkey

(1998)

Ukraine

(1999)

Pill

IUD

Condom

Periodic abstinence

Withdrawal

Other method

Contraceptive

method used by

couple (women

<20

years)

1

Country (survey year)

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The gap between typical and perfect use of user-dependent methods needs to be considered, especially for adolescents

1,21. Trussell J. Contraceptive efficacy. Contraceptive Technology 2011; Twentieth Revised Edition; 2. Apter D. Gynaecol Forum 2013;18(3):3.

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Factors influencing access to effective contraception are multi-

dimensional11. Bitzer J, et al. Eur J Contracept Reprod Health Care 2016;21:6,417-430

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The socioeconomic environment can create multiple barriers to obtaining contraception1

Poverty and marginalisationPursuit of social inclusion, peer group and maternal conformityFamily dynamics and valuesChildhood and domestic sexual abuseGender inequality

Partner pressure

Lack of policy for sexual and reproductive healthcare

Gender-based discrimination

Lack of access to education

Legal restrictions around access to contraception (for single women) and safe abortion

Health insurance

1. Bitzer J, et al. Eur J Contracept Reprod Health Care 2016;21:6,417-430For example

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Pressure to conform to cultural or religious values also plays a part1

Conflicting cultural normsUrban myths about contraceptionMoralistic attitudesChanging family structures

Forbidding of pre-marital sex and/or contraception

Perceived abortive nature of contraceptive methods

Opposition to artificial or permanent methods

1. Bitzer

J,

et al

. Eur J Contracept Reprod Health Care 2016;21:6,417-430For example

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Healthcare systems can create barriers to accessing contraception for adolescents

1 1. Bitzer J, et al. Eur J Contracept Reprod Health Care 2016;21:6,417-430

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A survey of US health facilities showed limited dedicated contraceptive provision for adolescents

1 1. Kavanaugh ML, et al. J Adolesc Health 2013;52(3):284–92.

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Inconvenient clinic hours and too few staff are key

challenges in facilities’ ability to provide youth-friendly services11. Kavanaugh ML, et al. J Adolesc Health 2013;52(3):284–92.

Clinic hours are inconvenient

Too few staff

Staff have too little time

Service and/or method costs are too high for adolescents

Confidentiality concerns of adolescents

Clinic location inconvenient

Inadequate staff training or experience with adolescents

Staff have difficulty relating to adolescents

0

10

20

30

40

50

60

General limitations to providing youth-friendly services

51

39

33

33

30

28

25

15

Percentage

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Adolescents who are sexually active, smoke or drink are less likely to access healthcare when needed

1Percentage of adolescents (health risks vs. no health risks) failing to access healthcare in the previous year (US study, n=12,102)

% adolescents

1.

Ford CA, et

al.

JAMA 1999;15;282(23):2227-34.

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Adolescents see HCPs as a highly trusted source of sexual health advice

1,21. Black AY, et al. Poster presented at SOGC, 2013. 2. Bitzer J, et al. Eur J

Contracept

Reprod

Health Care 2016;21:6,417-430

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Myths and misperceptions around COCs persist amongst adolescents and

healthcare providers1Prevalence of misconceptions

about COCs amongst teenagers (n=254) (users and non-users) and healthcare providers (n=114)

(Adapted from Hamani et al [2007], selected data presented)

% believing statements to be true

1. Hamani

Y,

et al. Hum Reprod 2007;22(12):3078–83.Causes weight gainCauses acne / hirsutismDoes not affect libidoInfluences moodCauses future infertilityCannot be used by adolescent smokersRequires breaks in use

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A consultation provides an ideal opportunity to address some myths or misperceptions that may artificially limit choice of method

1,2 MethodMyths or misperceptions amongst women that are not evidence-basedCombined oral contraceptive

s

They can cause weight gain

They require a pelvic examination prior to initiation

They are no more effective than a condom

They require you to take a ‘pill’ break every two years

They affect future fertility

Intrauterine contraceptionIt can only be used in women who have had children previouslyIt requires a major operation for placementIt means you cannot use tampons Hormone injectionsThey have long-term negative effects that can last the rest of a woman’s lifeThey can cause infertility CondomsThey can be used with any lubricant, including petroleum jelly

Vaginal

r

ing

It has to be inserted by a healthcare provider every month Bitzer J, et al. Eur J Contracept Reprod Health Care 2016;21:6,417-430; 2. Craig AD, et al. Womens Health Issues 2014;24(3):e281–9.

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A consultation provides an ideal opportunity to address some myths or misperceptions that may artificially limit choice of method

1,2 MethodMyths or misperceptions amongst women that are not evidence-based1,2

Combined oral contraceptive

s

They can cause weight gain

They require a pelvic examination prior to initiation

They are no more effective than a condom

They require you to take a ‘pill’ break every two years

They affect future fertility Intrauterine contraceptionIt can only be used in women who have had children previouslyIt requires a major operation for placementIt means you cannot use tampons Hormone injectionsThey have long-term negative effects that can last the rest of a woman’s lifeThey can cause infertility Condoms

They can be used with any lubricant, including petroleum jelly

Vaginal

ring

It has to be inserted by a healthcare provider every month Bitzer J, et al. Eur J Contracept Reprod Health Care 2016;21:6,417-430; 2. Craig AD, et al. Womens Health Issues 2014;24(3):e281–9.

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Conclusions

Adolescent access to contraception is impeded by multi-dimensional social, political, cultural and religious barriers Lack of sexuality education and knowledge of reproductive physiologyLimited access to services offering contraceptive counselling Lack of care designed specifically to meet the needs of adolescentsPresence of myths and misperceptions about methods that may limit choice of method and correct use

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