Contraception for Adolescents

Contraception for Adolescents
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  REVIEW Open Access Contraception for adolescents in low and middleincome countries: needs, barriers, and access Venkatraman Chandra-Mouli 1* , Donna R McCarraher 2 , Sharon J Phillips 1 , Nancy E Williamson 3 and Gwyn Hainsworth 4 Abstract Substantial numbers of adolescents experience the negative health consequences of early, unprotected sexualactivity - unintended pregnancy, unsafe abortions, pregnancy-related mortality and morbidity and Sexually Transmitted Infections including Human Immunodeficiency Virus; as well as its social and economic costs.Improving access to and use of contraceptives  –  including condoms - needs to be a key component of an overallstrategy to preventing these problems. This paper contains a review of research evidence and programmaticexperiences on needs, barriers, and approaches to access and use of contraception by adolescents in low andmiddle income countries (LMIC). Although the sexual activity of adolescents (ages 10 – 19) varies markedly for boysversus girls and by region, a significant number of adolescents are sexually active; and this increases steadily frommid-to-late adolescence. Sexually active adolescents  –  both married and unmarried - need contraception. Alladolescents in LMIC - especially unmarried ones - face a number of barriers in obtaining contraception and in usingthem correctly and consistently. Effective interventions to improve access and use of contraception includeenacting and implementing laws and policies requiring the provision of sexuality education and contraceptiveservices for adolescents; building community support for the provision of contraception to adolescents, providingsexuality education within and outside school settings, and increasing the access to and use of contraception bymaking health services adolescent-friendly, integrating contraceptive services with other health services, andproviding contraception through a variety of outlets. Emerging data suggest mobile phones and social media arepromising means of increasing contraceptive use among adolescents. Keywords:  Adolescents, Contraception, Low and middle income countries Introduction An estimated 16 million adolescents aged 15 – 19 give birtheach year [1]. Complications from pregnancy and childbirthare the leading cause of death in girls aged 15-19 in Low and Middle Income Countries (LMIC) where almost allof the estimated 3 million unsafe abortions occur [2].Perinatal deaths are significantly higher in babies born toadolescent mothers than in those born to mothers aged20 – 29 years, as are other problems such as low birthweight [2]. Preventing adolescent pregnancy is a key strat-egy in improving maternal and infant outcomes.This paper presents information on sexual activity andunmet need for contraception among adolescents in LMIC,barriers to access and use, and interventions that have suc-cessfully overcome these barriers. Methods 1. To determine the contraceptive needs of adolescentsin developing countries, we disaggregated data fromDemographic and Health Surveys (DHS) to exploreage of sexual debut (first sexual intercourse), use of contraception, and unmet need for contraceptiveservices by married and unmarried adolescents. Tofill gaps, we examined studies on the levels of HIV infection and unsafe abortion.2. To identify barriers that adolescents encounter inaccessing and using contraception, we drew fromtwo systematic reviews of qualitative studies. We * Correspondence: 1 Department of Reproductive Health and Research, World HealthOrganization, Avenue Appia 20, 1211 Geneva 27, SwitzerlandFull list of author information is available at the end of the article © 2014 Chandra-Mouli et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of theCreative Commons Attribution License (, which permits unrestricted use,distribution, and reproduction in any medium, provided the srcinal work is properly cited. Chandra-Mouli  et al. Reproductive Health  2014,  11 :1  also drew from two papers which took stock of thefield  –  one published in 2001 and the other in 2010.3. To identify effective interventions to increase accessand use of contraception among adolescents, wedrew upon evidence gathered by the World HealthOrganization (WHO) to develop guidelines onpreventing early pregnancy in adolescents. Evidence that adolescents are sexually active and have anunmet need for contraception We analysed DHS data from 16 diverse countries havingdata on married and unmarried adolescents. A substantialminority of adolescents was sexually active (had had sexualintercourse) in most of these countries; and this increasedsteadily from mid-to-late adolescence. (Table 1) Retro-spective data showed that more than a quarter of women(20 – 24) in Mali and Bangladesh and between 27-35% of men (20 – 24) in Brazil, Dominican Republic and Haiti re-ported that they had sex before age 15. One-quarterto three-quarters of men (20 – 24) in the African andthe Latin American/Caribbean countries we examined,reported having sex before age 18. In 9 of the 16 countries,40% or more of the women (20 – 24) reported having sexbefore age 18. Reported sexual activity varied widely by re-gion, country, and sex.In Mali and Bangladesh, 25% and 29% respectively of women 20 – 24 reported that they had been married underage 15 whereas in half the countries (8/16), 7% or fewerreported marriage under age 15. An even wider range isevident for marriage under age 18: 71% of women (20 – 24)from Mali reported marriage under 18 in contrast to 10%in Jordan. Similar variations are apparent in the rates of births under 15 and 18. Between 0-10% of women (20 – 24)reported a birth before age 15 and 4-46% reported birthsbefore age 18. Not surprisingly, Table 1 shows that thepercentages of adults (20 – 24) reporting sex, marriage, andbirths increase by age in every country.Originally, never-married adolescents were excluded fromthe DHS and researchers had to rely on retrospective data.Recently, some countries have begun interviewing unmar-ried adolescents about sexual activity, use of contraceptionand childbearing intentions. Table 2 gives prospective esti-mates of current contraceptive use and unmet contracep-tive need for women (15 – 19) for the same countries as inTable 1 except that Yemen and Brazil have been excludeddue to lack of data. Unmet need includes both fecundadolescents who want to forgo childbearing or delay itfor two years and are not using a method of contraception.It also includes pregnant or postpartum amenorrheic fe-males (period not returned since last live birth in the pasttwo years) who reported their current pregnancy was notwanted or was mistimed. In our table and in general, dataare unavailable for unmarried adolescents in the MiddleEast/North Africa regions and the South East Asia/EastAsia/Central Asia regions.For unmarried adolescents (15 – 19), current contracep-tive use ranges from 21%-64%; for the married, the rangeis even wider, 6%-67%. Percentages having unmet needrange from 34%-67% for the unmarried and 7%-62% forthe married. Unmet need is higher for the  unmarried  than the married in six out of seven countries havingrelevant data. This is possibly because contraceptive ser- vices are directed towards married women.The lack of access to contraception leads to early un-wanted pregnancies with tragic consequences in LMIC.   An estimated 16 million adolescents (15 – 19) givebirth every year, 95% in LMIC. Complications frompregnancy and childbirth are the leading cause of death for women (15 – 19). Births to girls under age15 pose especially high health risks for mother andinfants [2].   Some adolescents with unintended and unwantedpregnancies choose abortion. Where access toabortion is legally or logistically restricted, most Table 1 Sexual activity, marriage, and childbirth foradolescents under age 15 and 18 reported by populationaged 20~24 in 16 developing countries 1,2,3 Region Under 15 Under 18M F FM FB M F FM FBSub-Saharan Africa Ghana, 2008 5 7 5 2 27 41 25 16Mali, 2006 4 26 25 10 27 73 71 46 Tanzania, 2010 6 15 7 3 40 58 37 28Zimbabwe, 2010-11 4 4 4 1 23 38 31 21 Middle East/North Africa Egypt, 2008 - - 2 1 - - 17 7Jordan, 2009 - - 1 0 - - 10 4Morocco, 2003-04 - - 3 1 - - 16 8Yemen, 1997 - - 14 4 - - 48 25 Asia/Central Asia Azerbaijan, 2006 1 1 1 0 22 12 12 4Bangladesh 2011 1 28 29 9 6 64 65 40Cambodia, 2010 0 1 2 0 4 15 18 7India, 2005-06 - 13 13 3 - 43 45 22 Latin America/Caribbean Brazil, 1996 33 10 4 2 75 43 24 16Dominican Republic, 2007 27 16 14 3 72 51 40 25Haiti, 2012 35 13 3 1 77 51 18 13Peru, 2012 - 7 3 1 - 43 19 15 1 Key:  % of   M ales (M) and  F emales (F) 20 – 24 years old reporting they hadintercourse by age group and % of   F emales who reported they were  M arried(FM) and/or gave  B irth (FB) by age group. 2 Source:  The most recent DHS for each country, ICF International, 1996 – 2012. 3  The symbol  ‘ - ’  indicates no data available. Chandra-Mouli  et al. Reproductive Health  2014,  11 :1 Page 2 of 8  abortions are unsafe [3]. Worldwide, adolescentsaged 15 – 19 had an estimated 3.2 million unsafeabortions in 2008. In summary, sexual activity and unmet need for con-traception, are common among adolescents with cleardifferences by age, sex, region and marital status. Be-cause married adolescents are often pressured to bearchildren, increasing access alone will be insufficient toensure contraceptive use. Unmarried adolescents have anunacknowledged and frequently unmeasured need forcontraception. All sexually active adolescents, regardlessof marital status, deserve to have their contraceptive needsacknowledged, measured, and responded to. Evidence of the barriers that adolescents face inobtaining and using contraception Two systematic reviews of qualitative research studiedbarriers to modern contraceptive use among adolescentsin LMIC [4,5]. One found seven studies that met the in- clusion and quality assessment criteria - six from sub-Saharan Africa and one from South-East Asia [4]. Thelarger review of sexual behaviour included 268 studies(121 were high quality or contained empirical data), of which only 54 were from LMIC (not all included dataon contraceptive use) [5]. In the end, the two reviewsretained only a small number of studies conducted ina few countries. Both reviews concluded that the bar-riers that adolescents face in obtaining and using Table 2 Current contraceptive use and unmet need for contraception for women aged 15 – 19 in 14 developingcountries 1,2,3 Region Unmarried, sexually active women 15-19 a Currently married women 15-19Current use Unmet need b Current use Unmet need b Sub-Saharan Africa Ghana, 2008 42 53 14 62Mali, 2006 21 63 8 35 Tanzania, 2010 40 48 15 16Zimbabwe, 2010-2011 24 64 36 19 Middle East/North Africa Egypt, 2008 - - 23 7Jordan, 2009 - - 27 8Morocco, 2003-04 - - 38 10 South East Asia/East Asia/Central Asia Azerbaijan, 2006 Too few Too few 6 16Bangladesh, 2011 Too few Too few 47 17Cambodia, 2010 Too few Too few 27 16India, 2005-06 - - 13 27 Latin America/Caribbean Dominican Republic, 2007 41 47 46 27Haiti, 2012 28 67 26 57Peru, 2012 64 34 67 19 a Including currently unmarried female adolescents that had sex in the past 3 months. b  The calculation of the unmet need for family planning is based on responses to 15 questions and was recently revised. See Bradley et. al for complete definition(Bradley S, Trevor EK, Croft N, Fishel JD, Westoff CF. Revising Unmet Need for Family Planning. DHS Analytical Studies No. 25. Calverton, Maryland, USA: ICFInternational; 2012. Available from:[12June2012].pdf ). 1 Key:  % among each category. 2 Source:  The most recent DHS for each country, ICF International, 2003 – 2012. 3 “  Too few ”  indicates too few cases to calculate estimate;  ‘ - ’ indicates no data available.Note: The criteria used within the Demographic and Health Surveys programme to identify women with unmet need for family planning have recently beenrevised (Bradley et al., 2012).Women are considered to have unmet need for spacing if they are: ã At risk of becoming pregnant, not using contraception, and either do not want to become pregnant within the next two years, or are unsure if or when theywant to become pregnant. ã Pregnant with a mistimed pregnancy. ã Postpartum amenorrheic for up to two years following a mistimed birth and not using contraception.Women are considered to have unmet need for limiting if they are: ã At risk of becoming pregnant, not using contraception, and want no (more) children. ã Pregnant with an unwanted pregnancy. ã Postpartum amenorrheic for up to two years following an unwanted birth and not using contraception. Chandra-Mouli  et al. Reproductive Health  2014,  11 :1 Page 3 of 8  contraception are common across developing country settings and cultures.One set of barriers is in obtaining contraceptive methods.Adolescents experience many of the same barriers thatadults do, but some are specific to them. In many poorcommunities of LMIC, contraceptives methods are notavailable to adults or to adolescents [6,7]. Even when contraceptive methods are available, laws and policies pre- vent their provision to unmarried adolescents or to thoseunder a certain age [6,7]. Even where there are no legal re- strictions, health workers in many places refuse to provideunmarried adolescents with contraceptive information andservices because they do not approve of premarital sexualactivity [6,7]. And when they do provide contraceptive methods, they often limit this to condoms, wrongly believ-ing that long acting hormonal methods and intrauterinedevices are inappropriate for nulliparous women. A re-cently published study of public, private not-for-profit andprivate for-profit providers in rural Uganda confirms thesebarriers and points to others such as sporadic contraceptivestocks, costs and unfriendly service provision [8].The second set of barriers is in using contraception. Evenwhen adolescents can obtain contraception, social pressuremay prevent their use. Firstly, in many places youngwomen are under pressure to conceive and bear childrensoon after marriage. Contraception is considered only aftera first child is born [6,7]. Secondly, the stigma surrounding contraception prevents their use by adolescents not instable relationships. Proposing the use of a condom or car-rying one can lead to a woman being considered  ‘ loose ’  inmany places [9]. Thirdly, in many places adolescents havemisconceptions about the immediate and long term sideeffects of contraceptive methods on their health and ontheir future ability to bear children. Because of the result-ing fears and concerns, adolescents often consider ineffect-ive methods such as withdrawal and traditional remediesmore acceptable [10]. Fourthly, because of poor under-standing of how contraceptives methods work and how they should be used, adolescents use them incorrectly as isillustrated by the following statement by a young SouthAfrican woman [11]:  “ I take a pill when I know my boy-friend is coming and we are probably going to makelove. I sometimes forgot to take it before we make loveso I take it after we made love. ”  Finally, consistent useof contraception has been shown to be problematicamong adolescents. An analysis of DHS data from 40countries revealed that in most countries adolescentsare more likely to discontinue method use than olderwomen [12]. Male condoms are the method most com-monly used by adolescents given that they are readily accessible and inexpensive [7]. However, consistent con-dom use tends to decrease over time within stable part-nerships for they are associated with being  ‘ unfaithful ’ or as  ‘ not trusting ’  [13]. Sporadic sex or infrequent sexis often cited as a reasons adolescents do not usemethods consistently.In summary, adolescents  –  especially unmarriedones  –  in LMIC, face a number of barriers in obtainingcontraception and in using them correctly and consistently.These barriers operate at three levels  –  the individual, theimmediate environment and the wider environment. Evidence on effective interventions to increaseadolescents ’  access to and use of contraception In 2011, WHO issued Guidelines on preventing early pregnancy and poor reproductive outcomes in adolescentsin developing countries [1]. These Guidelines were basedon reviews of published systematic reviews and of individ-ual studies, and the collective judgment of an expert panel.Increasing access to and use of contraception was one of the four outcomes to prevent early pregnancy. (The otherthree outcomes were preventing marriage before 18 years;increasing knowledge and understanding of the import-ance of pregnancy prevention; and preventing coercedsex). The studies that met the inclusion criteria for thisoutcome were conducted in a number of LMIC. Somefocused exclusively on condom use, while others looked athormonal contraceptives and emergency contraception(EC). Some examined the use of contraception as a pri-mary outcome while others examined it as secondary tooutcomes such as HIV prevention or changing knowledgeand attitudes. Some focused on health system actions(such as over-the-counter or clinic provision of contracep-tion) while others focused on actions directed at commu-nity leaders and members. Collectively, they demonstratedincreases in contraceptive use (including condoms, hormo-nal contraceptives and EC) as a result of actions directedat multiple levels  –  laws and policies; individuals, familiesand communities; and health systems. The interventionsdiscussed below are drawn from WHO ’ s Guidelines.The Appendix contains a list of reviews and studieswhich fed into the development of WHO ’ s Guidelineson preventing early pregnancy and poor reproductiveoutcomes in adolescents in developing countries. Overcoming restrictive laws and policies In many countries, laws and policies restrict the provisionof contraception to unmarried adolescents or those below a certain age. Policy makers must intervene to reformthese laws and policies to ensure that adolescents are ableto obtain contraceptive information, counselling and ser- vices. Policy makers should also consider providing ado-lescents contraception at no or reduced cost [1]. Making social and group norms supportive In many societies premarital sexual activity is not con-sidered acceptable, and there is considerable resistance tothe provision of contraceptive information and services to Chandra-Mouli  et al. Reproductive Health  2014,  11 :1 Page 4 of 8
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