Adolescent and Youth Reproductive Health Module: 8. Contraceptive Options for Young People

Study Session 8  Contraceptive Options for Young People

Introduction

The Family Planning Module covers the different methods of contraception. In this session you will learn about contraceptive options that are suitable for young people (remember that by young people we mean those aged 10–24). If a girl becomes pregnant when she is very young, it can be damaging to her physically and can also have bad social and economic consequences for her and her partner. You will help young people by counselling them on delaying pregnancy and childbearing and by providing appropriate contraceptive methods. Many young people avoid using contraceptives or discontinue using them either because they have misinformation about contraceptive methods or because they are worried by side effects. It is important to dispel misinformation about contraceptives and address the side effects of contraceptive use to ensure that young people choose a suitable method of contraception and continue to use it properly.

Learning Outcomes for Study Session 8

When you have studied this session, you should be able to:

8.1  Define and use correctly all of the key words printed in bold. (SAQs 8.1, 8.2, 8.3, 8.4 and 8.5)

8.2  Explain why it is important for young people to delay pregnancy and childbearing. (SAQ 8.1)

8.3  Identify and explain contraceptive methods appropriate for young people. (SAQs 8.2, 8.3, 8.4 and 8.5)

8.4  Review emergency contraception and its role in prevention of unwanted pregnancy. (SAQs 8.5 and 8.6)

8.1  Why it is important to delay pregnancy and childbearing

8.1.1  Health risks of early pregnancy

Pregnancy before the age of 18 has several health risks (Fig 8.1). Some of these health risks include:

Prolonged or obstructed labour: adolescents younger than 18 often have not reached physical maturity and when they become pregnant, their pelvises may be too narrow to accommodate the baby's head during delivery. In these cases, obstructed delivery and prolonged labour are more likely, thereby increasing the risk of haemorrhage (bleeding), infection and fistula.

Pre-eclampsia (hypertension in pregnancy) is common in adolescent pregnancy. If it is left uncontrolled, it can progress to extreme hypertension. This condition could lead to the death of both the young mother and the baby.

Premature birth and stil birth: infants born to adolescent mothers are more likely to be premature, of low birth weight, and to suffer consequences of retarded fetal growth. Stillbirth is more common among adolescent mothers than older mothers.

Figure 8.1  Health worker talking with a young married woman.

Pregnancy in adolescents, especially if they are unmarried, is almost always unwanted.

In addition to the health risks, early pregnancy has psychological, social and economic consequences for both girls and boys, some of which are presented below.

8.1.2  Psychological and other consequences of early pregnancy for girls

Figure 8.2  A young pregnant girl watches sadly as her friends go to school.

Some of the consequences are:

• Pregnancy often means the end of formal education for adolescents because they drop out of school when they become pregnant. (Figure 8.2)
• Adolescent pregnancy changes a girl’s choice of career, opportunities and future marriage. Mostly unmarried mothers resort to low-paying and risky jobs, domestic work, and even prostitution to support their children.
• Early marriage due to an unplanned pregnancy is frequently an unhappy, unstable one that leads to divorce. Both mother and child face the stigma of illegitimacy when marriage doesn’t take place or when divorce occurs.
• Young mothers are often ill-prepared to raise a child, which may lead to childrearing problems like child abuse or neglect.
• Girls resorting to prostitution due to early and unwanted pregnancy are at higher risk of gender-based violence, substance abuse, and STIs such as HIV.

8.1.3  Psychological and other consequences of early pregnancy for boys

Some of the consequences are:

• Some boys refuse to take responsibility for the pregnancy, which can contribute to hardship for the mother and child and also can lead to future regret.
• Boys who become fathers lose opportunities for education and future economic advancement. Those who marry leave school to support their new families.
• Young fathers are often ill-prepared to raise a child, which may lead to childrearing problems like child abuse or neglect.
• Premature marriages which occur because of early pregnancy are frequently unstable and end in divorce.

As you have seen, pregnancy in adolescence has several bad effects. For this reason, it is important to prevent pregnancy in adolescents or delay it until a couple is in a secure and loving relationship. (Figure 8.3)

Figure 8.3  Young couple discussing family planning after the birth of their first child.

In Section 8.2 you will learn which contraceptive methods are the most appropriate ones for young people.

8.2  Contraceptive methods for young people

8.2.1  Combined oral contraceptives (COCs)

COCs are appropriate and safe for young people. Many young people choose a COC because this method has a low failure rate and also offers relief from dysmenorrhea (pain during menstruation). It is a straightforward method that does not interfere with sexual intercourse. This is a good method for you to recommend when it is clearly appropriate for the girl; the particular COC you would suggest will depend on what is available. Some pills are more oestrogen-dominant and others are more progestin-dominant. A COC with more progestin is helpful for girls who have painful and excessive menstrual bleeding.

Failure rates are higher for young girls than for older women. This is because young girls often fail to take pills regularly. Failure to take pills regularly is often due to lack of knowledge about pill taking. You should encourage condom use in addition to COCs for STI/HIV protection.

You can help young girls figure out where to keep pills and how to remember to take them at the same time daily by linking pill taking to a routine activity that they do on daily basis. COCs are available in 21-day or 28-day packages (Figure 8.4). Most girls do better using the 28-day pill because it is easier to remember to take a pill every day rather than stopping for 7 days. Carefully discuss with them when they should start taking the pill so that you both are clear about when she begins taking the pills. This will make it easier to determine later whether the pills are being taken correctly.

Figure 8.4  Contraceptive pills.

The most important issue is to make sure that young girls understand the necessity of taking pills correctly. Using the knowledge you gained in the Family Planning Module, show the girl the pill packet and explain how to take the pills. Review with her the possible side effects of COCs to make sure that she understands side effects very well and will return to you if she has any problems.

8.2.2  Progestin-only pills (POPs)

POPs are appropriate and safe for young girls. But POPs must be taken daily at approximately the same time every day to be effective in preventing pregnancy, because the progestin levels in the blood peak about two hours after they are taken and then rapidly decline.

If a girl is three hours late taking the pill, she will not be protected and so she should use a back-up form of contraception. POPs may not be the best choice for young girls who cannot remember to take POPs at the same time every day.

POPs are a good choice for girls who cannot tolerate the oestrogen in COCs or have a medical contraindication to the use of COCs.

If it is necessary for a girl to switch from a COC to a POP, she should start taking the POP at the end of the active 21 COC tablets. Because POPs do not protect against STIs/HIV, you should encourage condom use in addition to POPs. Remember that this is known as dual protection.

8.2.3  Depo-Provera (DMPA) injectable contraceptive

DMPA (Figure 8.5) is a safe and appropriate method for young girls and is particularly good for those who might have difficulty remembering when to take oral contraceptives. Since it may be difficult for young people to remember to return at regular intervals it may be helpful to use a reminder system that encourages clients to return 12 weeks after the previous injection. This allows for a two-week grace period where the injection can still be given up to 14 weeks without fear of pregnancy. DMPA does not protect against STIs/HIV; therefore you should encourage condom use as well.

Figure 8.5  Syringe with needle and vial containing DMPA. Remember to shake the vial vigorously before drawing the liquid into the syringe.

8.2.4  Implants

Figure 8.6  An implant.

Implants (Figure 8.6) are safe and appropriate for young girls and can be safely used by those who are infected with HIV or have AIDS, or are on antiretroviral (ARV) therapy. However you should urge these women to use condoms with implants.

You see some of the reasons why young people like implants in Box 8.1 below.

You have learned how you can respond to misconceptions and rumours in the Family Planning Module. Do you remember what misunderstandings on implants exist?

Young people think that implants move to other parts of the body, stop menstrual bleeding, lead to pregnancy outside the uterus (ectopic pregnancy), and make the woman unable to become pregnant even if removed (Figure 8.7).

Figure 8.7  Women discussing using contraceptive implants.

Young girls often have misunderstandings concerning implants. You need to identify what specific misunderstandings they have during your discussion with them on contraceptives and correct them.

Remember it is important to provide information about side-effects, to correct misunderstandings and to give counselling before providing contraception (Figure 8.8).

Figure 8.8  A Health Extension Practitioner explaining different methods of contraception and giving counselling on their advantages and side-effects.

In Box 8.2 below, you see some of the points you can use to correct young people’s misunderstandings about implants.

Counselling is essential because young girls must be prepared for irregular bleeding and must make plans about how they and their partner will react to the irregular bleeding. You should counsel them very thoroughly on the potential side effects of implants, mainly the irregular bleeding.

If a young girl chooses to use implants, you should make sure that she will have access to services to remove the implant whenever necessary.

Remember, you should also encourage girls who choose to use implants to use condoms as well because implants do not protect against STIs/HIV.

8.2.5  Intra-uterine contraceptive devices (IUCDs)

IUCDs (Figure 8.9) are appropriate for adolescents in stable, mutually monogamous marriages. Women under the age of 20 who have not given birth appear to have greater risk of expulsion and painful menstruation (monthly periods). After you inform them of the characteristics of IUCDs and counsel them, if adolescents who are married would like to use this method, you should refer them to the nearest health centre for further counselling and service provision.

Figure 8.9  (a) An IUCD; note the strings for easy removal (b) shows the position of the IUCD within the uterus.

8.2.6  Condoms

Figure 8.10  (a) Femal condom (b) male condom.

Condoms (Figure 8.10) are safe and appropriate for young people. Because they are available without a prescription and provide protection against STIs/HIV, they are a good method. There are male and female condoms, as you have learned in the Family Planning Module.

Young girls frequently are not assertive about the use of condoms when their partner rejects the idea. You should give them ideas about how to negotiate condom use.

Young people often lack the skills to use condoms correctly. You need to develop their skills so that they will use them properly (Figure 8.11).

Figure 8.11  Men talking about condom use.

8.2.7  Other female barrier methods (spermicides, cervical caps, diaphragms)

These female barrier methods are appropriate methods for young people, but they do require a high level of motivation for correct and consistent use. Use is related to intercourse and some young people find this inconvenient or feel it interferes with sexual pleasure.

8.2.8  Lactational amenorrhea method (LAM)

Figure 8.12  Prevention of pregnancy through exclusive breastfeeding during the first six months after birth.

8.2.9  Female and male sterilisation

While there is no medical reason to deny sterilisation, it is generally not recommended for people at the beginning of their childbearing years. This is because if they decide to have sterilisation, in the future they may be sad about their decision. Once they undergo sterilisation they can have no more children-this is why it is called irreversible contraception. However, there may be mitigating circumstances, such as HIV or the presence of some genetic diseases, which means that a young person may wish to consider sterilisation. Therefore when you encounter a young person who wants to have sterilisation, you should refer them to a higher health facility where further counselling could be provided. Sterilisation does not provide protection against STIs/HIV.

8.2.10  Abstinence

Figure 8.13  A young couple discussing abstinence.

Abstinence is appropriate for young people who have not yet begun sexual activity, as well as those who are already sexually experienced. There may be emotional or social advantages to delaying sexual intercourse until they are older, more mature, or married (Figure 8.13). Abstinence provides protection against STIs and HIV/AIDS.

In the next section you will be able to review what you learned about emergency contraceptives in the Family Planning Module.

8.3  Review of emergency contraceptives (ECs)

In this section we would like you to review a few points about emergency contraceptives to remind yourself of its importance in preventing pregnancy.

Figure 8.14  Emergency contraception pills.

Emergency contraceptive pills (ECPs) (Figure 8.14) should be available to young girls who have unprotected sex. The earlier ECPs are taken after unprotected sex, the greater the chances are that they will be effective. ECPs can be provided in advance to young girls so that they could use whenever needed, but they should be counselled that ECPs are for emergency use only. ECPs do not provide protection against STIs/HIV.

8.3.1  Some counselling issues of ECPs

Figure 8.15  A Health Extension Practitioner counselling a girl on ECP.

You should consider the following important points when you counsel young people on ECPs. (Figure 8.15)

• Show her the pills and explain how to use them.
  • She should swallow the first dose as soon as convenient, but no later than 120 hours after having unprotected sex.
  • She should swallow the second dose 12 hours after the first dose. Important: if more than 120 hours have passed since she had unprotected sex, she should not use ECPs.
  • If she vomits within two hours of taking a dose, she should take two tablets as soon as possible. If the vomiting occurs after the first dose, she will still need to take a second dose 12 hours later (you can give her extra pills). To reduce nausea she should take the tablets after eating or before bed.
  • Instruct her not to take any extra ECPs unless vomiting occurs. More pills will not decrease the risk of pregnancy further.

Important: if more than 120 hours have passed since she had unprotected sex, she should not use ECPs. ECPs do not interrupt or abort an established pregnancy.

• ECPs should not be used as a regular contraceptive method. After use of the ECPs a regular method should be started or resumed if pregnancy is not desired.
• ECPs do not protect from STIs/HIV/AIDS.
• ECPs can be used at any time during the menstrual cycle and more than once during a cycle if necessary.
• Review what to expect after using ECPs. Women will not see any immediate signs showing whether the ECPs have worked. The menstrual period should come on time (or a few days early or late). Tell her that if her period is more than a week later than expected, or if she has any cause for concern, she should return to you.
• Instruct her to return to you when she has her period if she wishes to use a contraceptive method to prevent future pregnancies.

In Box 8.3 we have presented the EC regimen for your review. This will help you provide ECPs for young girls who are in need of ECPs when you have no pre-packed ECPs.

Summary of Study Session 8

In Study Session 8, you have learned that:

1. Pregnancy before the age of 18 year has several health risks, which include obstructed or prolonged labour, pre-eclampsia (hypertension in pregnancy), unsafe abortion and premature and stillbirth. It also has economic, social and psychological consequences for both girls and boys.
2. As pregnancy in adolescence has several bad effects, it is important that adolescents prevent or delay pregnancy through the appropriate use of contraceptive methods.
3. Contraceptive methods that are safe and appropriate for adolescents’ use include combined oral contraceptives, progestin-only pills, Depo-Provera (DMPA) injectable contraceptive, implants and condoms.
4. IUCDs are appropriate for young people when they are in a stable, mutually monogamous marriage.
5. The lactational amenorrhea method is appropriate for a young woman when the following three conditions are fulfilled: under six months postpartum, fully or nearly fully breastfeeding, and amenorrhaeic.
6. Abstinence is appropriate for young people who have not yet begun sexual activity, as well as those who are already sexually experienced. As abstinence provides protection against STIs and HIV/AIDS, it is good method for young people.
7. Emergency contraceptives should be available for young girls who have unprotected sex but must be used with in the first 120 hours (five days) following unprotected sexual intercourse.

Self-Assessment Questions (SAQs) for Study Session 8

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions below. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.