Targeting factors for change: contraceptive counselling and care of female adolescents

Figures & data

Figure 1. Birth and abortion rates per 1000 15–19-year olds [7,19] (Adapted from Apter et al. [18])

Figure 2. Percentage of women aged 20–24 years reporting first intercourse in their teenage years [7,19] (Adapted from Apter et al. [18])

Figure 3. Mapping the factors influencing pregnancy risk in adolescence.

Table 1. Regional barriers to accessing effective adolescent contraception identified by the CARE group.

	Barriers
Region	Macro (socioeconomic)	Intermediate (health care system)	Micro (sexual and reproductive health care consultation)
Asia Pacific	Feelings of shame amongst sexually active young women Family planning laws	Unfriendly service attitudes Lack of skilled counsellors Poor access Lack of education on sexuality, reproductive health and contraceptive options	Myths and misconceptions about methods Dislike of taking something every day
Latin America	Social unacceptability of contraception in this age group Lack of open discussion at home Intra-familial abuse and violence Religious/moral considerations	Lack of education on sexuality, reproductive health and contraceptive options	Myths and misconceptions about methods
North America	Lack of parental support Religious/moral considerations	Confidentiality Cost Lack of health care providers Lack of time available Lack of education on sexuality, reproductive health and contraceptive options	Perception amongst clinicians that pelvic exams are mandatory in young women Misconceptions around risks and benefits amongst providers Misconceptions around risks and benefits amongst adolescents
Europe	Religious/moral considerations Differing family dynamics (Northern vs Southern Europe) Differing values of the migrant population regarding the role of women Different laws regarding sexual and reproductive rights including abortion and contraception Inconsistent pricing and insurance coverage of contraceptive agents	Lack of education on sexuality, reproductive health and contraceptive options Variable access to family planning services and contraception	Myths and misconceptions about methods
Russia	Health care laws state that adolescents younger then 15 years must be accompanied by their parents during counselling Social resistance regarding the implementation of education programs in schools, even if State-approved Lack of insurance coverage for contraceptive agents	Lack of skilled counsellors Poor access Lack of education on sexuality, reproductive health and contraceptive options	Reluctance of gynaecologists to prescribe contraception Lack of knowledge amongst clinicians Myths and misconceptions about methods

Table 2. Examples of regional programs providing good contraceptive counselling and care in sexual and reproductive health (SRH).

Country	Programme
Finland	• Standalone contraceptive counselling units, combined with pregnancy care or via separate youth units
United States	• Planned Parenthood and other non-profit agencies  • Other initiatives via Title X clinics, Bedsider, ACOG, ARHP, school-based clinics (selected cities) and the Affordable Care for all Act
Canada	• National Contraception Awareness Program and Compassionate Contraception Program (administered by the Society of Obstetricians and Gynaecologists of Canada) • Task-sharing programs for contraceptive provision in certain regions of the country • Sexual Health Clinics run through regional Public Health Agencies • Planned Parenthood and other non-profit agencies • Action Canada for Sexual Health and Rights; includes Action Canada Access Line that provides 24-hour nationwide information on SRH and referrals on pregnancy options
Indonesia	Counselling only  • Program on Planned Generation for Adolescent and University Students: provided by National Family Planning (through the Centre for Information and Counselling for Adolescents and Students) • University of Indonesia (CEERMIC-UI): Program for Adolescent Reproductive Health (provided by the Centre of Excellence for Education and Research in Integrated Maternal and Infant Care) Contraceptive counselling mostly on abstinence and condom use • Ministry of Health Program for Adolescence Health Care (Pelayanan Kesehatan Peduli Remaja [PKPR]) introduced in 2003 and by February 2012, covered 90% of all regencies • Indonesian Planned Parenthood Association: Sahabat Remaja (Friend of Adolescent)
Korea	• Nationwide counselling centres offering on/off-line counselling and general non-contraceptive counselling: www.teen1318.or.kr; www.cyber1388.kr • Counselling in schools by health care teacher (school nurse)
China	• China Youth Reproductive Health Project Evaluation of Different SRH Education and Service Models among Vocational High School Students in Shanghai • You & Me centres: exploring the differences in services provided by in-school and out-of-school counsellors in terms of innovative projects and youth participation • Marie Stopes International China: SRH services and education to improve the health and wellbeing of young people • A Quasi-experimental Operations Research Project to Provide Life-skills-based Training and Youth-friendly Service on SRH among Unmarried Migrant Youth in Shanghai • Applications of QQ Robot in school-based sexuality education and services • The 100% Condom Use Program
Philippines	• Teen Mom Clinic: Program of the Maternal and Fetal Medicine Centre (University of the Philippines-Philippine General Hospital) for mothers aged <19 years (antenatal care and monitoring, public health lectures, counselling and education, family planning services) • Program for Young Parents (PYP): Program of the Vicente Sotto Memorial Medical Centre in collaboration with EngenderHealth • Philippine Society of Sexual and Reproductive Health Nurses: Non-profit professional organisation of nurses who are interested or trained to provide SRH nursing education and services to Filipino individuals, couples and families • NGOs such as Likhaan Centre for Women’s Health: Primary Health Care Clinics for Women, four of which are based in poor communities and cater to over 30,000 patients a year • NGOs such as Luzon Health and Mindanao Health (Integrated Maternal, Neonatal, Child Health and Nutrition/Family Planning Regional Project in Luzon and Mindanao): A five-year health service strengthening project (United States Agency for International Development) implemented by RTI International that works across multiple organisations
Brazil	• Programs for adolescents based at University Units and following recommendations of the Ministry of Health, the Brazilian Federation of Gynaecology and Obstetrics, and the Brazilian Association of Paediatrics recommendations
Colombia	• Friendly facilities offering personalised advisory services, specialised consultation, contraception advice, diagnostic lab work, sexuality education, and advice on feasibility of pregnancy termination. Examples can be found at: https://www.minsalud.gov.co and • http://www.minsalud.gov.co/Documentos%20y%20Publicaciones/servicios%20de%20salud%20amigables_ppt.pdf • http://www.profamilia.org.co/index.php?option=com_content&view=article&id =479%3Aprograma-para- jovenes&catid =80&Itemid =18http://www.profamilia.org
Russia	• Adolescent gynaecological services:   – available in children’s outpatient departments (for ≤18 year old girls only) in cities, providing well-trained consultants free of charge (by appointment) – provided by general gynaecological outpatient departments In small cities and villages – Youth-friendly drop-in clinics: established mainly in large cities, combines counselling and teaching; staffed by gynaecologists and psychologists. More information at http://www.juventa-spb.info/page/33/ • Non-state institutions such as the Regional Centre of Social Education and Health (in Khabarovsk) address all areas of adolescent care (education, medical, rehabilitation) • Youth-friendly clinic websites provide online counselling (http://teen-info.ru/main/ • Hotlines: all youth-friendly clinics have a contraceptive counselling 24-h telephone service for adolescents

Table 3. Some of the common myths amongst women and health care professionals around the prescribing or use of methods of contraception.[86,88,89,101–104]

Method	Myths or misperceptions amongst women (not evidence-based)	Myths or misperceptions amongst HCPs (not evidence-based)
Combined oral contraceptives	They can cause weight gain	They should be stopped in women aged over 35 years
	They require a pelvic examination prior to initiation	They should not be used by women <35 years who smoke
	They are no more effective than a condom	They can’t be initiated until a woman starts her next period
	They require you to take a ‘pill’ break every two years	They require you to take a ‘pill’ break every two years
	They affect future fertility
Intrauterine contraception	It can only be used in women who have had children previously	They are unsuitable and/or unacceptable for nulliparous women
	It requires a major operation for placement	They are more difficult to place in nulliparous women
	It means you cannot use tampons
Depot injections	They have long-term negative effects that can last the rest of a woman’s life	They should not be used in adolescents
	They can cause infertility
Condoms	They can be used with any lubricant, including petroleum jelly
The vaginal ring	It has to be inserted by a health care provider every month

Figure 4. The GATHER approach to counselling about contraception (Adapted from Rinehart et al. [91])

Figure 5. SOS! mobile version: smartphone tools to aid compliance with contraceptive methods.[98]

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