How to help adolescents choose the right contraceptive

INTRODUCTION

Adolescence, the transition period between childhood and adulthood, is a unique time when young people question, explore, and experiment in all aspects of life, including dietary habits, personal relationships, substance use, and sexual activity. In the United States, an estimated 55% of male and female teenagers have had sexual intercourse by age 18, according to a 2017 report by the CDC’s National Center for Health Statistics.¹

Although adolescent pregnancy rates have been on a decline since their peak in the 1990s, the current rate in the United States, 15.4 per 1000 females aged 15 to 19 years, is the highest among developed countries.² Compared with the United States, Europe has a much lower adolescent pregnancy rate despite having a similar rate of sexual activity. This can be attributed to Europeans’ wider access to sexual health education and contraception.³

The higher rate of adolescent pregnancies in the United States also may be partially due to the lower rate of long-acting reversible contraceptives (LARCs) use in this population. Data have shown that LARCs such as the intrauterine device have higher efficacy, continuation rates, and satisfaction compared with short-acting contraceptives such as oral contraceptive pills (OCPs). Though they are an excellent choice for adolescents, in the United States, only 4.3% of adolescent females who are using contraceptives choose a LARC.³

Although contraceptive use at first intercourse has increased over the years, between 2011 and 2015, condoms remained the most popular pregnancy prevention method among teenagers (97%), followed by withdrawal (60%) and birth control pills (56%).¹ Despite these data, many adolescents still do not use any method of contraception at first intercourse and show irregular subsequent use.^1,4

Improving adolescent-centered counseling and care

Counseling is an intimate and interactive process between the patient and the health care provider. Counseling for adolescents differs from that for adults and requires an individualized approach, accounting for cognitive development, peer influence, familial influence, and media exposure that may contribute to personal preferences.

Motivational interviewing is a counseling technique used to encourage patients to adopt new, healthy habits. This strategy uses open-ended questions to identify the gap between current actions and desired behaviors. Motivational interviewing in sexual and contraceptive counseling allows for an open discussion about the patient’s long-term goals and accessible contraceptive options, which facilitates the decision-making process.

When discussing contraception with adolescents, it is crucial to focus on building trust and confidence. Creating a safe and nonjudgmental space ensures that adolescents feel supported and comfortable expressing their thoughts and concerns. The Contraceptive CHOICE project, a retrospective cohort study done in St. Louis, Missouri in 2006 included contraceptive counseling that started with warmly greeting the patient, having a judgment-free demeanor, and using open-ended questions to get more insight into the normal life of the teen. After building rapport, the discussion of contraception would begin.⁵

The GATHER strategy is a type of motivational interviewing technique that emphasizes informed decision-making and has been studied in the setting of contraceptive counseling. The key elements of the GATHER strategy are described in Figure 1.⁶

Active listening and validation

Active listening and validation play a significant role in fostering trust. Actively listening to adolescents’ thoughts, questions, and concerns goes a long way in establishing trust and rapport between the health care provider and the adolescent. Addressing cultural and religious beliefs is also important. Finding ways to bridge potential gaps by providing information that aligns with their cultural or religious perspectives is invaluable.

The 5 P’s

The CDC recommends obtaining a sexual history that covers the 5 P’s: partners, practices, protection from sexually transmitted diseases, past history of sexually transmitted infections (STIs), and prevention of pregnancy (Figure 2). The information obtained with this technique allows the provider to assess the patient’s risk level and subsequently develop a contraceptive strategy that caters to the individual’s needs.³

Determining understanding

Next, it is important to determine the patient’s understanding in order to effectively counsel them. Start by asking the patient what they already know about contraception and sexual health. Using age-appropriate language, models, and videos is useful for explaining contraceptive options and their associated adverse effects.

Providing accurate and comprehensive information is vital. Providers should always offer evidence-based and reliable information about contraception while addressing common myths and misconceptions (Figure 2). Questions should be encouraged, and understanding should be ensured using the “teach back” method.

Follow-up and ongoing support

Follow-up and ongoing support are essential to sustain trust and confidence. Adolescents should be made aware that they can reach out for further questions or concerns even after the initial conversation. Offering resources such as websites, educational materials, or support groups provides ongoing support and access to reliable information.

Teenagers should never be coerced into using contraception or a specific method of contraception. Provider biases regarding adolescents and contraceptives can pose a hindrance to care. Adolescents are eligible for the full range of contraceptives regardless of age, relationship, or marital or childbearing status. In the absence of medical contraindications, adolescents should receive thorough information on each method and its potential adverse effects. Providers must also address and debunk myths and misconceptions about contraceptives such as infertility, acne, and weight gain.

Furthermore, when providing care to younger patients, it is essential to reassure them that they have the autonomy to decide which contraceptive method best suits their body. If obstetrician-gynecologists do not believe they can provide the reproductive care their patients desire, they have a responsibility to promptly refer those patients to other health care professionals. See Figure 3

SDGs, Targets, and Indicators

SDGs Addressed:

• SDG 3: Good Health and Well-being
• SDG 4: Quality Education
• SDG 5: Gender Equality
• SDG 10: Reduced Inequalities
• SDG 17: Partnerships for the Goals

Targets Identified:

1. Target 3.7: By 2030, ensure universal access to sexual and reproductive healthcare services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs.
2. Target 4.7: By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including through education for sustainable development and sustainable lifestyles, human rights, gender equality, promotion of a culture of peace and non-violence, global citizenship, and appreciation of cultural diversity and of culture’s contribution to sustainable development.
3. Target 5.6: Ensure universal access to sexual and reproductive healthcare services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs.
4. Target 10.2: By 2030, empower and promote the social, economic, and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status.
5. Target 17.17: Encourage and promote effective public, public-private, and civil society partnerships, building on the experience and resourcing strategies of partnerships.

Indicators:

• Indicator 3.7.1: Proportion of women of reproductive age (aged 15-49 years) who have their need for family planning satisfied with modern methods
• Indicator 4.7.1: Extent to which (i) global citizenship education and (ii) education for sustainable development are mainstreamed in (a) national education policies; (b) curricula; (c) teacher education; and (d) student assessment
• Indicator 5.6.1: Proportion of women aged 15-49 years who make their own informed decisions regarding sexual relations, contraceptive use, and reproductive healthcare
• Indicator 10.2.1: Proportion of people living below 50 percent of median income, by age, sex, and persons with disabilities
• Indicator 17.17.1: Amount of United States dollars committed to public-private and civil society partnerships

Table: SDGs, Targets, and Indicators

Note: The specific information from the article supports the identification of these SDGs, targets, and indicators. The article discusses the need for universal access to sexual and reproductive healthcare services, education for sustainable development, gender equality in decision-making, social inclusion, and partnerships for addressing barriers to contraceptive use among adolescents.

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Source: contemporaryobgyn.net

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