Family planning and adolescent pregnancy

Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 209–222

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Family planning and adolescent pregnancy Ramiro Cartes Molina, MD, MPH, Ob-Gyn, FACOG, Professor *, Carolina Gonzalez Roca, MD, Ob-Gyn, IFEPAG Fellow, Instructor, Jorge Sandoval Zamorano, MD, Ob.-Gyn, IFEPAG Fellow, Associate Professor, Electra Gonzales Araya, SW, MSc, Assistant Professor Centro Medicina Reproductiva de la Adolescencia Faculty of Medicine, University of Chile, Luis Thayer Ojeda 15 25 Apart 701, Providencia, Santiago 7510556, Chile

Keywords: adolescent fecundity pregnancy prevention adolescent contraception

High adolescent fecundity principally affects developing countries. In spite of a decrease in the incidence of pregnancies in the developing countries over the past 13 years, the differences that exist with respect to developed countries turn adolescent fecundity into an indicator of the level of development of countries. The impact of adolescent pregnancy is evident in maternal and perinatal morbidity and mortality. Nonetheless, in addition to the age involved in precocious pregnancy, it also reflects previous conditions such as malnutrition, infectious diseases and deficiencies in the health care given to pregnant adolescents. The most important impact lies in the psychosocial area: it contributes to a loss of selfesteem, a destruction of life projects and the maintenance of the circle of poverty. This affects both adolescent mothers and fathers; the latter have been studied very little. Intervention with comprehensive health services and the maintenance of the education of adolescent mothers and fathers prevents repeat pregnancies. Evidence shows success in the prevention of the first pregnancy when the intervention includes comprehensive sexual education, the existence of preferential sexual and reproductive health services for adolescents, the handout of modern contraceptives gauged to the adolescence stage of the subjects and the existence of an information network. There is little research in contraception for adolescents, and for this reason, the indications given are projections of data obtained from adults. Ó 2009 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ56 2 9786484, 56 2 2235759; fax: 56 2 7356512. E-mail address: [email protected] (R.C. Molina). 1521-6934/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.bpobgyn.2009.09.008

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Introduction Family planning is a set of actions that are put at the disposal of human beings to use the fundamental human right to have the number of children they desire and establish the intergenesic intervals between them and the timing of their birth in the course of their reproductive life. This concept implies informed and aware decisions on the part of the couples that make up a family or are forming a family in accordance with the culture in which they live and develop. These concepts, which are very well known and have been extensively analysed, are decontextualised when it comes to adolescents, with the exception of those societies in which precocious marriage is part of their culture. A more adequate term would be adolescent contraception to prevent a first pregnancy and repeat pregnancies. By definition, adolescent pregnancy is pregnancy in females between the ages of 10 and 19, as this is the age group defined as adolescence. Nonetheless, bio-demographic information expresses adolescent fecundity as occurring between the ages of 15 and 19 years. Pregnancy in females under 15 years of age is extremely severe in every aspect and requires very complex and long-term solutions. The term precocious primigravida, which was so popular in the world of obstetrics up to the 1980s in the past century, was replaced by the concept of pregnant adolescent as a consequence of evidence of negative maternal and perinatal results and the deficiencies in prenatal care and treatment for females under 19 years of age. The two most important periods in human growth and development are the foetal period and adolescence. From this point of view, antenatal and prenatal care of pregnant adolescents should be provided by comprehensive and preferential attention programmes. The most severe effects of adolescent pregnancies are the social impacts that affect education, work and the social organisation of the family, which are a factor of poverty. Adolescent contraception and pregnancy are mainly treated as a female issue. Nonetheless, an indispensable consideration of the concept of sexual and reproductive health in adolescence is the permanent inclusion of both genders. This consideration is indispensable in the application of strategies for the prevention of adolescent pregnancy, of which adolescent contraception is a single aspect of these strategies. Magnitude of the problem and analysis of the international situation On the basis of information provided by UNFPA in a study that compared 1995 with 2008, fecundity rates between the ages of 15 and 19 have fallen in the last 13 years. Reduction rates are higher in the less developed countries.1 Adolescent Fecundity rates have fallen in all the Regions, with higher proportions in North America and Europe. Latin America and the Caribbean is the region with lower reduction rates as can be seen in Figures 1 and 2. Table 1 compares adolesent fecundity and avaliablity of contraceptives. The information is analysed according to regions, owing to their different cultural realities. The 10 countries with the higher fecundity rates between 15 and 19 years of age have been recorded, as have those with the lower rates. A summary is given of the average use of contraceptives in each five-country subgroup. In regions with less than 20 countries, each country in the region is tabulated, as shown in Table 1. In Africa, the countries with the lower adolescent fecundity rates have a higher prevalence of use of contraceptives (4 and 5 times more). Similarly, the five countries with the lower fecundity rates have a difference of more than 10 points with their counterparts that have fecundity rates of over 39 per 1000. The Latin American and Caribbean region has a somewhat similar profile, with the exception of the five countries with lower adolescent fecundity rates, evincing a lower frequency in use of contraceptives. This can be influenced by the fact that the region has a concentration of countries with very similar rates of fecundity and others with exceptionally low contraceptive use rates such as Haiti and Trinidad and Tobago. It is also a fact that clandestine abortions in these two countries is a factor that is very difficult to weigh in terms of adolescent fecundity. In Asia, there is a very close relationship between lower adolescent fecundity rates and greater use of contraceptives, with the exception of the five countries with lower rates ranging from 42 to 71 per 1000.

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140

140

1995 2008 Difference

120 100

116

80 60

60

65 53

40

32

20 0

211

-7

57

23 -9

-8

-20

-24

-40 World

More developed Regions

Less developed Regions

Less developed Countries

Fig. 1. Births per 1,000 women aged 15–19.

Europe has the lowest rates of adolescent fecundity and the highest prevalence of contraceptive use. In this region, the influence of legalised abortion is an important factor in adolescent fecundity. North America gives similar rates of contraceptive use but very different fecundity rates. It is probable that this has been affected by political and structural factors in the area of attention to adolescents, sex education at school and co-ordination with the health sector. In Oceania, the relationships between both variables are extremely clear in the four countries analysed. The region of former USSR countries shows that the countries with fecundity rates below 29 have only 6 more points in terms of prevalence of use. It is quite possible that the legalisation of abortion in this region explains the low fecundity rates among adolescents. Finally, the highest rate of adolescent fecundity (222 per 1000) is seen in the Democratic Republic of the Congo in Africa, with 21% of prevalence of use; the lowest is seen in the Democratic People’s Republic of Korea (1 per 1000), with 69% of prevalence of the use of contraceptives. Until a decade ago, infant mortality was an excellent health indicator that reflected the levels of poverty or development of countries. Nonetheless, the introduction of better health care, immunisations, modern medicine with a wider scope of action and the improvement of nutrition patterns in various developing countries have had a very important impact on infant mortality. Adolescent fecundity has become the most exact bio-demographic and health indicator of development levels in many countries. On comparing five countries of the Latin American and Caribbean region with the six developed countries with lower Infant Mortality rates in 2008 and their evolution since 1995, there is a 10-point difference between Sweden and Uruguay, a 2-point difference with Cuba and 4 points with Chile. These differences do not reflect differences in development. Nonetheless, when comparing the adolescent fecundity rates between Sweden and Uruguay, there is a difference of 56 points, 42 with Cuba and 55 with Chile. This can be seen in Figures 3 and 4. Adolescent fecundity gives an almost unequivocal reflection of the differences between developed and developing countries. This reflection also means that the solution is not circumscribed to contraception in adolescents, but that there are many actions to be taken that affect adolescent fecundity apart from poverty and underdevelopment. The impact of pregnancy on adolescents Morbidity in Adolescence In adolescence, the principal causes of disease and risk are related to their own lifestyles.2 The following can be described as the most important health-related problems linked to adolescent health.3

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Table 1 Higher and Lower adolescent fecundity and prevalence of contraceptive use by Regions and Countries. Reg/Count

Higher Adoles.Fecund.Rate Fecundity Rate

Contr.Use Prevalence

222 219 196 189 179 164 160 152 149 149

21 6 11 11.2 10 8 3 5 24 11.6 9 17

Latin America & Caribbean Nicaragua 113 Dominican Republic 108 Guatemala Honduras Venezuela Brazil Panama El Salvador Ecuador Jamaica

Africa Congo R.D Liberia Niger Guinea-Bissau Mali Chad Sierra Leone Uganda Guinea Mozambique

Asia Bangladesh Nepal Afghanistan Lao People’s D.R. India Palestinian occupied Territory Yemen Timor-Leste R.D. Philippines Cambodia

     

Lower Adoles.Fecund.Rate Fecundity Rate

Contr.Use Prevalence

Africa Burundi Botswana Mauritius Rwanda Egypt Swaziland Morocco Tunisia Algeria Libyan Arab Jamahiriya

55 52 41 40 39 33 19 7 7 3

20 44 76 43.2 17 59 46 63 63 55.6 61 45

72 61

Latin America & Caribbean Costa Rica Colombia

71 65

80 78

107 93 90 89 83 81 83 78

43 62.2 65 70 77 – 67 71.5 73 69

Mexico Uruguay Chile Peru Argentina Cuba Haiti Trinidad &Tobago

65 61 60 60 57 47 46 35

71 74.0 77 64 71 65 73 55.8 32 38

125 115 113 72 62 79

58 48 19 42.6 32 56 50

Asia Israel Malaysia Kuwait Oman China Singapore

14 13 13 10 8 5

68 55 52 57.2 24 87 62

71 54 47 42

23 10 34.8 51 40

Hong Kong Corea Rep of Japan Corea Dem. Rep.

5 4 3 1

84 81 70.0 54 69

9 9 9 9 8 7 7 7 6 6

77 66 76 72.6 70 74 74 78 71 72.2 78 60

Europa Bulgaria Romania Serbia United Kingdom Estonia Macedonia Slovakia Bosnia& Herzegovina Hungary Lithuania

Reg/Count

Europe 40 32 25 24 21 21 20 20 19 19

42 70 41 61.4 84 70 14 24 36 39.6 77 47

Finland Spain Greece Germany Norway Slovenia Belgium France Denmark Italy

Endemic diseases (for example, tuberculosis and malaria) Malnutrition and micronutrient deficiency Wounds resulting from violence and accidents Mental health problems Problems related to substance consumption Problems related to sexual and reproductive health Social and health problems triggered by early pregnancies

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136 EUROPE NORTH AMERICA AFRICA ASIA LAT.AM.&CAR. OCEANIA

120 104

100 80

79

76

60

60

45

40 20

213

40

40

28

27

27 18

0

-3,8-3,6 -11,1 -23,5

-20

-33,3 -33,3

-40 1995

2008

DIFFERENCE

Fig. 2. Adolescent fecundity rates 1995–2008 per 1000 women aged 15–19 years by regions.

Sexually transmitted diseases, including HIV/AIDS Aggressive traditional practices (for example, mutilation of female genitals) Sexual coercion

Morbidity in the Pregnant Adolescent Abortion Unsafe abortions are among the principal causes of death or of invalidating sequelae that harm the reproductive future of adolescent girls. Information gathered in 2002 showed that of the total number of abortions recorded, 14% corresponded to adolescents of 15–19 years of age in developed countries; 26% corresponded to Africa, 8% to Asia and 15% to Latin America and the Caribbean.4 There are only estimations of the number of illegal abortions. The most frequent hospital discharges for complications triggered by illegal abortions correspond to women of the low-income socioeconomic bracket, and this might be biased by a lack of knowledge of the behaviour of illegal abortions among women of wealthier sectors, which are associated with professionally performed clandestine abortions.5,6 A study revealed that the abortion rate increases progressively after the age of 24. The lower rates were found among women of 19 or under, and the higher risks of clandestine abortions in adolescents are described in Table 2.7

20 10 0 -10 -20 -30 -40 -50 -60

1617 14 11 12 5 5 7 6 6 67

57

1213 10 6 344455

Cuba Chile Costa Rica Trinidad&Tobago Uruguay Sweden Finland France Germany Canada U.K. USA

Infant Mortality 1995

Infant Mortality 2008

-17

-14 -17-17

-20

-25-24 -33 -40

-43

-50 -55

% Decreasing

Fig. 3. Infant Mortality Rates in Selected Countries Fecundity Rates of 15–19 years old in 1995 and 2008(*).

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100 80 60

93

Costa Rica Trinidad&Tobago Cuba Chile Uruguay Sweden France Finland Germany Canada U.K USA

92

60

56

64

60

40

60 61

35

33 27

20

13

9

13 13

0

42

39

27

24 9 9 5 7

15

-20

7

-24

-40

2

-22 -31-31

-42 -49

-60

-27 -34

-44

-66

-80 Fec Rate 1995

Fec Rate 2008

% Decreasing

Fig. 4. Fecundity Rates of 15–19 years old in 1995 and 2008(*) Selected Countries 1995–2008(*).

In 1996, it was estimated that approximately 80% of North American pregnancies between ages 15 and 19 were not planned, and that 43% of these unwanted pregnancies ended in abortion.7 One of every five women who have an abortion have serious infections, and some 15–20% of adolescents of between 15 and 19 years of age that are hospitalised have reached the hospital for abortion-related complications. The prevalence of adolescent abortions in Canada and the USA is of approximately 20% of the total abortion rate; in Cuba, it is slightly higher, with 25–26%. In Chile – which penalises abortion regardless of cause – hospital leaves for abortion-related complications in women under 19 is 10% and the figure rises to 20% in women under 24. Maternal Mortality and Morbidity and Perinatal Mortality and Services for Pregnant Adolescents When compared with women of over the age of 20, the risk of dying owing to a pregnancy- related cause is twice as frequent in girls of 15–19 years and 5 times greater in girls of 10–14 years. This possibility grows by fivefold when pregnant women of under 15 years of age are compared with those of over 20.8,9 The evolution of maternal, perinatal and infant mortality rates in adolescents must be observed over prolonged periods of time, because their annual variations are affected by the low number of deaths that do not allow for an in-depth analysis. A 10-year observation found that the odd ratios were higher than 1 in all indicators, but were only significant in neonatal and infant death, low weight at birth and the occurrence of an adolescent parent.10 The 2004 World Health Organization (WHO) report establishes that during pregnancy there is no evidence of increased blood pressure in adolescents when compared with adult rates. Anaemia is more frequent owing to nutritional factors and to the presence of parasites, especially in developing countries. A greater iodine deficiency is also described, especially in those countries that do not have iodine supplements in food. There is an increase of premature birth, which endangers the prognosis of the newborn child.11,12 Table 2 Predictive Risk Factors associated to clandestine provoked abortion in adolescents (Chile,1997). Predictive Risk factors

RR

p

First Intercourse at 12–14 years old First Intercourse at 13 and 15 ears old Primary School only Age at 2nd pregnancy 13 and 18 Low worker or domestic service Very low quality home environment Unemployment No religion

5,68 4,25 2,92 2,70 2,27 2,19 2,19 2,10

0.001 0.001 0.005 0.01 0.01 0.05 0.05 0.05

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The younger the adolescent, the higher the risk. There is enough evidence on the positive impact on maternal and perinatal health in the presence of integral attention services for pregnant adolescents that not only cover prenatal check-ups, but also cover their health, mental health, social and family requirements. Similarly, differentiated treatment according to levels of complexity and predictive risk factors contribute to a better effect on maternal and perinatal morbidity in pregnant adolescents.13–16 Psychosocial and Family Impacts A year after giving birth, only 11% of pregnant mothers continue with their studies. In 40% of homes with a female head of the household, she was an adolescent mother. As much as 42% of the couples of adolescent mothers are adolescents. A bleak environment is created, increasing the adolescent mother’s desertion of her child. In general, adolescents have no health insurance or social security and therefore have no rights to prenatal and postnatal social guarantees. Illnesses in newborns and in infants are more frequent, as are accidents at home. As much as 60% have a repeat pregnancy before 2 years, and generally by another father. There is a higher prevalence of sexually transmitted diseases and AIDS. It is more probable for the children of adolescent mothers to have lower school performance levels; they are also exposed to a greater risk of abuse and abandonment, and of becoming involved in criminal activities when adolescents or young adults, and have fewer probabilities of becoming socially and economically successful adults. Daughters of adolescent mothers have higher possibilities of becoming adolescent mothers themselves.17 Adolescent Paternity The forgotten males generally do not receive the treatment given to the mother and her child in social or health services. The relative risk of the progenitor of the child of an adolescent mother being another adolescent reached an OR of 135 and was significant in the above-mentioned study.10 There is a very negative perception of adolescent fathers. However, adolescent fathers can be extremely affected by paternity, even in those cases in which they try to evade their responsibility. They face a future that includes depending on their parents, being badly paid and badly qualified jobs. Adolescent fathers as a group are difficult to reach and are not incorporated into the medical and social attention offered to mothers and their children. Adolescent males can have a positive or negative influence on their young couple in the decision of using contraceptives.18–21 The child of an adolescent mother The study carried out in Chile, at the Centre for Reproductive Medicine, with PAHO/WHO support, obtained results that confirmed the findings of longer-term studies.22–24 The baby reaches its term in a unwelcome atmosphere with family problems that do not contribute to its general development. This is why child attention programmes consider that the children of adolescent mothers are high-risk children. In the areas of cognitive development and educational performance,,children at the age of 7 have showed lower reading skills as well as learning, behaviour and self-control problems. Apart from their mothers, these children tend to be brought up by their grandparents and relations, with frequent changes in caregivers owing to migration and displacement of the adolescent mother. On many occasions, the child is legally unprotected with serious problems regarding legal identity. The mother–child relationship or link is deteriorated in the first years of the child’s life, especially because the mother is still immature and is undergoing a period of development. A child morbidity study showed that of 25% of accidents which required hospitalisation, the most frequent were burns and fractures. The situation becomes more serious still in the case of raped adolescent mothers, and especially when the cause is an inter-family affair.25,26 Preventing adolescent pregnancy Age and previous fecundity in adolescence is extremely important when it comes to giving a method of contraception. From this point of view, the adolescents that request contraception are

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classified into three groups according to conflictive age, sexual behaviour, the type of relationship established with the partner and fertility. Table 3 summarises the most important findings at the Adolescent Centre for Sexual and Reproductive Health (CEMERA) in adolescents that request the prevention of a first pregnancy, of a second or of successive pregnancies.27 The group of adolescents without experience in a previous pregnancy is the most complex to treat in terms of contraception.Table 3 Organisation for pregnancy prevention in adolescents There are few places to which adolescents can go to ask for help and orientation on sexuality and reproduction issues. The requirements to set up and successfully operate an attention system specialising in the prevention of pregnancy, STD and AIDS are28,29: Services available for youngsters This means the existence of a service for youngsters. If facilities that treat adults and children are used, they can be adapted and used on different schedules and days. Information regarding availability of the services should be made available to schools, organised community groups giving details of timetables, requirements and costs. An adequate location that is easily accessible and not exposed to unnecessary public attention The installations should be in a place that is easy to reach, but offers the confidentiality required. Confidential Attention This means privacy regarding the information they require, interview, physical examination, medical record and information that might eventually be requested by adults. The confidentiality and medical secret with a child and adolescent is the bioethical basis of our professional practise, recognised as such by all legislations.30 Red-tape-free reception and entry The person in charge should be specially trained for this and must learn to listen. Effective service The service should be provided speedily and satisfactorily, almost immediately after it has been requested. An adolescent with unsatisfied demands never returns. Free or basic cost If the service is private, the charge, albeit symbolic, will teach the adolescent that it is a service that has been requested and s/he is responsible. Mature and positive attitude on the part of the team An underage individual should receive the same respect as an adult. Personalised, friendly and positive service This does not mean paternalism or overprotective attitudes. Election of the method Everything possible should be done to make the adolescent and partner take part in the choice according to the characteristics of the sexual activity involved. Give careful instructions on the first visit The first visit requires a complete clinical history with full details of psychosexual and endocrine development. Written technical standards These are necessary so that the team fulfils the basic objectives and shares criteria regarding the prescription and control of contraceptives. Awareness and review of legal aspects Experience has shown that these centres are not enough. It is imperative to develop school sexual education programmes and counselling at school, together with co-ordinated activities between the school and the adolescent health centre.17 Description of current contraceptive methods and their use in adolescents Periodic Abstinence Calendar Rhythm or KNAUSS–OGINO Method This is a retrospective method. In the clinical experience of CEMERA, and important quantity of pregnant adolescents had used this method before to be pregnant. There are no published experiences in nulligest adolescents and only one experience was found with adolescent mothers of 14–19 years of age.31,32

Table 3 Adolescent Characteristic by previous fecundity as criteria to perform contraception. Characteristics of an adolescent to initiate a MAC Age: under 16

Sexual Behaviour

Type of relationship

Unproved Fertility

Woman with NO previous pregnancy Male with no experience as an impregnator. Nulligests MOST CONFLICTIVE GROUP FOR USE OF CONTRACEPTIVES

It is easier to find young or intermediate age adolescents. Trend to terminate use of MAC Owing to end of relationship Increased puberal development but within normal ranges. Special risk with partner of 18 years or more

Initial with sporadic sex over the weekends. Avid desire to experiment with different sex relations, including practices that might lead to STD. Relationships that are marked by immaturity.

Still has not experienced pregnancy Concern for fertility, as has had a sexual experience without a pregnancy. Greater difficulty in the prevention,detection and treatment of STD and AIDS as there is an issue of dependency and no health system coverage.

PREGNANT woman but has suffered a spontaneous or provoked abortion. She is nulliparous. Progenitor has no experience as a parent GROUP WITH NO RESTRICTION IN THE USE OF CONTRACEPTIV Mother who has borne a child Father who is a father. She is a Primipara or Multipara GROUP HAS NO RESTRICTIONS IN THE USE OF CONTRACEPTIVES. THE SAME STANDARDS ARE APPLIED AS WITH ADULT

Less frequent in early Adolescence. for the Use of contraceptives. In the case of early adolescence, the same risks prevail. The male tends to repeat his non acknowledged parenthood. Not frequently an early adolescent. But there is a high risk of repeating pregnancy with another partner. 60% repeat pregnancy before 2 years. CEMERA

Associated with a more constant sexuality. When this does not occur, it is associated with mental health problems

Initial, weak or very weak There is a search for an idealised relationship. Short periods of relationship and Frequent change of partner. Associated with family problems, Especially with precocious adolescents. Resistance to the use of condoms More stable couple. More maturity in the relationship. Early adolescents show no Maturity as a couple.

partner. 60-70% continues with the parent of her child. Parents take on a protective Attitude with grandchild. Male who accepts paternity Accepts contraception.

Proven fertility in the Female and the male.

They tend to stabilise Their relationship as a couple but live apart. Moderate sexuality in the first year after giving birth. Then, if there is no stable partner, sexuality is taken up again just before pregnancy. Male who does not admit paternity tends to repeat it.

Fertility has been proven. There are still doubts regarding fecundity in spontaneous abortion. Health coverage has not changed

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Previous Fecundity

217

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Base temperature and syntothermic method The complexity of this method does not make it recommendable for adolescents. Cervical mucus or billings method This is a way of life rather than a contraceptive method, and should be used in stable couples. A study of the total users of the periodic abstinence methods showed that 8.1% were between 15 and 24 years, with significantly high rates of failure.33 Vaginal and barrier methods Coitus Interruptus It is amply used with very bad results in the first sexual relations because of imperfect ejaculatory control. As much as 27% of unexpected pregnancies are described with the habitual use of this method and 4% in the perfect use. Of the total of unwanted pregnancies in a group of kidney transplant patients, it reached 92%.34,35 Condom or preservative Male In one study, failure reached 15% in daily use and 2% in perfect use. The success of condoms in adolescents depends on the cultural change of its use. It should be taken as a requirement of sexual hygiene rather than as a mere method of contraception.36,37 Female Its effectiveness varies from 0.8% with perfect use to 9.5% with regular use. Experiences in adolescents are scarce, and its use is predominant among sex workers. In other experiences, the use was not well accepted because of the manipulation and training required. They are expensive to use.38–40 Diaphragm It is less accepted by adolescents because of its manipulation and size. The 50-mm size does not exist in Latin America. Diaphragm failure rate in adults is 2%, while the rate among adolescents increases to 40%.41 Spermicides They have a minimum risk and offer partial protection against STD as they change the vaginal pH. In adults, the failure rate is 2–5% and in adolescents, 21%.42 Vaginal Sponge (Polyurethane sponge with a 1 g of nonoxinol 9) It is not available in most of the Latin American countries. However, those who have used it, describe its numerous advantages. Intrauterine devices Publications with Tcu, 7cu and Levonorgestrel T in the nulliparous of over 19 years of age show no great differences with multiparous women. No experiences were found with nulligests or nulliparous women of under 18 years of age.43–46

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Hormonal methods Oral Hormones Current methods have very low risk, few side effects and are highly effective. A study compared adolescents of between 14 and 19 years who used monthly injectable hormones and second-generation oral hormones.47 The study should what in the case of oral contraceptives, the discontinuation rate was 60.6%, 45.7% and 35.4% at 6, 9, and 12 months respectively, with one pregnancy (0.88 Pearl Index). The first cause of abandoning the method was loss in the sequence, the second by medical advice and the third for reiterated forgetfulness or misuse. In the case of these contraceptives, abandonment rates are very high in adolescents. Privacy is relative when it comes to this kind of medication, and this makes continuous use more difficult.48

Long-term injectable hormones (3 months) (a dose of 150 mg of intramuscular Depomedroxiprogesterone (DMPA) every 3 months) It is not a routinely used contraceptive in adolescents because of the significant weight gain it entails when compared with users of oral contraceptives and non-users. Headaches and alterations of the menstrual cycle lead to a high frequency of abandonment. There is a reduction in bone density, which is recovered on discontinuation of the use of DMPA.49–51 It is recommended for use on adolescents in the following cases: * Low intelligence quotient adolescents or those who should be treated for reasons of biological or mental health. * Adolescents who are at risk of sexual abuse and are unable to use another temporal method. * Adolescents with problems related to mental health, personality and family conflicts. * Abandoned or homeless adolescents, who lead a promiscuous sex life and with enormous conflicts and difficulties for their social and cultural rehabilitation.

Monthly injectable hormones There are two WHO/HRP studies with medroxiproesterone (MPA) (25 mg) and oestradiol cyprionate (5 mg) and another combination of norethisterone enanthate (50 mg) and oestradiol valeriate (5 mg). However, there is very little experience of this combination with adolescents. A comparison of the MPA in women of 12 to 21 years old, with DMPA and Oral Hormones (OH) has been made. Discontinuation at 12 months was of 20%, 22% and 17% with MPA, DMPA and OH, respectively. Obese and overweight women were concentrated in the users of MPA and DMPA.52 Another study with 14- to 19-year-old adolescents, most of whom were in the extremely high-risk group, included a 12-month observation with the norethisterone combination, which resulted in an excellent option for adolescents and resulted in no pregnancies.47

Silastic implants with pure progestagen These are subcutaneous injectable capsules with levonorgestrel or desogestrel. Norplant has six capsules and lasts for 5 years. Experiences with adolescents under 18 are scarce, as is the case of the levonorgestrel with two capsules and a duration of 5 years. There have been experiences with implants with a single capsule of etonogestrel for risk cases similar to those described for DMPA and norethisterone. There is another implant with a nortesterone capsule, which is in its stage of research III and has no information for adolescents, as yet.

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Transdermal patch It has 150 mcg of norelegestromine and 20 mcg of etinilestradiol. A study included 40 young women between the ages 18 and 22, of which 28 women were of an average age of 18. Half of the group were adolescent mothers. The patch was well accepted, with no pregnancies; 21% presented a total detachment of the patch and 32% presented a partial detachment. A total of 39% women discontinued the study and 27% did so because they were unable to buy the patch. No pregnancies were registered. In another study, a total of 62 adolescents, with an average age of 17.9 years with an average use of 10 months, presented no pregnancies. Discontinued use was caused by detachment or skin irritation (10%).53 Vaginal ring There are two approved rings: (1) the progesterone ring for after birth – there are no data with adolescents, and (2) a ring which is a combination of ethonogestrel and 120 mg ethynil oestradiol (15 mg) – there are no studies in adolescents aged under 18.54 Emergency method or postcoital pill or pill for the next day or the day after Clinical experience indicates that all sexually active adolescents or adolescents who are about to become sexually active should receive counselling in this area and should be part of the counselling activities of a first consultation. They should be taught the Yuzpe method, if they cannot go to a centre; and they should also be given a web page address in their native languages, which they can use when they have no access to a telephone or to a hot line or if they need help over a holiday or a weekend.55,56 In summary, adolescent pregnancy principally affects developing countries and contributes to maintaining the circle of poverty; in cultural terms, it is an integrational transference of adolescent fecundity, with repeated patterns. The higher the adolescent fecundity rates the lower prevalence in the use of contraceptives. The prevention of adolescent pregnancy is possible with a quality education system including sexual education, a carefully co-ordinated network of preferential attention services for adolescents, with communication media that give adolescents information regarding sexual and reproductive health. Modern contraception is a powerful tool to be given within the framework of an adequate system for adolescents, although the subject requires more research.

Practice points * Adolescent fecundity is the most exact bio-demographic and health indicator of development levels in many countries. * The causes of the most prevalent morbidities in adolescent pregnancy are a consequence of lack of prenatal care, of previous nutritional deficiencies and of infections and parasite infections that exist in the adolescent’s environment, but increase of premature birth, which endangers the prognosis of the newborn child, is a real problem of adolescent pregnancy. * Prevention of adolescent pregnancy is possible with the existence of sexual education, preferential attention services for adolescents and information regarding adolescents’ sexual and reproductive health. * Modern contraception is a powerful tool to be given within the framework of an adequate system for adolescents. * Adolescent contraception and pregnancy are issues that include both genders.

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Research agenda  Evaluation of the impact of intervention action on adolescent pregnancy prevention.  Consequences on adolescent mother, children and family of pregnancies under 14 years.  Contraceptive use in minor age for prevention of first pregnancy and repeat pregnancy

References *1. United Nations for Population Activity. The State of World Population. Avaliable at: www.unfpa.org; 1995 and 2008. 2. gdgdgdhhdhdhdhdhdhdg ´venes en las Ame´ricas. Implicaciones en 3. Schutt-Aine J & Maddaleno M. Salud Sexual y Desarrollo de Adolescentes y Jo Programas y polı´ticas. Washington DC: Organizacio´n Panamericana de la Salud, 2003. 4. United Nations, World Youth Report, 2005: Young People Today, and in 2015 5. Oluyoka Peju. The MDGs and Pregnancy in Adolescents. Reducing Maternal Mortality. CAH, Department of Reproductive Health and Research. 6. The Alan Guttmacher Institute. Sharing responsibility. Nueva York: Women Society and abortion worlwide, 1999. 7. Bott S. Unwanted pregnancy and induced abortion among adolescents in developing countries: Findings from WHI case studies. Sex Reprod Health 2000; 1: 351–366. 8. Sandoval J, Molina R, Siles T, Cumsille F, Pereda C, Martinez L & Molina T. Aborto inducido de adolescentes en comunidades de Santiago.Rev. Ch. Avaliable at: Obstet Ginecol Inf Juv 1997; 4(3): 21–30 www.cemera.cl/sogia/1997.html. 9. The Alan Guttmacher Institute. New York: Sex and America’s Teenagers, 1994. 10. Tristan Flora. Avaliable at: http://www.flora.org.pe/el%20aborto.htm. ˜ os. Ana´lisis de la u´ltima de´cada del 11. Donoso E, Becker J & Villarroel L. Embarazo en la Adolescente chilena menor de 15 an siglo XX. Rev Ch. Obstet Ginecol 2001; 5: 391–396. *12. Adolescent Pregnancy. Issues in Adolescent Health and Development. Department of Child and Adolescent Health and Development. Department of Reproductive Health and Research. Geneva: WHO, 2004. 13. Shiao P, Andrews C & Helmreich R. Maternal Race/Ethnicity and Predictors of Pregnancy and Infant Outcomes. Biological Research for Nursing 2005 July; 7(1): 55–66. 14. Duenhoelter JH, Jime´nez JM & Bauman G. Pregnancy performance of patient under fifteen years of age. Obstet Gynecol 1975; 46: 49–52. *15. Molina R, Luengo X, Sandoval J, Gonzalez E, Castro R & Molina T. ‘‘ Factores de riesgo del embarazo, parto y R.N. en adolescentes embarazadas ‘‘. Rev. Ch. de Obstet. y Ginecol. Inf. Y de la adolesc 1998; 5: 17–28, www.cemera.cl/sogia/pdf/ 1998/V1factores.pdf. 16. Card J. Teen Pregnancy prevention: Do any programs Work? Annual Rev Public Health 1999; 20: 257–285. *17. Kirby D. No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington DC: the National Campaign to Prevent Teen Pregnancy, 1997. 18. Gonzalez E. Aspectos sociales en la adolescente embarazada. En: Salud Sexual y Reproductiva en la Adolescencia. In ´ neo. Chile: Santiago, 2003. Molina R, Sandoval J & Gonza´lez E (eds.). Editorial Mediterra 19. Robinson Bryan E & BarretRobert L. ‘‘Piccoli Padri’’ Revista de Psicologı´a Contemporanes 1986; 78: Italia: Firenze, 1986. 13–16. 20. Card JJ & Wise SL. ‘‘Teenage mothers and teenage fathers: The impact of early childbearing on the parents’ personal and professional lives’’. Family Planning Perspectives 1978; 10(4): 199–205. *21. Gonza´lez E. El Varo´n y la paternidad Precoz. En: Salud Sexual y Reproductiva en la Adolescencia. In . Molina R, Sandoval y J ´neo. Chile: Santiago, 2003. & Gonza´lez E (eds.). Editorial Mediterra 22. Spingarn R & Durant R. Male Adolescents Involved in Pregnancy: Associated Health Risk and Problem Behaviors. Pediatrics 1996; 98(2): 262–268. 23. Youth Risk Behavior Survey. YRBS. USA: CDC, 2003. ˜ os. OPS, AMR/87/ 24. Molina R., Luengo X., Gonza´lez E., Encuesta de seguimiento de madres adolescentes y sus hijos de 2 a 5 an 132895. 1987 25. Furstenberg F & Brooks-Gunn Phillip M. Adolescent mother in later life. Cambridge university Press, 1987. 26. -Luengo X & Gonzalez E. Hijos de madres adolescents. EN: Salud Sexual y Reproductiva en la Adolescencia. In Molina R, Sandoval J & Gonzalez E (eds.). Editorial Mediterraneo. Chile: Santiago, 2003. 27. Abusos Sexuales en Adolescentes. Factores de riesgo Predictivo. En: Salud Sexual y Reproductiva en la Adolescencia. In ´neo. Chile: Santiago, 2003. Molina R, Sandoval y J & Gonza´lez E (eds.). Editorial Mediterra 28. Molina R. Adolescencia y Embarazo: Un problema emergente en Salud Pu´blica. Mediterra´neo. In Molina R, Sandoval J & Gonzalez E (eds.). Salud Sexual y Reproductiva en la Adolescencia. Chile: Santiago, 2003, pp. 442–450. ´n Cientı´fica No 552. 29. Woodward K & Silber TJ. ‘‘ Anticoncepcio´n ‘‘. In: La Salud del Adolescente y del Joven. Publicacio Washington D.C: Organizacio´n Panamericana de la Salud, 1995, pp. 264–272. *30. Rivera R, Cabral de Mello M, Jonson SL & ChandraMouli V. Contraception for adolescents: Social, clinical and servicedelivery considerations. Internat. J Gyenecol& Obstet 2001; 75: 149–163. *31. Mulchahey KM. Practical approaches to prescribing contraception in the office setting. Adolesc Med Clinic 2005; 16: 665–674. 32. Che Y, Cleland JG & Ali MM. Periodic abstinence in developing countries an assessment of failure rates and consequences. Contraception 2004; 69(1): 15–21. 33. Kalaca S & Cebeci D. Cali S, Sinai I, Karavus M, Jennings V. Expanding family planning options: offering the Standard Days Method to woman in Istanbul. Fam Plann Reprod Health Care 2005; 31(2): 123–127.

222

R.C. Molina et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 209–222

34. Are´valo M, Jenning V, Nikula M & Sinai I. Efficacy of the new Two Days Method of family planning. Fe´rtil Sterl 2004; 82(4): 885–892. 35. Lessan-pezeshki M, Ghazizadeh S, Khatami MR, Razeghi E, Seifi S, Ahmadi F & Maziar S. Fertility and contraceptive issues after kidney transplantation in women. Transplant Proc. 2004; 36(5): 1405–1406. 36. De Visser R. Delayed application of condoms, withdrawal and negotiation of safer sex among heterosexual young adults. AIDS Care 2004; 16(3): 315–322. 37. Shew ML, Fortenberry JD, Tu W, Juliar BE, Batteiger BE, Qadadri B & Brown DR. Association of Condom Use, Sexual Behaviors, and Sexually Transmitted Infections with the duration of Genital Human Papilomavirus Infection among adolescent woman. Arch Pediatr Adolesc Med 2006; 160(2): 151–156. 38. Novak DP & Karlsson RB. Gender differed factors affecting male condom use. A population-based study of 18-year-old Swedish adolescents. Int J Adolesc Med Health 2005; 17(4): 379–390. 39. Valappil T, Kelaghan J, Macaluso M, Artz L, Austin H, Fleenor ME, Robey L & Hook 3rd EW. Female condom and male condom failure among women at high risk of sexually transmitted diseases. Sex Transm Dis 2005; 32(1): 35–43. 40. Posner SF, Bull SS, Ortiz C & Evans T. Factors associated with condom use among young Denver inner city women. Prev Med 2004; 39(6): 1227–1233. 41. Marshall S, Giblin P, Simpson P & Backos A. Adolescent girls’ perception and experiences with the reality female condom. J. Adolesc Health 2002; 31(1): 5–6. 42. Cuyo MA, Toroitich-RutoC Grimes DA, Schulz KF & Gallo MF. Sponge versus diaphragm for contraception: A Cochrane review. Contraception 2003; 67(1): 15–18. 43. Jain JK, Li A, Nucatola DL, Minoo P & Felix JC. Nonoxinol-9 Induces Apoptosis of endometrial Explants by Both Caspasedependent and -independent apoptotic Pathways. Biol Reprod 2005; 73: 382–388. 44. Veldhuis HM, Vos AG & Lagro-Janssen AL. Complications of the intrauterine device in nulliparous and parous women. Eur J Pract 2004; 10(3): 82–87. ˜ o FJ & Vasquez-Estrada LA. A comparative randomized study of three different IUDs in 45. Otero-Flores JB, Guerrero-Carren nulliparous Mexican women. Contraception 2004; 69(3): 250–260. 46. Suhonen S, Haukkamaa M, Jakobsson T & Rauramo I. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception 2004; 69(5): 407–412. 47. Pakarinen P & Luukkainen T. Five year experience with a small intracervical/intrauterine levonorgestrel-releasing device. Contraception 2005; 72(5): 342–345. *48. Molina R, Sandoval J, Montero A, Oyarzu´n P, Molina T & Gonza´lez E. Comparative Performance of a Combined Injectable Contraceptive (50 mg norethisterone enanthate plus 5 mg Estradiol Valerate) and a combined oral contraceptive(0.15 Levonorgestrel plus 0.03 Ethinil estradiol) in adolescent. J Pediatr Adolesc Gynecol 2009; 22: 25–31. 49. Calderoni ME & Coupey MS. Combined Hormonal Contraception. Adolesc. Med. Clin 2005; 16: 517–537. *50. Cromer BA, Lazebnik R, Rome E, Stager M, Bonny A, Ziegler J & Debanne SM. Double-blind randomized controlled trial of estrogen supplementation in adolescents girls who received depot medroxyprogesterone acetate for contraception. A. J Obstet Gynecol 2005; 192: 42–47. 51. Gold MA & Hertweck SP. Lara-TorreE. Use of DMPA by adolescents. J Ped Adolesc Gynecology 2005; 18(6): 435–437. 52. Bonny AE, Ziegler J, Harvey R, Debanne SM & SecicM Cromer BA. Weight gain in obese and nonobese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no hormonal contraceptive method. Arch Pediatr Adolesc Med 2006; 160(1): 40–45. 53. Petta CA, Hays M, BracheV Massai R, Hua Y, Alvarez-Sanchez F, Croxatto H, D’Arcagues C, Cook LA & Bahamondes L. Delayed first injection of the once-a-month injectable contraceptive containing 25 mg of medroxyprogesterone acetate and 5 mgof E(2)-cypionate: effects on ovarian function. Fertl Steril 2001; 75(4): 744–748. Comment in: Fertil Steril 2002; 77(6):1308-9; Author reply 1309–11. 54. Duijkers I, Killck S, Bigrigg A & Dieben TO. A comparative study on the effects of a contraceptive vaginal ring Nuva Ring and an oral contraceptive on carbohydrate metabolism and adrenal and thyroid function. Eur j Contracept Health Care 2004; 3: ˜ os). 131–140 (mujeres 18 a 40 an 55. Gold MA, Woldford JE, Smith KA & Parker AM. The effects of advance provision of emergency contraception on adolescents women’s sexual and contraceptive behaviors. J Pedaitr Adolesc Gynecol 2004; 17: 87–96. *56. Ortiz ME, Ortiz RE, Fuentes MA, Parraguez VH & Croxatto HB. Post coital administration of levonorgestrel does not interfere with post-fertilization events in the new- world monkey Cebus Apella. Advance Acces Published. Hum Reprod 2004; April 22: 1–5.