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One-year contraceptive follow-up of adolescent patients
One-year contraceptive
follow-up of adolescent
patients VALERIE
JORGENSEN,
Philadelphia,
M.D.
Pennsylvania
This paper reviews the one-year contraceptive follow-up of adolescent postpartum patients. Routine contraceptive methods are safe and effective but are not widely used for sustained periods. Discontinuation of a contraceptive method was more closely related to family attitudes than to the complication rate.
P E N N s Y L v A N I A Hospital, Philadelphia, Pennsylvania, developed an adolescent obstetrics and gynecology clinic 3vz years ago in an effort to provide intensive obstetric care for this “high-risk” group of patients.2 Two years ago, a family planning program was incorporated into the same clinic. The purpose of this paper is to report our oneyear postpartum contraceptive follow-up of these adolescent girls.
to choose one of four options: ( 1) to remain on oral contraceptives, (2) to have an intrauterine contraceptive device (IUD) inserted, (3) to be fitted for a diaphragm, or (4) to decline all contraceptive methods. Foams and jellies alone were not prescribed because we felt they were ineffective in the hands of this adolescent population. If the patient chose to continue on oral she was given a 3 month contraceptives, prescription and was scheduled to return for follow-up and pill renewal every 3 months. The medications prescribed included Norinyl1,” 28 day pack, and Ortho Novum l/50,+ 21 day pack, depending on physician preference. If the patient chose an IUD or a diaphragm, insertion or fitting was accomplished at that visit, and she was seen at the same clinic in one week, then in one month, 3 months, 6 months, and one year in follow-up. At each visit she was checked by the nurse and the physician. She was also followed periodically by the Social Service, After one year, she was transferred to the adult family planning clinic. Peer group family planning teaching ses-
Procedure This study involves a follow-up of 221 eleven- to seventeen-year-old patients during a one-year period following the initiation of a contraceptive method. Each patient was started on oral contraceptives on the fifth postpartum day unless she had a medical contraindication or personal objection. An appointment for the postpartum clinic was scheduled in 5 weeks. At the 5 week postpartum follow-up, the patient was allowed From the Departments of Obstetrics and Gynecology, Pennsylvania Hospital, and the School of Medicine, University of Pennsylvania. Received
for publication
f;I;pted
for
publication
March 9, 1972. September
21,
Reprint requests: Dr. Valerie Jorgensen, Dept. of Ob./Gyn., Pennsylvania Hospital and School of Medicine, 8th and Spruce Sts., Philadelphia, Pennsylvania 19107.
*Syntex norethindrone, followed by tOrtho drone with
484
Laboratories, Inc., Palo Alto, California (21 1 mg., with mestranol, 0.05 mg., tablets 7 inert tablets). Pham. Corp., Raritan, New Jersey (norethinmestranol, 0.05 mg.).
Volume Number
115 4
Contraceptive
Table I. Contraceptive Gynecology
Clinic,
follow-up Pennsylvania
statistics in the Adolescent Hospital
follow-up
of adolescent
Obstetrics
No.
Per
patients
485
and
cent
Patients lost to follow-up
-
.-
2 13
96
8
184 90 82 2
83 49 44 1
!!9
162 147 138 135 5
73 66 62 61 2
42 15 9 3
Patients followed Patients started on oral contraceptives on fifth postpartum day At 5 week postpartum visit Patients returning Patients selecting oral contraceptive Patients selecting IUD Patients selecting diaphragm Patients declining contraceptive methods Family planning follow-up (time period beginning after the postpartum visit) One-month checkup Three-month checkup Six-month checkup One-year checkup Repeat pregnancy in one year Total patients lost to follow-up
221
sions were conducted throughout the year to reinforce the family planning concept and to deal with the adolescent’s social and emotional problems concerning the use of contracepti0n.l These sessions are conducted at the 3 month, 6 month, and yearly follow-up periods.
4 IUD expulsions and one perforation through an undetected old cervical laceration. This complication was detected at the one-week follow-up, and a new IUD was properly placed. Our complication rate (i.e., expulsion, heavy bleeding, or severe pain) was approximately 4.5 per cent. Three patients on oral contraceptives de(blood veloped postpartum hypertension and were taken off the pressure > 140/90) pills and asked to return in one month. Another contraceptive method was used. In each case the blood pressure returned to normal within the month and a medical evaluation was not necessary. Sixty per cent of these girls were available for a one-year contraceptive follow-up. Of the 135 girls remaining in the clinic, 47 per cent were on oral contraceptives, and 53 per cent had the IUD. Five known repeat pregnancies occurred within the first 8 postpartum months. Dickens’ states that the mean interval until repeat pregnancy is 14.2 months in a similar adolescent clinic at the Hospital of the University of Pennsylvania.
Results
from
The
Population
Council,
IOSS
86
Between postpartum discharge and the first visit in 5 weeks, 37 patients were lost to follow-up, yielding an attrition rate of 16 per cent (Table I). Many of these patients changed addresses or gave false addresses and could not be reached despite intensive efforts such as letters, phone calls, and visiting nurses. Ninety-four per cent of the adolescents returning for the 5 week postpartum follo\t--up chose some form of contraception; 49 per cent elected to continue on oral contraceptives and 44 per cent chose the IUD or diaphragm, As indicated above, the IUD (Lippes loop, copper T”) or diaphragm was placed immediately at this visit because rescheduling for still another appointment interrupted the continuity of care and caused these adolescents to Iose interest. There were ‘Supported by a grant York, New York.
37 immediate
New
Comment Our special adolescent family planning program was incorporated into our adolescent obstetric clinic for two reasons: Prior
486
February Am. J. Obstet.
Jorgensen
to this time, greater than 65 per cent of our patients were being lost to follow-up immediately after delivery, and peer group teaching techniques could be incorporated in an attempt to achieve more effective use of family planning methods. The immediate postpartum use of oral contraceptives was initiated because in our experience the adolescent girl was most receptive to family planning immediately post partum. A 4 week delay in starting a contraceptive method had previously served to reinforce any underlying ambivalence or indifference toward contraception. Any delay also allowed time for opinions about contraception from the patient’s grandmother and/ or mother to be influential. Family members are often only aware of the much-publicized side effects of the oral contraceptives and the IUD, and they are not aware of their medical safety if used properly. Immediate use of the oral contraceptives is viewed by the family as part of the “postpartum healing process” and seems to be more readily acceptable at this point in time. No known postpartum complications have resulted from early contraceptive use in our clinic.4 Family planning education is initiated in the prenatal period and reinforced in the postpartum period. It is offered as an alternative method of placing mastery and control into the adolescent’s hands. Peer group therapy sessions and individual counseling sessions are utilized to reinforce and reteach family planning during this one year postpartum period.3 In our experience we have been unable to work successfully with our patients’ mothers, grandmothers, or boyfriends, many of whom offered resistance to
REFERENCES
Dickens, H. 0. : Personal communicafion. 2. Jorgensen, V.: AM. J. OBSTET. GYNECOL. 816, 1972. 1.
112:
15, 1975 Gynecol.
all contraceptive methods. Ninety-seven per cent of all young ladies who discontinued a contraceptive method did so because their mother, grandmother, or boyfriend did not want them to use it because of their muchpublicized side effects, rather than because they were having problems with their chosen method of contraception. Each adolescent selecting oral contraceptives is required to arrange her own repeat appointments. This step, which involves considerable initiative on the patient’s part, is not exhibited consistently. Since the IUD users were involved in a clinical research study,* they were either notified by mail of their next appointment or called personally by the clinic secretary as stipulated in the study format. Conclusions Family planning methods for adolescents can be instituted most consistently and effectively in the immediate postpartum period without major complications. Peer group teaching techniques with frequent reinforcement is effective with the adolescent population. An attrition rate of 38 per cent during the first year of follow-up is far too high and can only be mitigated by teaching family planning concepts on a family and neighborhood level, to include the mother, boyfriend, and siblings of the adolescent patient. Largescale education of communities with regard to the relative safety of good family planning practices should aid in the acceptance of these methods by the adolescent and her family. *Supported by a grant New York, New York.
from
The
Pop&don
Council,
3. Pion, R. J,: Clin. Obstet. Gynecol. 14: 409, 1971. 4. Rech, F. M., and Schwarz, R.: Fertil. Steril. 17: 556, 1966.
follow-up of adolescent
patients VALERIE
JORGENSEN,
Philadelphia,
M.D.
Pennsylvania
This paper reviews the one-year contraceptive follow-up of adolescent postpartum patients. Routine contraceptive methods are safe and effective but are not widely used for sustained periods. Discontinuation of a contraceptive method was more closely related to family attitudes than to the complication rate.
P E N N s Y L v A N I A Hospital, Philadelphia, Pennsylvania, developed an adolescent obstetrics and gynecology clinic 3vz years ago in an effort to provide intensive obstetric care for this “high-risk” group of patients.2 Two years ago, a family planning program was incorporated into the same clinic. The purpose of this paper is to report our oneyear postpartum contraceptive follow-up of these adolescent girls.
to choose one of four options: ( 1) to remain on oral contraceptives, (2) to have an intrauterine contraceptive device (IUD) inserted, (3) to be fitted for a diaphragm, or (4) to decline all contraceptive methods. Foams and jellies alone were not prescribed because we felt they were ineffective in the hands of this adolescent population. If the patient chose to continue on oral she was given a 3 month contraceptives, prescription and was scheduled to return for follow-up and pill renewal every 3 months. The medications prescribed included Norinyl1,” 28 day pack, and Ortho Novum l/50,+ 21 day pack, depending on physician preference. If the patient chose an IUD or a diaphragm, insertion or fitting was accomplished at that visit, and she was seen at the same clinic in one week, then in one month, 3 months, 6 months, and one year in follow-up. At each visit she was checked by the nurse and the physician. She was also followed periodically by the Social Service, After one year, she was transferred to the adult family planning clinic. Peer group family planning teaching ses-
Procedure This study involves a follow-up of 221 eleven- to seventeen-year-old patients during a one-year period following the initiation of a contraceptive method. Each patient was started on oral contraceptives on the fifth postpartum day unless she had a medical contraindication or personal objection. An appointment for the postpartum clinic was scheduled in 5 weeks. At the 5 week postpartum follow-up, the patient was allowed From the Departments of Obstetrics and Gynecology, Pennsylvania Hospital, and the School of Medicine, University of Pennsylvania. Received
for publication
f;I;pted
for
publication
March 9, 1972. September
21,
Reprint requests: Dr. Valerie Jorgensen, Dept. of Ob./Gyn., Pennsylvania Hospital and School of Medicine, 8th and Spruce Sts., Philadelphia, Pennsylvania 19107.
*Syntex norethindrone, followed by tOrtho drone with
484
Laboratories, Inc., Palo Alto, California (21 1 mg., with mestranol, 0.05 mg., tablets 7 inert tablets). Pham. Corp., Raritan, New Jersey (norethinmestranol, 0.05 mg.).
Volume Number
115 4
Contraceptive
Table I. Contraceptive Gynecology
Clinic,
follow-up Pennsylvania
statistics in the Adolescent Hospital
follow-up
of adolescent
Obstetrics
No.
Per
patients
485
and
cent
Patients lost to follow-up
-
.-
2 13
96
8
184 90 82 2
83 49 44 1
!!9
162 147 138 135 5
73 66 62 61 2
42 15 9 3
Patients followed Patients started on oral contraceptives on fifth postpartum day At 5 week postpartum visit Patients returning Patients selecting oral contraceptive Patients selecting IUD Patients selecting diaphragm Patients declining contraceptive methods Family planning follow-up (time period beginning after the postpartum visit) One-month checkup Three-month checkup Six-month checkup One-year checkup Repeat pregnancy in one year Total patients lost to follow-up
221
sions were conducted throughout the year to reinforce the family planning concept and to deal with the adolescent’s social and emotional problems concerning the use of contracepti0n.l These sessions are conducted at the 3 month, 6 month, and yearly follow-up periods.
4 IUD expulsions and one perforation through an undetected old cervical laceration. This complication was detected at the one-week follow-up, and a new IUD was properly placed. Our complication rate (i.e., expulsion, heavy bleeding, or severe pain) was approximately 4.5 per cent. Three patients on oral contraceptives de(blood veloped postpartum hypertension and were taken off the pressure > 140/90) pills and asked to return in one month. Another contraceptive method was used. In each case the blood pressure returned to normal within the month and a medical evaluation was not necessary. Sixty per cent of these girls were available for a one-year contraceptive follow-up. Of the 135 girls remaining in the clinic, 47 per cent were on oral contraceptives, and 53 per cent had the IUD. Five known repeat pregnancies occurred within the first 8 postpartum months. Dickens’ states that the mean interval until repeat pregnancy is 14.2 months in a similar adolescent clinic at the Hospital of the University of Pennsylvania.
Results
from
The
Population
Council,
IOSS
86
Between postpartum discharge and the first visit in 5 weeks, 37 patients were lost to follow-up, yielding an attrition rate of 16 per cent (Table I). Many of these patients changed addresses or gave false addresses and could not be reached despite intensive efforts such as letters, phone calls, and visiting nurses. Ninety-four per cent of the adolescents returning for the 5 week postpartum follo\t--up chose some form of contraception; 49 per cent elected to continue on oral contraceptives and 44 per cent chose the IUD or diaphragm, As indicated above, the IUD (Lippes loop, copper T”) or diaphragm was placed immediately at this visit because rescheduling for still another appointment interrupted the continuity of care and caused these adolescents to Iose interest. There were ‘Supported by a grant York, New York.
37 immediate
New
Comment Our special adolescent family planning program was incorporated into our adolescent obstetric clinic for two reasons: Prior
486
February Am. J. Obstet.
Jorgensen
to this time, greater than 65 per cent of our patients were being lost to follow-up immediately after delivery, and peer group teaching techniques could be incorporated in an attempt to achieve more effective use of family planning methods. The immediate postpartum use of oral contraceptives was initiated because in our experience the adolescent girl was most receptive to family planning immediately post partum. A 4 week delay in starting a contraceptive method had previously served to reinforce any underlying ambivalence or indifference toward contraception. Any delay also allowed time for opinions about contraception from the patient’s grandmother and/ or mother to be influential. Family members are often only aware of the much-publicized side effects of the oral contraceptives and the IUD, and they are not aware of their medical safety if used properly. Immediate use of the oral contraceptives is viewed by the family as part of the “postpartum healing process” and seems to be more readily acceptable at this point in time. No known postpartum complications have resulted from early contraceptive use in our clinic.4 Family planning education is initiated in the prenatal period and reinforced in the postpartum period. It is offered as an alternative method of placing mastery and control into the adolescent’s hands. Peer group therapy sessions and individual counseling sessions are utilized to reinforce and reteach family planning during this one year postpartum period.3 In our experience we have been unable to work successfully with our patients’ mothers, grandmothers, or boyfriends, many of whom offered resistance to
REFERENCES
Dickens, H. 0. : Personal communicafion. 2. Jorgensen, V.: AM. J. OBSTET. GYNECOL. 816, 1972. 1.
112:
15, 1975 Gynecol.
all contraceptive methods. Ninety-seven per cent of all young ladies who discontinued a contraceptive method did so because their mother, grandmother, or boyfriend did not want them to use it because of their muchpublicized side effects, rather than because they were having problems with their chosen method of contraception. Each adolescent selecting oral contraceptives is required to arrange her own repeat appointments. This step, which involves considerable initiative on the patient’s part, is not exhibited consistently. Since the IUD users were involved in a clinical research study,* they were either notified by mail of their next appointment or called personally by the clinic secretary as stipulated in the study format. Conclusions Family planning methods for adolescents can be instituted most consistently and effectively in the immediate postpartum period without major complications. Peer group teaching techniques with frequent reinforcement is effective with the adolescent population. An attrition rate of 38 per cent during the first year of follow-up is far too high and can only be mitigated by teaching family planning concepts on a family and neighborhood level, to include the mother, boyfriend, and siblings of the adolescent patient. Largescale education of communities with regard to the relative safety of good family planning practices should aid in the acceptance of these methods by the adolescent and her family. *Supported by a grant New York, New York.
from
The
Pop&don
Council,
3. Pion, R. J,: Clin. Obstet. Gynecol. 14: 409, 1971. 4. Rech, F. M., and Schwarz, R.: Fertil. Steril. 17: 556, 1966.