Journal of Reproductive Health and Contraception

Keywords

Contraceptive; Adolescent; Birth control; Practices

Introduction

Background

One of the challenges facing family planning programs worldwide is the birth control knowledge and practices amongst adolescents when exposed to the risk of pregnancy. There is general consensus that the risk of pregnancy and sexually transmitted infections (STIs) in teenagers remains is high [1-5]. The problems related to teenagers unprotected sexual activity, low contraceptive use either because of lack of knowledge or availability and reliance on clandestine abortion are apparent [6-8]. Otoide [9] report that some teenagers hold the opinion that abortion may be required only occasionally, poses no real or immediate threat. Researchers further report that this belief was reflected in the views of a 22-year-old undergraduate who drew a relationship between the use and ease of abortion and the continuous, daily use of oral contraceptives: "One dilation and evacuation is safer than 16 packs of daily pills....many girls say this."

Fear of long term morbidities such as pelvic inflammatory diseases (PID), menstrual disorders, infertility, obesity etc with long term sequelae, medical, social are not unwarranted. A comparative study was done in rural institute to know the birth control practices amongst adolescents.

Adolescents, especially those unmarried, seldom use contraception. Sexually active adolescents who have sex with a steady partner often claim that intercourse is not the result of premeditated or conscious decisions but just “happens”, so they are unlikely to be prepared with contraception. Many adolescents are unable to obtain contraception (including emergency contraceptives) to avoid unwanted pregnancy. Even those adolescent who can obtain contraceptive do not always use them correctly and consistently [10].

Materials and Methods

Study subjects 500 women of less than 20 years and two controls of 20-34 years for each study subjects (1000), a total of 1500 subjects were interviewed with the help of a predesigned pretested questionnaire. Confidentiality was assured and ensured. Analysis was done about contraceptive use, birth control practices amongst adolescents and adults.

62 percent study subjects and 63.4% controls also were rural, as are the health seekers of this rural institution, catering to the needs of rural as well as urban masses. Socio economic status was similar but literacy was better in adolescents due to overall change in literacy of females in recent times. Only 13.8% adolescents were using or had ever used some form of contraception compared to 30.03% controls. Of the study subjects 31(6.2%) had used condom, 10(2%) had used it before first conception and 21(4.2%) after the first birth. Of the 24 adolescents who had intrauterine device (IUD), three had post abortal insertion and 21 had after the first birth. All the 12 women who used oral contraceptive pills (OCP) had started use after first birth. Two women after having 2 children each, had undergone sterilization by the age of twenty (Table 1).

Amongst adolescents 64.86% induced abortions were in second trimester compared to 13.79% second trimester abortion in controls (significant difference P<0.05) and of the second trimester abortions in adolescents 60% were around 18 weeks and 40% between 14 to 16 weeks (Table 2).

Discussion

Health professionals face with the dilemma of how to refine programmatic and research efforts to maintain the progress that has been made while reducing risk behaviours that remain too prevalent amongst adolescents [1].

According to WHO reports an estimated 222 million women in developing countries would like to delay or stop childbearing but are not using any method of contraception. Reasons include limited access to contraception, particularly among young people, poorer segments of populations, or unmarried people, limited choice of methods, fear or experience of side-effects, cultural or religious opposition, poor quality of available services, genderbased barriers etc. The unmet need for contraception remains high [11]. WHO’s review has revealed that prevailing attitude also places constrains on adolescents’ ability to negotiate the timing of sexual activity and use of contraceptives [12].

After their study of correlates of sexual activity and condom use among secondary school students in urban Peru, Mgnani [13] have concluded that expanding the focus of reproductive health programs for adolescents to target some of the factors that influence adolescents’ behaviour is likely to enhance the impact of such interventions. Although improving adolescents’ knowledge of reproductive health and access to contraceptives is necessary and important, interventions directed to this goal alone may not be sufficient to avert teens ‘risk –taking. There are variations in various countries.

Santelli [14] report that European teens are more likely than U.S. teens to use contraceptives generally and to use the most effective methods. They therefore have substantially lower pregnancy rates. In U.S half of states explicitly allow minors to obtain contraceptive services without their parents’ involvement or interpret the absence of a law in favor of minors’ access [15]. The remaining states allow access to contraceptive services without parental involvement only for certain groups of minors, such as married teens. While parental involvement can be helpful to some minors, others will remain sexually active but will not seek contraceptive services if they are required to tell their parents [16], putting themselves at increased risk for unintended pregnancy and STIs.

According to study conducted by Martinez [17] in U.S. the majority of sexually experienced teens (78% females and 85% males) used contraceptives the first time they had sex. Martinez [17] reported that the use of contraceptives during first sex by females aged 15–19 has increased, from 48% in 1982 to 78% in 2006–2010. Adolescents are apparently unlikely to use contraceptives, the first time they have sex. Darroch [18] reported that a greater proportion of U.S. women reported no contraceptive use at either first or recent intercourse, 25% and 20%, respectively, in France 11% and 12%, respectively, Great Britain 21% and 4%, respectively and Sweden 22% and 7%, respectively. Likewise other studies reveal a third of sexually active teens report failure to use any effective contraceptive during their most recent episodes of intercourse [19,20] In the present study no one had used any contraceptive in their first intercourse.

Adolescents who have sex at age 14 or younger are less likely than older teens to have used a method at first sex and take longer to begin using contraceptives [21]. Martinez G [17] also reported that the condom is the most common contraceptive method used at first intercourse, 68% of females and 80% of males used it the first time they had sex and in 2006-2010, some 96% of sexually experienced female teens had used a condom at least once, 57% had ever used withdrawal and 56% had used the pill. Smaller proportions had used other methods and one in five sexually active female teens (20%) and one-third of sexually active male teens (34%) reported having used both the condom and a hormonal method the last time they had sex. Researcher further report that between 2006–2010, 86% female teens and 93% male teens reported using contraceptives at last sex. These proportions represent a marked improvement since 1995, when only 71% female teens and 82% male teens had reported using a method at last sex. However, the proportions were generally unchanged between 2002 and 2006–2010. Finer and Philbin [21] reported that in 2009, 4.5% of female teen contraceptive users relied on long-acting reversible contraceptives, including IUDs and implants. This is an increase from 1.5% in 2007 and just 0.3% in 2002. Kavanaugh [22] reported that in 2006–2008, eight percent of females aged 15–17 and 18% of females aged 18–24 had ever used emergency contraception.

Table 1:Contraceptive use amongst adult and adolescent girls.

Table 2:Abortion amongstadults women and adolescents.

Frost [23] reported that among sexually active teen females, 66% received contraceptive services in the last year; about onethird received this care from publicly funded clinics, the rest from private health care providers. Also adolescents adhere to myths about sex [24], for instance, they are not old that “the first time” doesn’t count, that they must have intercourse much more frequently than they do in order to conceive. But the trend is changing in American teens, the majority of sexually experienced teens 78% of females used contraceptives the first time they had sex. The use of contraceptives during first sex by females aged 15-19 has increased, from 48% in 1982 to 78% in 2006-2010 [17].

India is the first country in the world to launch Family Planning Programme in 1952 (NPP, 2000). According to NFHS-2, among young women age 15-19 in Maharashtra, 14% have already begun childbearing, a little lower than the national average (16%). Young women in rural areas are twice as likely to have begun childbearing as young women in urban areas (18% and 9% respectively) (NFHS-3). With only 7 percent of 15-19 year old using contraceptive as per the NFHS 3, the unmet need for family planning is higher among 15-19 year-olds at 27% compared to 13% unmet need across all age groups. Teenage pregnancies account for almost 16% of the total pregnancies in India and almost 9% of total maternal deaths [25-28].

It has also been reported that compared with adult women, contraceptive use among adolescents is more likely to result in an undesirable outcome [29].

In the present analysis only 2.4% adolescents were using OCP. However amongst adults also it was only by 3.2%, because OCP use is low in this part. Greydanus [30] has reported that teens accounted for 30% of all abortions performed in 1993. In our earlier analysis of induced abortions also it was revealed that more than 29% induced abortion were in adolescents [31], 29.5% abortions were performed in unwed adolescents [32], however in a recent analysis the figure was around 18.5% [33]. More of private services are available so adolescents are likely to use private or even self-medication by medical method, because services are faster and with more privacy. Self-induced abortion is also attempted by medical methods. Nearly 63% of the study subjects had abortion around 14 weeks, 40% around 14-16 weeks. The teenagers are more likely to have later abortions than older teenager. In their study 75% of all abortions at 15 years of age were beyond 12 weeks and 34.5% at 19 years [34]. It is related to awareness and capacity to get services needed. Some report beyond 5 months after limit of abortion has to be given support for birth [35].

It is believed that there is not only poor contraceptive use but also there are disturbing rates of discontinuation, failure of contraception among adolescents. Among sexually active teenage girls aged 12 to 18 years, 20% of oral contraceptive users become pregnant over a period of six months [36].

In India the numbers of adolescents and adult women who know about any contraceptive methods has been reported as 90.2% and 96.2% respectively whereas the percentage of women who were using any contraceptive methods has been reported to 7% and 42% respectively [37]. Adolescents are very much aware of contraceptive methods but they are not using, it may be due to shyness or fear. In the present study 13.8% adolescents were using some contraceptive compared and 30.3% adults. Due to socio cultural milieu there is lack of contraceptive knowledge amongst adolescents when unwed. Opponents say that giving birth control advice to teens promotes promiscuity [38]. However studies done by Kirby [39] Santelli [40] showed that comprehensive education about contraception delays the onset of sexual behaviour, reduces the number of sexual partners, and improves the use of contraceptives. There is wide disparity between contraceptive knowledge and practice, which needs to be bridged. There is need to review policies and practices regarding reproductive health, sexuality and family life education. Ultimately, community based efforts to change social norms and values concerning adolescents; reproductive health issues and empowering communities to address these issues are likely to be the most cost-effective approaches for best of reproductive health of adolescents’ outcomes.

Conclusions

Contraceptive use amongst adolescents is quite low. They seek induced abortion for unwanted pregnancy quite late. It seems, a lot needs to be done to promote contraceptive use and create awareness and ensure availability, use of safe early abortion amongst adolescents. It should be part of family life education. Physician at all levels are positioned to help to prevent the negative biological consequences of adolescents’ sexual activity, disease and unintended pregnancy.

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