Contraceptives for Adolescents

Introduction
Adolescence, defined by the World Health Organization (WHO) as ages 10 to 19, is a time of
tremendous physical, cognitive, and social change and when many people initiate sexual activity.
This phase of life also presents with fatal and life-threatening health risks due to risky behaviors.
Engagement in risky sexual behaviour, for instance, is due to the fact that majority of the
adolescents tend to assume independence, however, lack the information and self-confidence to
make informed decisions about their sexuality .
These high risk sexual behaviours predispose them to various reproductive health issues which
majorly affect girls such as early child bearing, sexually transmitted diseases (STDs) including
HIV/AIDS, unsafe abortions and maternal mortality.
Adolescents (10-19 years) account for 24.19% (6.4 million) of Nepal's population (Census
2011).
Based on data and information collected, adolescents are not fully aware of their sexual and
reproductive health and rights (SRHR) nor are they able to exercise them fully.
As per the National Demographic Health Survey, 2011:
 The median age that girls marry is 17.8 yrs. whereas the legal age at marriage is 20 years,
 More than 2 in 5 girls are already married.
 17% girls from 15-19 years are already mothers/ or pregnant with their first child.
 Unmet need for contraception in married adolescents (15-19 years) is 41.6%.
 86% of married adolescents aged 15-19 are not using a modern contraceptive method.
 Nearly 1 in 10 adolescents experience physical violence during pregnancy.
 Adolescent birth rate for women aged 15-19 years is 71 per 1000 (MICS 2014).
 36.4% of youth (15-24 yrs.) who correctly identify ways of preventing the sexual
transmission of HIV and reject major misconceptions (MICS 2014).

Factors That Increase the Risk of Early Sexual Activity in Adolescents

 Low socioeconomic status

 Living in a single-parent home
 Engaging in risk-taking behavior (e.g. cigarette, alcohol, drug use)
 Having sexually active peers
 In some cases, early or rapid pubertal development
Contraceptives for adolescent
Condom: most suitable and also has no or nominal side effects. Prevents from both pregnancy
and STIs. 98% effective in perfect users.
COCs: For motivated clients it is generally very safe for adolescents. But it can’t prevent STIs.
POP: Less effective than COCs ( especially for typical users) an also can’t prevent STIs.
Injectable (DMPA):
Suitable for some longer time and if they are felling difficulty in using other devices needed
frequent care.
Sometimes, associated with spotting of blood, irregular menstruation, increased wt and skin
changes and can’t prevent from STIs.
Sub- dermal plant:
Less indicated to adolescents but if they are feeling difficulty in using other devices needed
frequent care. Also associated to disfigurement due to sub dermal placement and can’t prevent
from STIs. Sometimes, associated with spotting of blood, irregular menstruation, increased wt
and skin changes.
IUCD: Only indicated to those ruling out STIs and don’t have multiple sex partners. Don’t
prevent STIs.
Spermicides: less effective and don’t prevents STIs, not suitable
Coitus Interrupts: Not so effective and also don’t prevent STIs.
Permanent sterilization: Not suitable for adolescent.

Contraception for Women age over 35 years

Women over the age of 35 years are in need of safe and effective contraception because
pregnancy can carry increased health hazards for mothers and their babies.
Therefore , attention should be given to provide counseling and more effective services related to
family planning to above 35 years women because of following reasons:
 The maternal mortality is 5 times higher in women around 40 years in comparison to 20
years.
 The infant/ neonatal mortality is also doubled when the mother’s age is doubled.
 Contraception for Women age over 35 years CONTI...
 Congenital anomalies , especially chromosomal anomalies like down’s syndrome, are
also associated with increased age of the mothers.
 Increases risk of spontaneous abortion.
Choices of contraception for women over 35 years
COCs
POCs
IUCDs
Condom
Minilap
COCs Recommendation
Beneficial for supplementation of estrogen menopause, but not indicated to those who take 20 or
more cigarettes per day.
POCs ( Implants,POPs)
Used safely by women over 35 years of age and in the perimenopausal years (40-50s) even if
they are heavy smokers that means suitable for smokers.
Implants are highly recommended for women over 35 ( long term, do not want to use permanent
method)
IUCDs
May be used safely by women if not at risk for STI ( e.g HIV/ AIDS).
Progestin containing IUCDs reduce menstrual flow.
Condom: Can be used safely
Permanent:
Appropriate for clients/ couples who are certain about desire for permanent contraception
Post Abortion Family Planning counseling and contraceptive
After abortion the fecundity of women will return soon like menstrual phase. Along with the post
abortion services, FP services should also be provided. But in most of the developing countries,
these two services are not provided by one unit of care.
Post abortion family planning should include the following components:
 Counseling about contraceptive needs in terms of the clients reproductive goals.
 Information and counseling about all available methods, their characteristics,
effectiveness and side effects.
 Choices among methods ( e.g Short and Long term, their characteristics, effectiveness
and side effects)
 Assurance of contraceptive supply
 Access to follow up care
 Information and awareness about the need for protection against sexually transmitted
disease.
When to start:
Post abortion family planning services need to be initiated immediately because ovulation may
occur as early as 11 days following treatment of incomplete abortion and usually occurs before
the first menstrual bleeding.
Therefore , all women receiving post abortion care need counseling and information to ensure
that they understand it:
They can become pregnant again before the next menses.
There are safe contraceptive methods to prevent or delay pregnancy.
Where and how they obtain family planning services and methods.
Choices for post abortion contraception
COCs or POPs: Suitable if no conditions for contraindication seen.
IUCD: Not suitable if abortion is done/ occurred in 2nd trimester as the uterus is large and floppy
.
We have to wait for next 4 weeks advising other methods till then.
In other conditions, PID or infections should be ruled out and IUCD can be inserted.
Condom : Safe and can be used
Natural methods: Not suitable as time of ovulation cannot be ascertained.
Female sterilization: Indicated to rule out sepsis. If sepsis occurs wait till healing, usually 3
months.
Male sterilization: indicated but back up methods should be used till 3 months .
Post Partum Contraception:
Definitions :
Post-partum : This is the period beginning immediately after the birth of a child and extending
for about four to six weeks.
IUD OR IUCD: Is a small usually T – shaped plastic device that is wrapped in copper or
contains hormones , inserted into the uterine cavity mostly for the purpose of contraception.
Post – partum IUD (PPIUD) :The insertion of an IUD into the uterine cavity during post-
partum period
Trans – caesarean: Procedure done within the period of the CS
Stages of postpartum period
Post - placental: Inserted within 10 minutes the placenta is expelled in a vaginal delivery
Immediate postpartum: Insertion within 48 hours of delivery , before the client leaves the
hospital.
Trans - ceasarean: Insertion following a cesarean delivery, before the uterine incision is
sutured.
Post - abortion: The IUD is inserted following an abortion.
Note: An interval IUD inserted at any time between pregnancies after 4 weeks post-partum
or completely unrelated to pregnancy
Timing of PPIUCD
Immediate postpartum (within 10 minutes of delivery of placenta)—post placental or intra
cesarean
Early postpartum (<48 hours after delivery)
NOTE: IUDs should not be inserted between 48 hours and 4 weeks
TYPES OF PPIUCD INSERTION:
The three types of PPIUD insertion are:
1. Post placental: Immediately following the delivery of the placenta (active management
of the third stage of labor [AMTSL]) in a vaginal birth, the IUD is inserted with an
instrument or manually.
2. Intra cesarean: Immediately following the removal of the placenta during a cesarean section,
the IUD is inserted manually before closure of the uterine incision
3.Early postpartum:
Not immediately following the delivery/removal of the placenta but within two days/48 hours of
the birth (preferably within 24 hours, e.g., on the morning of postpartum Day 1), the IUD is
inserted with an instrument during a separate procedure.
[Note: At 4 weeks and beyond, IUD insertion is no longer considered PPIUD insertion; it is
regular or interval IUD insertion because the uterus and cervix have mostly returned to their pre-
pregnancy state.]
NOTE: IUDs should not be inserted between 48 hours and 4 weeks because of a higher risk of
complications during this time.
Contraception for HIV infected Patient
 Contraceptive Options for HIV-infected Women
 Women with HIV have a right to decide whether they want to become pregnant and bear
children.
 If an HIV-infected woman chooses not to have children, or wants to space her family, she
should be able to make informed, voluntary decisions about contraception and then
receive her method of choice. Such use of contraception by HIV-infected women is an
important way to reduce HIV-positive births.
 HIV-infected women can use most contraceptive methods safely.
 Need to weigh the advantages and disadvantages of various methods and consider the
effects of each method on her own health, risk of infecting others with HIV, and response
to HIV/AIDS treatment.
 Counsellors should help each HIV-infected woman assess her contraceptive needs,
review all options available to her, and determine whether she and her partner will be
able to use a particular method or combination of methods safely, correctly, and
consistently.
Barrier methods for HIV patient
Condom Effectiveness :
Proven to protect Condom against STI/HIV
Reduces HIV incidence by 80- 97% when used correctly and consistently
Condoms should be promoted, together with an additional form of contraception, as an ideal
method of contraception.
This reduces the transmission of HIV to her current and possible future partners if they are at risk
of HIV infection. If they are already infected the use of condoms is still advised, as in addition to
the prevention of conception, it prevents the transmission of sexually transmitted infections and
prevents infection with new strains of HIV
The effect of condoms is not altered by the use of ART.
Other barrier methods
Barrier methods other than condoms offer only modest protection against pregnancy and are
generally not recommended for women with HIV.
Frequent use of spermicides containing nonoxynol-9 (N- 9) may increase the risk of reinfection
with other strains of HIV because N-9 can disrupt the lining of the vagina, making it more
vulnerable to infection. Studies have also shown that N-9 offers no protection against STIs.
Diaphragms and cervical caps are not recommended for women with HIV or AIDS and women
at high risk of HIV infection because they are usually used with spermicides containing N-9. •
Recent study (Mira trial) showed no increase HIV protection with diaphragm use.
Modern methods of Contraception
Hormonal methods:
The World Health Organization (WHO) recommends that HIV-infected women can safely use
hormonal contraceptives — including combined oral contraceptives (COCs), the injectables
depot-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET- EN), and
implants such as Norplant.
IUDs
Women with HIV can generally start using either a copper-bearing IUD or a hormonal IUD.
Specific guidance includes: –
Women with HIV who do not have AIDS can generally have copper-bearing and hormonal IUDs
inserted.
Women with AIDS who are on ARVs and are clinically well generally also can have the IUD
inserted.
IUD insertion usually is not recommended for women who have AIDS and are not on ARVs,
however. The IUD also is not usually recommended for women who are using ARVs but are not
clinically well.
If an IUD user becomes infected with HIV or if an IUD user with HIV develops AIDS, the IUD
generally does not need to be removed. She should be monitored for signs of PID.
Sterilization
Offers couples a safe, highly effective, permanent method of contraception. May be a good
option for HIV- positive women and their partners who have decided to forgo or end
childbearing, and it raises no particular health concerns for HIV-infected women.
HIV-discordant couples in which the man is HIV-negative and the woman is HIV-positive may
want to consider male sterilization because it does not depend on the woman's health.
Studies show a reduction in consistent condom use in couples after one partner has undergone
sterilization. Couples should be counseled about the importance of using condoms if they might
be at risk of HIV infection.
Female Sterilization and Vasectomy
Female sterilization and vasectomy are Safe
For people with AIDS, special arrangements should be made to perform the procedure in a
setting with a qualified provider, with appropriate equipment and support.
Women or men with acute AIDS-related illness may have to wait until their condition improves
before undergoing the procedure