In 2011, WHO issued Guidelines on preventing early pregnancy and poor reproductive outcomes in adolescents in developing countries [
1]. These Guidelines were based on reviews of published systematic reviews and of individual studies, and the collective judgment of an expert panel. Increasing access to and use of contraception was one of the four outcomes to prevent early pregnancy. (The other three outcomes were preventing marriage before 18 years; increasing knowledge and understanding of the importance of pregnancy prevention; and preventing coerced sex). The studies that met the inclusion criteria for this outcome were conducted in a number of LMIC. Some focused exclusively on condom use, while others looked at hormonal contraceptives and emergency contraception (EC). Some examined the use of contraception as a primary outcome while others examined it as secondary to outcomes such as HIV prevention or changing knowledge and attitudes. Some focused on health system actions (such as over-the-counter or clinic provision of contraception) while others focused on actions directed at community leaders and members. Collectively, they demonstrated increases in contraceptive use (including condoms, hormonal contraceptives and EC) as a result of actions directed at multiple levels – laws and policies; individuals, families and communities; and health systems. The interventions discussed below are drawn from WHO’s Guidelines.
The Appendix contains a list of reviews and studies which fed into the development of WHO’s Guidelines on preventing early pregnancy and poor reproductive outcomes in adolescents in developing countries.
Making social and group norms supportive
In many societies premarital sexual activity is not considered acceptable, and there is considerable resistance to the provision of contraceptive information and services to unmarried adolescents. To overcome this barrier, it is important to improve the understanding of influential community leaders and of the community at large on adolescent’s needs for information and contraception, and the risks to their wellbeing of not responding to these needs [
1].
In many places, social and group norms hinder discussion between couples about contraception. In addition, knowledge gaps and misconceptions prevent use or proper use of contraceptive methods. Mass media (radio and television programmes), peer-education, and inter-personal communication and information education communication materials (such as posters and leaflets) have been used successfully to communicate health information to adolescents, and to influence their norms [
1]. In recent years, the ways adolescents communicate have changed radically. Mobile phone technology, the Internet and social media are increasingly being used even in LMIC. These technologies are potentially valuable for communicating contraceptive information and options to adolescents conveniently and discretely [
14].
Improving knowledge and understanding
The evidence of the benefits of curriculum-based comprehensive sexuality education is strong. The most successful sexuality education programmes provide accurate and age-appropriate information and in addition, develop life skills and provide support to deal with thoughts, feelings and experiences that accompany sexual maturity (e.g. falling in love and refusing unwanted sex). They are also linked to contraceptive provision and services [
15].
Although policies requiring sexuality education for adolescents are in place in many countries, they are poorly implemented, if at all. Health and education policy makers and managers must ensure that curriculum-based sexuality education is widely and effectively implemented. Complementary efforts are needed to reach the many adolescents who are not in school [
1].
Because many adolescents have knowledge gaps and misconceptions about contraception and their side effects, they must be provided accurate information and given opportunities to ask questions and discuss their concerns. They must also be told where they could get contraception [
1].
Improving access to contraception
This means making a wide range of contraceptive methods available and accessible to adolescents, and supporting them to choose a methods that meet their special needs through counselling. In line with WHO’s eligibility criteria on contraceptive provision [
16], a range of methods are appropriate for adolescents as age alone is not a contraindication for any method (apart from sterilization). Long acting reversible methods such as intrauterine devices or implants can also be good choices for adolescents depending on their needs and preferences.
Adolescents in many places are unwilling to visit facilities providing contraception because they view them as unfriendly. There is growing evidence of the value of making health services adolescent friendly [
16]. WHO’s Guidelines on adolescent pregnancy call for making health services adolescent friendly to make it easier for adolescents to obtain the contraceptive methods they need [
1].
What are Adolescent Friendly Health Services?
To be considered adolescent-friendly, health services should be accessible, acceptable, equitable, appropriate and effective, as outlined below [
16]:
-
Accessible
-
Adolescents are able to obtain the health services that are available
-
Acceptable
-
Adolescents are willing to obtain the health services that are available
-
Equitable
-
All adolescents, not just some groups of adolescents, are able to obtain the health services that are available
-
Appropriate
-
The right health services (i.e. the ones they need) are provided to them
-
Effective
-
The right health services are provided in the right way, and make a positive contribution to their health
To improve access to contraception, health facilities must be made easy to get to and welcoming, they must have adequate stocks of a range of contraceptive methods, and adolescents must be supported to choose the ones that meet their needs and preferences by empathetic and competent health workers.
Contraceptive education, counselling and provision could be integrated into other health services used by adolescents – including STI management, HIV counselling and testing, comprehensive abortion care services and postpartum care. For many adolescents, contact with these services may be their first opportunity to have a face-to-face discussion about contraception with a competent person. Integration into postpartum services offers the opportunity to reach first-time mothers with information on birth spacing so they can delay a second pregnancy.
In making health services adolescent friendly, it is important to build on what already exists - modifying general health facilities and building the competencies and attitudes of existing health-service providers, rather than setting up new facilities and assigning some health-service providers exclusively for adolescents. Having said this, dedicated health facilities could be useful to reach marginalized groups of adolescents (such as sex workers) who may be reluctant to use a service-delivery point open to all [
17].
Even if health facilities are adolescent-friendly, they are unlikely to attract all adolescents [
18]. Therefore, contraception should be provided through a variety of outlets. Outreach to adolescents in venues where they socialize can improve their access to contraceptive information and services – on the spot or through referral [
19]. Making pharmacies and shops adolescent-friendly could greatly expand ready access to over-the-counter contraceptive methods. Some countries have begun to task-shift contraceptive services to community-level providers in response to shortages of qualified medical personnel [
20]. Adolescents could benefit from these efforts if confidentiality can be assured.
In summary, there is fairly good evidence - from research studies and small-scale and time limited projects – on effective ways of increasing access and use of contraception by adolescents. They include favourable laws and policies; multifaceted communication programmes directed at community leaders and members, and at adolescents - that inform, educate and create supportive norms for the provision and use of contraception; accurate and age-appropriate curriculum based sexuality education; and the provision of a wide range of contraceptive methods through different adolescent-friendly outlets [
1]. The challenge is to build on these small-scale and time-limited initiatives to build large scale and sustained programmes [
21]
.