Introduction
About 16 million girls aged 15 to 19, and around 1 million girls under 15, give birth
every year in the world. Most of these cases occur in developing countries.[1] Complications during pregnancy and childbirth are the second cause of death for
15–19-year-old girls globally.[1] Even though pregnancy at an early age may pose challenges, like social, economic,
and educational ones, adolescents are at a high risk for rapid repeat pregnancy: ∼
12–49% of adolescent mothers are pregnant again in the first year after delivery.[2] From 1990 to the early 2000s, adolescent pregnancy rates declined markedly, and
86% of this decline was attributed to increased consistent contraceptive use.[3]
Unintended pregnancy in adolescents may be accompanied by morbidities that can be
potentially dangerous. The base to prevent an unwanted pregnancy and its complications
is effective contraception.[4] The contraceptive method most commonly used by adolescents is the condom (96% of
young women who have ever used a contraceptive reported previous condom use), followed
by withdrawal (57%).[4] Among hormonal methods, experience with combined oral contraceptives is most common
(56%), followed by depot medroxyprogesterone acetate (DPMA) injection (20%). More
than 13% of adolescents have used emergency contraception, and 15% have used periodic
abstinence.[4] Frequent follow-up is important to maximize adherence for all methods of contraception,
and to promote and reinforce healthy decision-making.[5]
[6] Moreover, regularly scheduled contraceptive follow-up visits should address use,
adherence, adverse effects, and complications.[5]
[6] An opportune time to introduce or to talk about contraceptive methods with adolescents
is the postpartum period. Effective postpartum contraception is a unique opportunity
to lengthen inter-pregnancy intervals.[7] The aim of this study was to determine which methods of contraception are used before
and after pregnancy among adolescents who have had children.
Methods
A cross-sectional study was performed, and data was obtained from medical records
of all adolescents who underwent childbirth review consultation at the Hospital da
Mulher, Universidade Estadual de Campinas – CAISM, Brazil, between July 2011 and September
2013. CAISM is a reference center that has a specialized area with a multidisciplinary
team to take care of adolescents during pregnancy and the postpartum period. Routinely,
in a pre-consultation talk, the teenagers received explanations about adequate contraception
methods for this period by a trained professional, and the importance of double protection
to avoid sexual transmitted diseases is emphasized. Moreover, when necessary, psychologists
and social workers can evaluate them.
The inclusion criterion was adolescents aged between 10 and 19 years who were attended
in puerperal medical consultation. The exclusion criterion was a first consultation
after 90 days postpartum. All data were routinely transcribed into a specific form
and inserted into a spreadsheet created in Epi Info 7, a public domain suite of inter-operable
software tools. Statistical analyses were performed using averages, standard deviation,
percentage correlations, and Fisher's exact test. The statistical software used was
the Statistical Analysis System (SAS) version 9.4 for Windows, Copyright © SAS Institute
Inc. SAS and all other SAS Institute Inc. product or service names are registered
trademarks or trademarks of SAS Institute Inc., Cary, NC, USA. and p-values < 0.05
were considered statistically significant.
The study was approved by the Research Ethics Committee (CAAE number – 11909413.6.0000.5404).
The recommendations of the Declaration of Helsinki were followed.
All recommendations of the Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) statement were followed.
Results
A total of 196 postpartum adolescents were included. The first postpartum follow-up
consultation happened between 20 and 83 days after birth (the average was 44 days),
and the majority (70%) was exclusively breast-feeding.
Sociodemographic and gynecologic characteristics, as well as mode of delivery and
habits, are described in [Table 1]. The average age of patients was 16.18 years ( ± 1.43); more than half had the
menarche at the age of 12 years or younger (65%), the first sexual intercourse occurred
between 13 and 14 years for 49% of them, and 76% had a vaginal delivery.
Table 1
Sociodemographic and gynecologic characteristics, mode of delivery, and habits of
postpartum adolescents
|
Average (SD)
|
N
|
%
|
|
Age at birth
|
16.18 (1.43)
|
|
|
|
≤14
|
|
21
|
10.8
|
|
≥15
|
|
175
|
89.2
|
|
Menarche*
|
11.9 (1.4)
|
|
|
|
≤1/212
|
|
113
|
65
|
|
> 12
|
|
60
|
35
|
|
First sexual intercourse**
|
14.06 (1.32)
|
|
|
|
≤12
|
|
24
|
13.6
|
|
13–14
|
|
86
|
49.0
|
|
≥15
|
|
66
|
37.4
|
|
Parity
|
|
|
|
|
1
|
|
176
|
89.8
|
|
≥2
|
|
20
|
10.2
|
|
Mode of delivery
|
|
Vaginal
|
|
149
|
76
|
|
C-section
|
|
47
|
24
|
|
Breastfeeding***
|
|
Exclusive
|
|
125
|
70
|
|
Mixed
|
|
37
|
21
|
|
Artificial
|
|
15
|
9
|
|
Schooling****
|
|
Elementary
|
|
84
|
57
|
|
High School
|
|
64
|
43
|
|
Smoking*****
|
|
9
|
5
|
|
Alcohol*****
|
|
8
|
4
|
|
Total
|
|
196
|
|
Abbreviation: SD, standard deviation.
Missing:*23; **20; ***19;****48;*****8
There are positive correlations between the age of the adolescent at the moment of
childbirth and the age at menarche (r = 0.3), between the age of the adolescent at
the moment of childbirth and at the first sexual intercourse (r = 0.419), and also
between the age at menarche and the age of the first sexual intercourse (r = 0.46)
([Table 2]).
Table 2
Correlation between maternal age at birth, at menarche, and at first sexual intercourse
in adolescents
|
Age
|
Menarche
|
First sexual intercourse
|
|
|
196
|
173
|
163
|
N of observations
|
|
Age
|
1
|
0.29933
|
0.41877
|
Spearman coefficient
|
|
|
< 0.0001
|
< 0.0001
|
p
|
|
173
|
173
|
163
|
N of observations
|
|
Menarche
|
0.29933
|
1
|
0.4626
|
Spearman coefficient
|
|
< 0.0001
|
|
< 0.0001
|
p
|
|
176
|
163
|
176
|
N of observations
|
|
First sexual intercourse
|
0.41877
|
0.4626
|
1
|
Spearman coefficient
|
|
< 0.0001
|
< 0.0001
|
|
p
|
Contraception before pregnancy was used by 74% of these adolescents. The most frequent
method used was combined oral contraceptives (COCs, 56.85%) followed by condoms (34.4%)
(data not shown). Among the primiparas, 57% used COCs before pregnancy, and 37% reported
the use of condoms. Among adolescents with two or more deliveries, 57% reported the
use of COCs, and 22% used DMPA (data not shown). Comparing primiparas and adolescents
with two or more births, the type of contraceptive used prior to pregnancy is statistically
different (p = 0.0086 in Fisher's exact test).
The main reason for abandoning the use of contraception was the occurrence of an unintended
pregnancy (41%), followed by reports of side effects (22%), behavior issues (18%),
desire for pregnancy (16%), and difficult access to contraception (3%) (data not shown).
Among the included patients, the majority (134) mentioned a preferential contraception
method to use after delivery, and 62 were indifferent and required the recommendation
of a physician to decide what method was the best for them at that moment.
After the births, DMPA was the contraception method most frequently used (71%), followed
by oral contraceptives (11.8%) and intrauterine devices (IUDs, 11.2%).
[Table 3] shows a comparison between the desired contraceptive method and the prescribed method
during postpartum follow-up consultations among 134 girls who manifested a preferred
contraceptive method. There is a good agreement between the two categories analyzed
(Kappa agreement coefficient of 0.75).
Table 3
Correlation between desired contraceptive method and prescribed contraceptive method
in adolescents at the first postpartum consultation
|
Desired contraceptive method
|
Prescribed contraceptive method
|
|
|
Frequency
|
Oral contraceptive
|
DMPA
|
IUD
|
Others
|
Total
|
|
Oral contraceptive
|
17
|
8
|
0
|
2
|
27
|
|
DMPA
|
0
|
77
|
0
|
2
|
79
|
|
IUD
|
1
|
5
|
17
|
0
|
23
|
|
Others
|
0
|
0
|
0
|
5
|
5
|
|
Total
|
18
|
90
|
17
|
9
|
134
|
Abbreviations: DMPA, depot medroxyprogesterone acetate; IUD, intrauterine device.
Frequency missing = 62; Symmetry test, p = 0.05; Kappa = 0.75 (CI 95% 0.65–0.85).
Discussion
This study aimed to evaluate the contraception before and after a pregnancy in adolescents.
Our data show that the most used method before pregnancy was COC, and the most prescribed
method was DMPA, followed by COC and IUD. Among teenagers with two or more deliveries,
the contraception method most used before pregnancy was COC as well. The age at the
childbirth was influenced by the age at menarche and at the first sexual intercourse.
Teen childbearing is a public health care problem that has potential negative health,
economic, and social consequences for mother and child. More important than the first
pregnancy in adolescence, repeated teen childbearing further constrains a mother's
education and employment opportunities.[8] Another problem is that in the second pregnancy, the rates of preterm low birth
weights are higher when compared with the first birth.[8] One study that evaluated 365,000 births in adolescents aged 15 to 19 in the United
States showed that 18% were repeated births.[8] A Brazilian study showed that 61% of adolescents who have had a pregnancy during
the adolescent period had another pregnancy in the 5 subsequent years.[9]
Our data show us that the later menarche is, the later is the start of sexual activity,
and pregnancy also happens later. Because we cannot delay addressing menarche during
the medical consultation, the subject of abstinence is very important. According to
the orientation of the American Academy of Pediatrics, when used consistently, abstinence
can be an effective means of contraception and sexual transmitted infections (STIs)
prevention, and a viable strategy for reducing unintended pregnancies and STI.[5] In Brazil, a study showed that the main risk factor for a pregnancy in adolescents
was the first sexual intercourse before the age of 15 years, with an odds ratio (OR)
of 3.6.[10]
The fact is that once sexual activity begins, it is necessary to initiate effective
contraceptive methods. Moreover, for patients with a history of a pregnancy during
adolescence, it is necessary to intensify the guidance and prescription of effective
methods of long duration. One study showed that of 367,000 births among adolescents
aged 15–19 years, 18.3% were repeat births. In that study, 91% of adolescents used
contraceptive methods for 2 to 6 months after delivery; however, only 22% were using
the most effective methods.[8]
Our data also show that the rate of previous use of contraception prior to pregnancy
among adolescents was of 74%. Fifty-seven percent of patients used COCs, and 34% used
condoms. Our numbers differ from those found by the American Academy of Pediatrics,
which estimated that among adolescents who had already used some form of contraception,
condoms were the most used, followed by withdrawal and the pill.[5] But these numbers do not reflect routine use, only knowledge and perhaps irregular
use of any method. A systematic review conducted by Meade found that 31–66% of pregnant
women and mothers had never used any contraception, and over a third had never used
condoms.[2]
Another problem is that these data can imply that teens are not worried about sexually
transmitted diseases. If adolescents use condoms correctly, the condoms are effective
in reducing the incidence of these diseases.[2]
[6] However, they are less effective than hormonal contraceptives in preventing pregnancy.[2]
[6] Thus, the recommendation is to use dual protection; in addition to condoms, the
use of long-acting hormonal contraception should be encouraged.[2]
[6]
The CAISM, offers a referral service for high-risk and teenage pregnancy. It was the
first hospital in Brazil to start giving special attention to adolescents by promoting
a differentiated service. The accompaniment of the teenagers starts in prenatal care,
and the hospital has a multidisciplinary approach with good adherence in the postpartum
consultation. This is why we decided to initiate the contraception method study at
this time. Nevertheless, the teenagers stay in our service for at least 6 months or
until they are secure and have adapted to the contraceptive method.
We found that DMPA was the main prescribed contraception at first visit postpartum
(67%). This number differs from those found by Dozier et al[11]; they found that 31.3% of patients in the postpartum period used DMPA, and of these,
62% had received the injection before hospital delivery. This is a particularly favorable
strategy for avoiding repeated pregnancy in adolescents because the failure rate of
the DMPA method when used perfectly is of 0.2%. However, in the clinical practice,
considering the typical use, the percentage of unintended pregnancies is 6%.[5] Even though our professionals are promoting the use of long-acting reversible contraceptive
(LARC) methods during pre-consultation and during consultation, our population is
somewhat resistant to using them. Our problem is that the public health care system
does not offer intradermal implants, and due to cultural factors, the teenagers do
not want to use IUDs. Because of this, our best option is DMPA, which can be used
in the postpartum period with breast-feeding, and has minor dependence on the reliability
of teenagers. It is probable that this is the reason for our high index of prescriptions
of DMPA. In recent years, it has been noted that this trend has been changing, and
we are seeing higher rates of IUD insertions, mainly after the inclusion of Levonorgestrel
IUD in our service. Teenagers favor the use of Levonorgestrel IUD, principally due
to the possibility of amenorrhea.
Our study has some limitations. It was a retrospective study using medical records,
data collection was not controlled, and we had some data loss. Despite that, it is
possible for us to know about our population and to plan how to approach the teenagers
when the topic is contraception after childbirth. However, few studies have comparatively
evaluated the contraceptive methods used before and after a pregnancy in adolescence.
Other institutions should review their management protocols in contraception for adolescents
to decrease the incidence of unintended pregnancies.
As the main reason to prescribe contraception for teenagers in the postpartum period
is to prevent unintended pregnancies, the most suitable contraception is the use of
LARCs, basically represented by the IUDs and the implants. The American College of
Obstetricians and Gynecologists recommends the insertion of LARC methods as a first
line contraceptive option to avoid unintended pregnancies, and one of the strategies
is to not only clarify patients about the method, but more than that: to stimulate
the prescription by the providers.[12] Improving the knowledge of the providers about LARC methods can decrease the barriers
and improve the prescription of these methods.[13] The percentage of women experiencing an unintended pregnancy within the first year
of use was similarly down between the IUD user (copper and levonorgestrel) and single-rod
contraceptive implant (respectively 0.05, 0.8 and 0.2).[5] A study involving 10,000 women showed that the methods with most rates of unintended
pregnancy are patch, ring, oral and injectable. It shows that the cause most related
with the failure of LARC methods is the delay between the choice of the method and
the day of the insertion. The study suggests that it is better for women to insert
the method in the day they decide to use them.[14]
Another advantage of using LARCs is the high adherence rate to the method after months
of insertion. A study by Secura et al[15] found that LARCs, basically comprising intrauterine devices and implants, showed
a lower rate of discontinuation among adolescents after 24 months of follow-up compared
with non-LARC methods (⅔ LARC × ⅓ non-LARC).[15]
[16] Another study showed that, after one year, 82% of adolescents were still using LARC
methods compared with 49% that were still using non- LARC methods. After two years,
those numbers were 67% and 37% respectively.[17]
In the years of monitoring, the methods that did not register any pregnancy were copper
IUD and subdermal etonogestrel implant. Levonorgestrel IUD and DMPA showed a low failure
rate (∼ 5 failures per 1,000 teenagers).[5] The methods with the highest failure rate among teenagers were oral contraceptive
pills, contraceptive patch, and the ring.[5]
Long-acting reversible contraceptives have another advantage when considering the
possibility of inclusion of contraception in the postpartum period. A study made by
Han et al showed that offering an immediate postpartum implant (IPI) for teenage mothers
is cost-effective, comparing the costs of the insertion and removal of the implant
and the cost of the etonogestrel implant with pre-natal costs and an infant's medical
care for the first year of life.[18] According to a Centers for Disease Control and Prevention (CDC) publication, offering
LARCs immediately in the postpartum period is an example of how to facilitate access
to contraception for adolescent mothers.[8]
In the data presented in the CDC publication, ⅕ of teens using contraception postpartum
reported the use of LARCs (18% reported IUD and 3.3%, implant).[8] The use of contraceptive pills and DMPA was reported by 29% and 21% of postpartum
teen mothers respectively.[8] Our data are smaller than that reported by the CDC. For our adolescents, IUD insertion
rate in the postpartum period (after 42 days postpartum) was of 13%. The rate of teen
mothers who wanted IUD as a contraceptive method in the postpartum period was of 17%,
but for some reason it was not entered, either by the difficulty of insertion, pain,
or the impossibility of insertion at the time of the query (such as the presence of
discharge or absence of suitable material). Implants are not offered in the public
health care system. This study served as a warning to our service, and we are in the
process of increasing the integration of LARCs.
Long-acting reversible contraceptive methods are safe and effective for most teenagers,
as this population is at a high risk for inconsistent use of methods that are dependent
on users.[6]
[19] In addition, they should be the option of choice because they are independent of
the user and require no effort after insertion.[16] However, teens face several barriers to the use of LARCs, such as cost, difficulty
of access, and lack of offer of the method.[20]
More than the difficulties in the use of LARCs, we see that adolescents from Latin
America continue to face problems and substantial barriers to education and development
services in sexual and reproductive health care. Consequently, the majority of sexually
active adolescents do not use modern contraceptive methods consistently to prevent
pregnancy and sexually transmitted diseases.[21] In the region, 50% of women have their first pregnancy during adolescence.[22]
[23] A study conducted in three countries (Bolivia, Ecuador, and Nicaragua) evaluated
sexual and reproductive health, and concluded that when teenagers develop strong relationships
in a secure, safe environment, they can build the life skills that they need to take
control of their own destinies. And there must also be a clear focus on the macro-level,
with a political and financial commitment to create empowering legal frameworks, and
to implement sexual and reproductive health care programs for adolescents.[21]
Contraception in adolescents is a challenge before a pregnancy, but we believe that
it is of special importance in the postpartum period. It is necessary to explain to
the girls about contraceptive methods and what risks of pregnancy they are exposed
to when using the method chosen. Our efforts must be concentrated on methods that
are independent of teenage behavior: that is the best way to avoid pregnancy in the
years after the childbirth. If it is not possible to use LARC methods, it is important
to evaluate the adaptation of the girls to the method chosen and, only after that,
refer the teenagers for primary health care.
Working with contraception among adolescents involves several political, medical,
cultural, and social issues that would culminate with the increasing number of services
and the dissemination of the importance of contraception. In particular for people
in this age group, it is important to increase accessibility to the services and,
especially, to demystify prejudices related to the subject.
