Emergency Contraception in Adolescents
Emergency contraception (EC) refers to contraceptive methods that can be used by women in the first few days following unprotected intercourse to prevent unwanted pregnancy (1).Defined in this way EC has the following characteristics :
The often used popular term of ´morning-after pill´ is inappropriate and confusing and may be an obstacle to more widespread use since ´morning after´ suggests a need for immediate and urgent action. Also, not all available EC methods are based on hormonal methods (3).
References to postcoital preparations for oral and vaginal use as well as to postcoital douching can be found as far back as 1500 BC on Egyptian papyri and have been passed on from one generation to the next for thousands of years. Most of these methods derive from a combination of magic and elementary knowledge of physiology.
The development of hormonal methods of EC goes back to the 1960s when the first human trials of postcoital administered high dose estrogens were undertaken. Combined estrogen-progestogen combination therapy (the so-called Yuzpe regimen) was introduced in the early 1970s, while the postcoital insertion of an intrauterine contraceptive device (IUD) for EC was first reported in 1976. Other compounds that have been used, some with promising results, include progestogens, danazol and very recently the antiprogestogen mifepristone( RU 486).
EC methods are effective as well as simple to use for the majority of women who may need them.
The need for EC is clearly demonstrated by the occurrence of unwanted pregnancies and induced abortion and by high rates of unwanted pregnancies among adolescents. Today most of the women who have used EC are from developed countries, mainly from Europe where specially packaged products have been available for several years. However, the practice is now spreading to developing countries as a result of large WHO studies and the interest of many family planning programs in finding ways to prevent unwanted pregnancies. In December 1995, the Yuzpe regimen was added to the WHO list of essential drugs.
The most common reasons for requesting EC in selected studies are shown in table 1.
Table 1. Reasons for requesting emergency contraception.
*failed coitus interruptus, rape, forgotten pill(s), vomiting after taking pills, etc.
WHO. Emergency contraception. A guide for service delivery. Geneva 1998.
Methods of EC
The most common methods of EC
1) Increased doses of combined oral contraceptives (COC) containing ethinylestradiol and levonorgestrel (Yuzpe regimen).When pills specially packed for ECare available or when high-dose pills containing 50microgram of ethinylestradiol and 250 microgram levonogestrel (or 500 microgram dl-norgestrel) are available :
2) High doses of progestogen-only pills containing levenorgestrel.
Emerging data indicate that an alternative hormonal regimen consisting of levonorgestrel-only pills is equally effective as the Yuzpe regimen but has a significantly lower incidence of side-effects.When pills containing 750 microgram levonorgestrel are available :
3) Copper-releasing IUDs.The IUD is especially indicated when :
Emergency methods are generally not as effective as other contraceptive methods. For exampel,even when the Yuzpe regimen is administered within the recommended 72 hours, it fails to prevent one-quarter of the pregnancies that would be expected without the therapy (21). Although insertion of an IUD after unprotected intercourse is more effective and can be initiated later than the hormonal regimes (up until the expected start of implantation) its usefulness is limited because of the risk of infection and it is not usually recommended for nulliparous women.
Pregnancy in adolescents
Many unwanted pregnancies occur during adolescence when young women and their partners become sexually active before they are fully aware of the need for contraception or before they have had access to appropriate services. Sexarche (age of the first coitus) is happening earlier nowdays, resulting in younger adolescents engaging in intercourse. Emergency contraception can be very useful in these circumstances.
Over one billion people are between the age of 10 and 19, a fifth of the world’s population. Each year 15 million women under the age of 20 become mothers, accounting for just over 10% of all births. Between 20% and 60% of pregnancies and births to women under 20 are unplanned (24).
An unwanted pregnancy has psychosocial and health consequences for the adolescent mother and her newborn baby. How serious these consequences are depends largely on the degree of support provided by the young woman’s partner, family, health services and society in general.
Socio-economic and cultural factors influence the age at which young women have their first sexual intercourse and whether or not they are likely to practice contraception. Thus,the frequency with which adolescent pregnancy occurs varies across countries and socio-economic levels. Fertility rates range from 54 to 153 per 1000 women aged 15-19 years in Latin American countries and from 23 to 236 per 1000 in African countries, with Central Africa being the region with the highest proportion of pregnant adolescents (the mean rate is 207per 1000 women ).In contrast, the fertility rate in developed countries is around 30 per 1000 women aged 15-19 years, with lowest rates (below 20 per 1000 teenage women) found in parts of Europe and Eastern Asia. As a general rule, rates tend to be highest among the poor and less educated women- precisely those who are least equipped to cope with the negative consequences of teenage pregnancy. U.N,1995; Paxman J et al.,1993).
The idea of adolescent sexuality is not easily accepted by the family, the school or society at large. For this reason,adolscents in many countries are denied education on sex or family life. The education they are given is inadequate and fails to take account of their real needs. Furthermore, adolescents seldom have proper access to reproductive health care and contraceptive services.
Adolescent sexuality is typically characterized by difficulties in negotiating behavior with partners, by unstable relationships, conflicting emotions, secretiveness, sometimes rebellion and often by unprotected intercourse -especially in the early days of sexual activity. Adolescent women who fall pregnant may sometimes perceive motherhood as the route to recognition as adults or even as a pathway to the desired status of marriage.
These facts are alarming to all health care professionals concerned about the general health and well-being of tenagers.Given the complexities of sexual decision making, multiple strategies are necessary to encourage more adolescents to delay the initiation of sexual intercourse and choose abstinence. When adolescents choose to have sexual intercourse, multiple strategies are necessary to encourage them to avoid sexually transmitted infections and unintended pregnancy. One strategy to prevent unintended pregnancy among sexually active adolescents should be increasing awareness of emergency postcoital contraception.
EC is useful in preventing unwanted pregnancies in adolescents and there is no evidence that knowledge of this method of contraception has the effect of encouraging sexual activity among young people. On the other hand, the need for E.C.may be the stimulus that brings adolescents into contact with health care personel thus providing opportunities for counseling on responsible sexual behaviour, contraception and the prevention of sexually transmitted diseases (STDs), including HIV/AIDS.
Results of research
1) Knowledge of EC
In a 1995 nationally (USA) representative telephone survey (12) only 36% of adult men and women indicated that they knew that´ something could be done´ within a few days after unprotected sex to prevent pregnancy. Recent studies of awareness of and knowledge about EC among different populations of women in Australia, England and New Zealand found that at least two third were aware of EC pills (8-10).
Few studies have been conducted to assess teenagers’ awareness. A small study (16) in the United States (1997) of 133 girls and women aged 13 to 20 years found that just 44% had heard of EC. In contrast, a study in teenagers in Scotland revealed that 98% of girls and 87% of boys aged 14 to 15 years had heard of EC. One third (31%) of the teenaged girls in the study said that they had used EC Pills (9). A study of pregnant teenagers in England found that 81% had heard of EC (7).
Table 2. Knowledge about EC in teenagers aged 14-15 years in Scotland (survey)
Graham A.Green et al,1996 BMJ. 312(1567-1569)
Table 3. Knowledge about EC in pregnant teenagers in England (survey)
Pearson VA et al, 1995, BMJ, 310: 1644
A recent study in USA revealed that fewer than one quarter (23%) of teenage girls or boys were aware that ´something could be done after unprotected sex to prevent pregnancy´. Only slightly more (28%)had heard of EC or morning after pills. Teenage girls were somewhat more likely than teenage boys to have heard of EC pills (33% compared with 24%). Just 1 in 10 teenagers has heard of EC pills and was aware that something could be done after sex to prevent pregnancy (14).
Table 4. Knowledge about EC in teenagers aged 12-18 years in one nationally representative telephone survey/USA
Delbanco S et al, Arch.Pediatr. Adolesc. 1998,152 ;727-733.
Focusing on reponses from teenage girls, the most noteworthy differences in whether they had heard of EC pills occur by age and ethnicity.
Table 5. Knowledge of teenagers for EC differences by age, race or ethnicity
* Less than 1%. Adapted by Delbanco S et al, Arch.Pediatr. Adolesc. Aug.1998;152 :727-733.
These data reflect the fact that older teenage girls are more likely to be sexually experienced or have friends who are. Older teenagers may also be more likely to have an unplanned pregnancy scare. Forty-five percent of sexually experienced teenage girls reported that they have taken a pregnancy test (14). It is possible that a small proportion of these girls may have been informed about EC pills by a health professional when they went to have a pregnancy test, although the overall knowledge among teenage girls who had a pregnancy test was low. Older teenage girls were also slightly more likely to read women’s magazines, which have devoted some coverage to EC during the last few years. Older teenage girls may be less inclined to say that they would use EC because they have more confidence in their ability to use contraception or because they feel more capable of dealing with an unplanned pregnancy.
2) Use of EC
However, having heard of EC pills does not necessarily indicate that teenagers have sufficient knowledge about how to use them. Delbanco et al surveyed that of the 423 teenagers who had heard of EC pills one third (32%) did not know that they need to get them from a physician and three quarters (74%) underestimated the time how long after sexual intercourse they can initiate the regimen. Only 9% knew that EC pills could be used as long as 72 hours after unprotected sex. Teenage girls and boys were equally misinformed on each of these issues (14).
After being informed about EC pills two third (67%) of girls responded it would be likely they would use them. Of teenage girls who had not heard of EC pills before the survey, 64% said that it would be likely they would use them. Of teenage girls who had heard before the survey, 74% said that they would use them.(14).
Table 6. Teenage girls likelihood of using EC pills (%)
*Less than 1%. Adapted by Delbanco S.et al, Arch.Pediatr. Adolesc.Aug,1998;152 :727-733.
African American teenage girls while less likely to have heard of EC pills than their white or latina peers reported being more likely to use them once informed about.
Among those who had heard of EC pills, teenage girls who knew that the pills can be taken as long as 72 hours after sexual intercourse were not much more likely to say they would use them than girls who did not know this (84% vs75%)(14).
Sexually active teenage girls who reported using birth control most or all the time were less likely than those who reported using birth control sometimes or not at all to say that they would use EC pills (69% compared with 79%)(14).
Of the teenage girls who knew they need to get a prescription for EC pills 69% said that they would be likely to use them if needed. In contrast ,all those who did not know they need a prescription reported being likely to use EC pills (100%)(14).
In Finland by mailing a questionnaire to a national sample of 3000 women aged 18-44 years for the knowledge and use of hormonal EC 10% of the women aged under 25 and 4% of all respondents had sometimes used EC. Unmarried women were more likely to report having used hormonal EC than married women and nulliparous women reported more use than did parous women.(17).
In a Devon market town (England),of 373 registered girls aged 15-19 years, 59 (16%) had consulted a general practitioner about EC, 19 of them more then once. The Yuzpe regimen was prescribed eighty times and 2 girls became pregnant. Four of the 59 girls using EC had subsequent unwanted pregnancies (11).
Table 7. Number and percentage of girls aged 15-19 years who had consulted a GP for EC (England)
Seamark CJ et al, J R Soc Med. 1997 ;90 :443-444.
3) Sources of information
When asked which source they prefer most for information on birth control, teenage girls cited their parents. However teenagers were more likely to say they get their information on birth control and pregnancy from school rather than from their parents.Where teenaged girls get information on birth control and pregnancy it also appears to make a difference in whether they report being likely to use EC pills. More of those who said they learn a lot about birth control and pregnancy from health professionals reported that they would be likely to use EC pills (83%) than those who said they learn a lot about these topics from their friends (71%), school staff or classes (69%) or their parents (64%)(14).
Also magazine readers who turn to magazines for information on sex or birth control were more likely to say that they would use EC pills than those who do not turn to magazines for information on these topics.
School,friends,magazines and health professionals may potentially be important sources of information on ECpills. Those tenage girls who rely on these sources for general birth control information were more aware of EC pills than were teenagers who rely on other sources.
Table 8. Sources of knowledge about EC in adolescents (Scotland)
Graham A.Green et al. 1996 BMJ 312 ;1567-1569.
Table 9. Sources of information on EC in adolescents (USA)
*-Lees than 1%. Adapted by Delbanco S.et al. Arch.Pediatr.Adolesc.Med.Aug 1998 ;152 :727-733. It appears that for some teenage girls the likelihood of using EC pills is influenced by the perceived barriers to services,such as the need to get a prescription from a physician or the short time frame in which they think pills are effective. The data also suggest that teenagers who where aware they would need to get prescription from a physician for EC pills were less likely to think they would use them.The challenges of getting to a physician when many teenagers do not have a regular provider, sharing sensitive information and finding a physician who will prescribe EC also may seem overwhelming (18).Teenagers’ lack of knowledge about these hurdles may slightly bias them towards saying they would be likely to use EC pills.
4) Health professionals
With regard to health professionals however earlier research has shown that even obstetricians/gynecologists do not take a significant role in informing patients about EC. They rather tend to inform patients only in response to emergency situations.
Unintended pregnancy among teenagers may be reduced by improved sex education. In a survey in Edinburgh over 90% of both, teachers and pupils, were in favor of involving medical students in sex education (22).
Delbanco at al found in a survey that 77% of physicians reported being very familiar and 22% being somewhat familiar with EC pills. Most did not have objectives or concerns about prescribing them (70%). Among 77% who said they were very familiar, with the method, the majority considered EC pills to be very safe (88%) and very effective (85%). Overall, 84% thought EC pills are very safe, 78% thought they are very effective. Only 7% mentioned that discussion about emergency contraception occurred usually during routine contraceptive counseling. Regardless of emergency or routine interactions, few physicians informed their female patients of EC pills : 80% told 10% or fever of their patients about them. Although 70% reported prescribing EC pills within the last year, 77% of those did so five or fever times.
Unfortunately,in the USA most physicians are under-utilizing this important contraceptive method. In a survey (19) of 167 physicians with expertise in adolescent health, only 80% of those who prescribe contraception provide EC and than only a few times a year at most. Physicians who where more likely to prescribe EC pills where obstetricians-gynecologists (92%), younger physicians which graduated from medical school after 1970 (77%) and those practicing in academic centers(76%). Most require a visit for pregnancy testing and 46% inappropriately restricted the use based on the time in the menstrual cycle or limited the prescription to 24-48h post intercourse. Close to one third would not give the method if the teenager knew she would continue the pregnancy in the event the method failed, despite that no data is available to support adverse pregnancy outcomes. Others felt use of the method would encourage future risky sexual behavior. The authors concluded that providers need better knowledge regarding the safety and behavioral effects of EC pills as well as proper training to ensure physicians are comfortable enough to prescribe it according to recommended protocols.
Table 10. What physicians think about providing EC
Gold MA et al. Fam.Plann.Perspect.Jan.1997;29(1) :15-19.
While 41% of physicians providing EC counsel adolescents about the method during family planning visits, only 28% do so during visits for routine health care, 16% counsel women who are not yet sexually active about the method.
In a survey (20) of the British Cooperative Clinical Group most clinics (79%) provided EC for adolescents but few (14%) had full contraception service. Genitourinary medicine clinics in UK provide a range of services, including extensive education in the community to promote sexual health among adolescents.
The results (23) suggest that sexual health screening should be encouraged in women attending genitourinary medicine clinics (GUM) for EC and that the use of a program improves the quality of information obtained. From a group of patients aged 17-29 years examined in a GUM, 68.8% were in a relationship and 41.3% were not using regular contraception. 33.8% accepted sexual health screening and of these, 14.8% were currently suffering from STD (23).
Overall critical assessment of information retrieved
Emergency contraception can be a valuable tool for reducing unplanned pregnancies, many of which result in unsafe abortion. They are the only methods couples can use to prevent pregnancy after they have had unprotected sexual intercourse or a contraceptive accident. E.C.is needed because no contraceptive method is 100% reliable and few people use their methods perfectly each time they have sex.
EC also has an important role as a treatment for women who are victims of sexual assault.
The surveys indicate that there is an obvious need for more information for both, health care providers and patients. Adolescents need to be informed that EC reduces the risk of pregnancy. Most teenagers are aware that EC exists but underestimate the length of time after unprotected sexual intercourse that EC is an option, perhaps partly because it is often referred to as the ‘morning after´ pill. This distinction is significant because of the emergency context in which this contraceptive option is used, knowing that ‘something can be done´ does not translate into having information essential to its use.
Discussing emergency contraception within the context of pregnancy-prevention counseling needs to become part of routine care. For many adolescents, obtaining EC is an entry into the health care system and provides them an opportunity to be educated about safer sex practices, contraception and the importance of regular health screening. Discussing EC with patients at routine health visits will enable them to participate fully in their health care decisions and diminish the physical, psychological and social stress associated with unintended pregnancy. Easy access to contraceptive services is essential to increase the use of EC.
All social classes and age groups need to accept that sexual activity is not only bound to reproduction but is pleasurable in itself. Many doctors believe that the material wealth of our society leads to permissiveness. Others have questioned just how comfortable some adolescents are with their decision to engage in sexual intercourse.
All the communities have to accept the reality of adolescent sexuality, formal and informal sex education and readily accessible contraceptive services.
When adolescents choose to have sexual intercourse, multiple strategies are necessary to encourage avoidance of sexually transmitted infections and unintended pregnancy. Many adolescents need access to health care with facilities for contraception, counseling and screening for STD. The authors argue that the confidentiality of clinics is likely to be attractive to adolescents concerned about parental disapproval of their sexual behavior and perhaps sexual orientation and STDs. Some clinics (U.K) have a policy that all attenders under 16 years should see a health-adviser. Health advisers with appropriate counseling skills may play a useful role in addressing the problems and distress encountered during adolescence.
It is recommend that clinicians routinely discuss sexuality and ask about sexual behaviors when seeing adolescent patients for routine health visits. Appropriate discussions should encourage healthy sexual decision making. The choice of abstinence should be supported. For sexually active adolescents, options to reduce risk of sexually transmitted infections and pregnancy should also be supported.
Health professionals could play a larger role in informing their patients about EC. According to our bibliographic research, many adolescents at risk for unintended pregnancy reported that they rely on health professionals for information about birth control. This suggests that strategies to increase awareness about emergency contraception should focus on health professionals, encouraging them to discuss emergency contraception as part of routine contraceptive counseling.
Schools and media could be used more effectively to maximise the potential benefits of EC in adolescents.
Yet implementation of EC by physicians has been limited and only a small percentage of adolescents take advantage of this option each year. Lack of a specially packaged and marketed product for this indication has been a major barrier.
Also it is recommended that clinics should become more ‘adolescent friendly´ perhaps with dedicated staff and a set clinic time for teenagers. Health authorities should provide medical facilities designated for adolescents, such as screening for STD. On the other hand clinics should provide a range of services, including extensive education in the community to promote sexual health among adolescents.
EC is not an ideal form of contraception since it has a higher failure rate than regular forms of contraception. The literature illustrates the very clear need for new and better of emergency contraception methods.
Edited by Aldo Campana,