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New Vision
Teens and contraception: Which way?
Irene Nabusoba
October 5, 2009
Ann-Marie, 16, knew about condoms from school. "When used correctly, they can help prevent HIV transmission and unwanted pregnancy," the teacher had told them.

"But children your age should abstain from sex," the health educators cautioned. "Only 'big' people can use condoms while married people should stay faithful," they emphasised.

The problem is Ann-Marie, like many of her peers, was already sexually active. Unfortunately, she was not using condoms. The only time she and Fredo attempted to use a condom, he had stolen it from his older brother and it burst, but they had sex anway.

Now a mother of a three-month-old baby and out of school, Ann-Marie is one of the many adolescents excluded from the benefits of modern family planning methods. For her and others like her, fear and embarrassment stops them from seeking these services.

"I know of a boy whose father stopped paying fees for him because he found condoms in his suitcase. That meant that he was already having sex," says Annette Nabuduwa, a social worker.

"Others know about the family planning methods but don't know how to use them well and where to get them," Nabuduwa adds. "And our own health providers have not made it any easy for our youngsters. Rather than offer educative counselling, they lecture them on why they are having sex 'early' which discourages adolescents from seeking family planning services."

Cultural barriers

Nafissatou Diop, an international adolescent reproductive health advocate, says the biggest issue is to overcome social cultural barriers and open family planning services to young people.

"We need to recognise that opposition to family planning programmes is higher when it addresses young people under the age of 20 because they are not supposed to have sex," Diop says, adding: "and if they have sex, it should be within marriage, and if they are married and have sex, then they should be having children."

Diop, the country director of Population Council in Senegal who has worked for decades on issues of reproductive health, HIV/AIDS plus safe motherhood in Africa, says a lot of sexual activity goes on among adolescents.

"And those girls - even if they are married - sometimes don't want to have children. We also need to realise that many marriages in sub-Saharan Africa are forced. So most of those girls do not want children as soon as they get married," she observes.

Uganda's situation

Young people aged 10-24 years constitute a third of the total population, with 24% aged between 10 and 19 years, according to a 2006 report, 'Adolescent Sexual and Reproductive health in Uganda'.

The report says there is early initiation of sex, with about 30% of 12-19 year-olds having sexual intercourse. However, the study says, adolescents are poor users of contraceptives, despite high levels of knowledge and approval.

"Ninety six percent of adolescents aged 15-19 reported knowledge of at least one contraceptive method, but only 22% women reported ever using it. The most common methods they know are male condoms, the pill and injectables," it states.

The publication observes that health services targeting adolescents are often limited to schools. It regrets that these services are limited to curative services and information on growth and development through films, plays and seminars. Consequently, sexual and reproductive health services like modern family planning methods are more theoretical, not youth-friendly and have not attracted many adolescent clients where they are provided.

Many adolescents have been found to fear the risk of pregnancy more than HIV. To them, death is a farfetched reality.

"We have to realise that young people are having sex. Education is good, but we need to deal with the reality that young people need family planning services," Diop says. "Most adolescents are fearful and embarrassed to seek such services. This implies lack of adolescent friendly services as well as community support for adolescents to seek contraception," she adds.

Dr. Peter Ibembe, from Reproductive Health Uganda, says they provide family planning services to adolescents seeking them, non-segregatively.

"We often counsel them first, like we do with everybody else," he says. "But we are moving into friendlier adolescent health services. We have recruited many young professionals who can easily identify with adolescents," he says.

"We need family planning services for the youth because many unwanted pregnancies end in risky abortion and its consequent complications. We don't want this," Ibembe says.

The Uganda Demographic and Health Survey 2006 indicates that 24% of Ugandan girls have had sex by the age of 15 and the teenage pregnancy rate is at 24%.

The fertility rate, estimated at 6.9% has been attributed to low levels of education, low incomes and social status, early marriages, low contraceptive use, religious beliefs, as well as the need for old-age security. Contraceptive use among teenagers is as low as 23% and 50% of the population marries before the age of 18, says the Population and Housing Census 2003 report.

Statistics from the ministry of labour and social development indicate that teenage pregnancy rate in Uganda stands at 31% for the nations over 3 million female teenagers. It adds that this undermines the efforts of young people to effectively contribute towards national development.

Pregnancy is a significant cause of death for girls aged 15-19, with complications of child birth and unsafe abortion being the major factors.

An estimated 297,000 induced abortions are performed every year in Uganda, according to the Guttmacher Institute study on unintended pregnancy and induced abortion in Uganda. Adolescents are the most affected.

Ibembe says friendly adolescent reproductive health programmes ensure that teens know where to find the services, guarantee confidentiality and anonymity; and must be affordable. "Once these three conditions are met, other secondary factors influence teens to make an initial visit like location, ease of transportation, convenience of clinic hours, length of appointment wait and ease of admission by the health workers," he says.

Government policy

Dr. Anthony Mbonye, the assistant commissioner reproductive health in the ministry, says the Government is emphasising adolescent-friendly services by retraining health workers in counselling, creating special corners for adolescents in health facilities and recreation facilities to occupy them.

"We have reduced adolescent pregnancy from 43% in 1995 to 325 in 2001 and 25% in 2006," he says.

"In school, we just give them information on sexuality and safer sex practices. We cannot provide them with condoms," he says.

Nonetheless, critics argue that while adolescents in some parts of the country have benefited from such friendly services, there are few or even no models of youth-friendly services that are self-sustaining.

"Many of them rely on donor funding for survival," says Liz Kobusinge, an advocacy officer on health and nutrition. "A major consideration in the development and scaling up of adolescent-friendly services is the need for long-term investment by the Government and/or international donors," she adds.

Sustainability is the ability of an institution to continue providing quality services and products for the young people, even when donors phase out funding.

Any reproductive health programme for adolescents deserves to be sustainable. Such a programme is able to continue with its activities and meet its objectives every year, to make plans for the future and carry them out, despite changes in the external context.

However, reproductive health programmes for adolescents are challenging because they operate in an ever-changing environment. Apart from changes in source and level of funding, the consumers' demands also change.

What should be done?

Existent policies supporting the provision of youth-friendly services should be strengthened. Adolescents should be involved in the design, implementation and evaluation of programmes, Kobusingye argues. She says in both public and private programmes, ensuring satisfaction of the young people is important for increasing demand for the services.

"Health workers should be provided with specific training to be able to communicate with adolescents and to build competence in handling their health concerns.

"Above all, adolescent health programmes and policies should be interdisciplinary and reach beyond the health sector. Efforts should be scaled up to adequately confront the enormous health challenges facing adolescents," Kobusingye advises.

Ibembe describes optimal family planning services for adolescents as those that include accessible, comprehensive and multi-disciplinary care provided in confidence by no judgmental staff with good counselling and communication skills.

"It could be approached from those seeking post-abortion care to avoid a repeat risk of an unwanted pregnancy, doing voluntary HIV counselling and testing, antenatal and post-natal clinics, pregnancy testing," he notes.

"Some policy makers feel that family planning services should not be totally free, so that teenagers must take some responsibility for the provision. Nonetheless, they should be low-cost for adolescents, as they have limited financial resources," says Ibembe.

He adds: "Like with HIV counselling and testing, outreach adolescent programmes on family planning can mark an entry point for family planning services for high risk adolescents like school drop outs, sex workers, small industry employees and adolescents in unions. They also bring parents and the general community on board to respect adolescents' reproductive health rights other than reprimanding them for their decisions," he adds.

Medical perspective

Hormonal methods are generally appropriate for all youth. World Health Organisation places no restrictions on the oral use of contraceptives, combined injectables, or implants on the basis of age. The guidelines also place no restrictions on the use of progestin-only injectibles for persons at least 18 years old. Because of limited evidence that these injectibles decrease bone mineral density on younger adolescents, those younger than 18 can still use them, but should have access to counselling and medical follow up.