Empowering adolescent girls to access and use contraception is a global public health priority. High unmet need for contraception translates into high numbers of unintended pregnancies, and into high maternal mortality in countries with poor maternal health care systems. That is why reducing the unmet need for contraception is a key target in millennium development goal five.
Globally, progress is being made in reducing the unmet need for contraception, but it is slow with more progress in some countries than in others. Bangladesh and Malawi are cited as success stories. In Bangladesh, the use of contraception among married women aged 10 to 49 rose from 49% in 1996/97 to 61% in 2011. However, among married adolescents aged 15 to 19 years, contraception use rose by a lesser margin – from around 33% in 1996/97 to 47% in 2011. In Malawi, the use of contraception in married women aged 15 to 49 years rose from 13% in 1992 to 46% in 2010, whereas among married adolescents aged 15 to 19 years, it rose from 7% in 1992 to around 29% in 2010.
Barriers adolescents face in getting and using contraception
Erratic availability, cost, laws and policies prevent unmarried adolescents in low and middle income countries from accessing contraceptives. Even when there are no legal restrictions, health workers often refuse to provide unmarried adolescents with contraceptives because they do not approve of premarital sex. And when they do provide contraceptives, they often limit these to condoms, wrongly believing that long-acting hormonal methods and intra-uterine devices are inappropriate for all young women and those who have not had children.
Even when adolescents are able to obtain contraceptive methods, social pressure may prevent their use. First, in many places young women are under pressure to bear children soon after marriage. Contraception is considered – if it is considered at all – after the first child is born. Second, the stigma surrounding contraception prevents their use by adolescents who are not in stable relationships. A young woman who proposes condom use, for example, runs the risk of being considered 'loose'. Third, adolescents in many places have misconceptions about health effects of contraceptives, including their future ability to bear children. As a result, they tend to prefer traditional remedies or to use ineffective methods such as withdrawal. Fourth, many adolescents have poor understanding of how contraceptive methods work and use them incorrectly. Finally, sporadic and infrequent sex leads to an inconsistent use of contraceptives. But even within stable relationships, the use of condoms tends to decline over time because they suggest a lack of trust.
Efforts to overcome these barriers
An outstanding example of overcoming the barriers that adolescents face accessing contraception is Pathfinder International's Prachar project. Intended to promote change in reproductive behaviour of adolescents project in Bihar, India, events were held for newly married couples to celebrate their marriage and emphasise the benefits of delaying having children and provided couples with a small supply of oral contraceptive pills and condoms. Further, male and female counsellors spoke to young married men and women individually in their homes on reproductive health. The project also targeted unmarried adolescents aged 15 to 19 with workshops on sexual and reproductive health. The programme successfully delayed marriage of both male and female participants. It led to significant increases in contraceptive demand and contraceptive use among married women under 25 and delayed childbearing.
The challenge is to build on the lessons learned from projects such as Prachar to build large scale and sustained nationwide programmes. Core elements of that project are now being applied at scale in India's Bihar state, but that is unusual. Many other projects aimed at providing contraceptive information and services to adolescents in India and elsewhere continue to be small-scale and time-limited.
But there is growing readiness among government officials to change this. At the Family Planning 2020 partnership (FP2020), there is a real opportunity to translate this readiness into action. FP2020 is a global partnership which aims to support the rights of women and girls to decide freely and for themselves, whether, when and how many children they want to have. It works with governments, civil society, multilateral organisations, donors, the private sector and the research and development community to enable 120 million more women and girls to use contraceptives by 2020. This is good news for adolescent sexual and reproductive health.
Venkatraman Chandra-Mouli is adolescent health and development co-ordinator and Karlien Braet is an intern at the World Health Organisation. Follow @WHO on Twitter
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