By Melinda Young
Barriers to contraception use have long hindered reproductive healthcare progress for young people in many nations around the world, including places in the United States. A decade-old project, funded by the Gates Foundation and other groups, sought to improve contraceptive access through technology. But research shows that digital methods are not the game changer many expected.1
“We talk about how there’s a lot of work to improve contraceptive use over the last 20 years,” says Cate Lane, MPH, an independent consultant in Potomac, MD, and author of a new paper on facilitating adolescent contraceptive use.1 There was a belief by big funders that technology could reveal insights into contraception barriers in ways that standardized research programs did not, she adds.
“There was this notion that we could use this methodology to get into young people’s heads and identify barriers and opportunities to reach more young people,” Lane says. “What I found is that the insights they thought they were generating were not any different from what we had generated over the years through surveys and studies.”
For instance, the technology approach focused on the relationship between providers and adolescents, an area that already had been explored in research. “We know what you can do to make providers more supportive and friendly to young people,” Lane says. “The problem is the social mores in a society that say young people should not be having sex or using contraceptives or go to health services.”
These social mores are an important challenge to adolescents accessing reproductive healthcare. “I have worked in the U.S. and internationally, and young people in this country definitely face many challenges to accessing contraception,” Lane says. “These include parental consent laws, pediatricians who are not set up to deal with kids who are sexually active and who may have a sexually transmitted infection (STI).”
Even in countries where half of the population is younger than age 30 years, there are too few providers available to work with adolescents in the realm of reproductive health. “We should do more at the preservice level of training nurses and doctors because adolescents make up a big part of the population,” she says. “Young people are healthy, but they are at risk of pregnancies, STIs, HIV, and mental health issues.”
In places where adolescents marry young or start families while they are young, they may have babies with brief intervals between pregnancies, and they may have little power to access contraceptives, she adds. In some places, as well as with misinformation spread online, there is a fear that contraception affects a person’s fertility. This may stop some adolescents from using the most effective female contraceptive, the implant, even though it allows for a quick return to fertility, she notes.
“Injectables have the longest return to fertility and are the most common method in some countries,” Lane says. “IUDs [intrauterine devices], implants, and pills allow a return to fertility pretty quick.”
A decade of failed improvements has shown that money needs to be focused less on a game changer and more on using strategies that work, including those that address social norms, she adds. “We need to look at the evidence base we’ve created over the last 40 years,” Lane says. “We know we need to help young people build their skills to access these services and address social norms, including parents, teachers, and peers, that prevent young people from using contraception.”
Strategies should combat misinformation, for instance by providing accurate information about how contraception does not make a person infertile. Other misinformation includes the idea that a person who becomes pregnant while using an IUD could end up with a baby holding the IUD in its hand or having it embedded in its forehead, she says.
“It reminds me of playground rhymes, where it becomes a part of your background,” Lane says. “These things are permeating and promulgated by social media and our friends, and a lot of young people will know they’re not welcome at these facilities, so they won’t try to make an appointment.”
Initial research using technology to improve contraception use showed an uptick of contraception in the communities that had these programs. But none were sustained over time, she notes. “There was no population use increase in contraception use except in Ethiopia, which implemented a massive program of health extension workers and had a women’s development army that they mobilized to talk with married adolescents about birth spacing,” Lane explains.
For most societies, some proven strategies for increasing contraception use include investments in programs that have proven beneficial, including multisectoral programming and engagement. “We have to go beyond reinventing the wheel,” she says. “We need to get stakeholders with a better understanding of young people, strengthen healthcare systems, provide youth-friendly services.” Communities can look to work done by the World Health Organization (WHO) to create adolescent-responsive health systems, for instance.
Social determinants of health also play a role in contraception use. For example, when researchers talked with youth about contraception and pregnancy, young people said they did not have jobs and needed jobs and skills. A multifaceted program could provide young people with skills training, such as teaching them coding, and then present information about contraceptives. “We’re increasingly aware of the need to use social determinants to address a young girl’s decisions and wellbeing,” Lane says. “Changing social norms is messy and not linear, and you can’t drive a straight line through it.”
The same is true among various communities in the United States, where young people sometimes have inaccurate understanding of what pregnancy and parenthood entail. “I used to work at a rural Planned Parenthood clinic, years ago, in California,” Lane explains. “For a lot of young people, having a baby is a pathway to adulthood.”
Lane recalls one 17-year-old client who was 12 weeks pregnant when morning sickness struck. At 15 weeks, she was saying she did not want to do this. “Her friend said, ‘You have to help her understand because she thinks a baby is like a Cabbage Patch doll and will love her unconditionally,’” she says. There also are teens whose mothers welcome the chance to have a “do-over baby,” a grandchild they can help raise, she adds.
“If you live in a small town, and your future is working at Target, having a baby, then people treat you differently,” Lane explains. “In other countries, a 16-year-old with a baby is considered an adult with the rights and privileges of adults.”
Communication campaigns about contraception must be sustained to be effective. Those implementing programs need to use funding frugally, putting resources into what has evidence of working. They also need to know that a model that works well in one place may not work as well in another.
“They need to find ways to collaborate and leverage each other’s efforts,” Lane says. “It’s hard work and messy and not linear, but that’s where we need donors to be going.”
Robert Hatcher, MD, MPH, founding author of Contraceptive Technology and professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta, says that contraceptives are more than birth control. For example, he says, intrauterine devices that elaborate the hormone levonorgestrel (Mirena and Liletta) are Food and Drug Administration-approved for treatment of heavy menstrual bleeding. They are protective against endometriosis, endometrial hyperplasia, endometrial cancer, and fibroids, Hatcher says. For teenagers, he says, they may be most important against menstrual blood loss and menstrual cramps and pain. “Contraceptives are much more than methods of birth control, and their use for other purposes needs to be discussed far more than now occurs,” Hatcher says.
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
Reference
- Lane C, Ferguson BJ, Chandra-Mouli V. Is a search for game changers preventing us from focusing on the necessary tasks of systems strengthening and norm change to facilitate adolescent contraceptive care? Reprod Health. 2024;21(1):125.
A decade of failed improvements has shown that money needs to be focused less on a game changer and more on using strategies that work, including those that address social norms.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content