Contraceptive Counseling for Adolescents

Abstract

The majority of adolescents become sexually active during their teenage years, making contraceptive counseling an important aspect of routine adolescent healthcare. However, many healthcare providers express discomfort when it comes to counseling adolescents about contraceptive options. This Special Report highlights the evidence supporting age-appropriate contraceptive counseling for adolescents and focuses on best practices for addressing adolescents’ questions and concerns about contraceptive methods.

What is contraceptive counseling?

Contraceptive counseling is the process by which a patient is introduced to available methods of contraception and guided in selection and use of a method. Ideally, contraceptive counseling is a dynamic conversation during which the patient and provider discuss method availability and pros and cons of each method, with the focus being the individual needs and desires of the patient. The conversation should include not only accurate information about available methods, but also education about correct and consistent method use. This process can be time-consuming; in the USA, the average adult woman spends about 35 minutes at a family planning appointment [1]. Given the often complex needs of adolescents, contraceptive counseling takes additional time and skill when done correctly.

In addition to time constraints, lack of evidence regarding what constitutes efficacious contraceptive counseling is a barrier to providing high-quality contraceptive counseling. Few studies have pursued this topic and those that have are largely weak in measuring the impact of counseling [2]. Instead of focusing on direct outcomes such as method choice, consistent method use, accurate method use and unintended pregnancy, the current literature mainly focuses on indirect outcomes, such as contraceptive knowledge. Studies that have looked at how contraceptive counseling affects contraceptive behavior or pregnancy rates have not found a significant impact of counseling type on outcomes [2]. Recommendations about contraceptive counseling practices are therefore mostly rooted in theory, rather than evidence.

For adolescents, it is critical to integrate a contraceptive need assessment into every primary care visit, as most individuals have sexual intercourse for the first time during adolescence [3]. Adolescents may not explicitly approach their providers with a request for contraception; the provider must take a thorough history in order to determine whether contraception is indicated. Adolescents often present after the onset of sexual activity for their first family planning visit [4]. Adolescent providers should ask at every visit whether their teen patients have had sex or are planning to have sex. If the answer to either question is yes, it is important to then determine the teen's contraceptive plan. The majority of adolescents in the USA are now using condoms at first sex – a great shift from contraceptive behavior three decades ago – and the conversation about contraception therefore should focus on dual method use. Dual method use means initiating a more effective method of contraception for pregnancy prevention in conjunction with condom use for sexually transmitted infection prevention.

Some providers may want to encourage adolescents to abstain from sexual activity, rather than provide comprehensive contraceptive counseling. However, there is no evidence that promoting only abstinence is effective at reducing sexual risk behaviors among adolescents [5]. Rather, experts promote combining education about contraception and sexually transmitted infection prevention together with a discussion about the benefits of refraining from sexual activity, particularly when one is not ready for a sexual relationship [6].

Setting the stage for contraceptive counseling

Setting the stage for contraceptive counseling means assuring the adolescent that his/her care is confidential. Research suggests that some adolescents will not access reproductive care unless they trust that their care is confidential [7]. Providers should first explain to the adolescent and parent/guardian, if present, that the standard of care is to provide adolescents with confidential time at every visit, time during which the adolescent is interacting with the provider without the presence of a parent. After asking if the parent has any concerns or questions, the provider can then request, in a polite and open manner, that the parent/guardian have a seat in the waiting room. When the provider is alone in the room with the adolescent, it is then important to reiterate an accurate statement about the adolescent's right to confidentiality, which differs by state.

Confidentiality is just one aspect of the trust that must be established between patient and provider; there are additional provider attributes that can help an adolescent feel comfortable during contraceptive counseling and potentially improve effectiveness of counseling. Adolescents have identified expertise, trustworthiness and availability as important qualities of the contraceptive counselor [1]. Madden et al. described how rapport-building between patient and provider was standardized during the contraceptive counseling conducted for the contraceptive CHOICE project, a project that was successful at helping women initiate highly effective contraceptive methods with good adherence and satisfaction [8]. The CHOICE project relied on a technique for contraceptive counseling that encompassed nonmedical conversation prior to formal contraceptive counseling, including greeting clients in a friendly way and asking them about their lives using simple, open-ended questions [8].

While establishing confidentiality and rapportbuilding are critical for establishing a solid base for contraceptive counseling, it is also important to recognize that an adolescent's partners, family members and friends greatly influence her contraceptive selection and method adherence. Teens rely on advice from trusted people in their lives, both about contraceptive initiation and contraceptive selection [9]. It is therefore important for the provider to be aware of the opinions and biases of these partners, friends and relatives and to include these people in the conversation, if the adolescent desires. At the least, understanding mother's and partner's feelings about and support for different contraceptive methods can be useful in understanding contraceptive choice and future adherence.

Relationship context impacts contraceptive counseling and selection differently for adolescents than it does for adults. While most adolescents have been in at least one relationship by the middle of adolescence [10], the tendency for adolescents to transition into and out of relationships is associated with gaps in contraceptive use and puts teens at risk for unintended pregnancy. This phenomenon argues on behalf of long-acting reversible contraceptive (LARC) methods, which have higher rates of continuation and efficacy than other methods of contraception [11,12].

Adolescent development also differentiates adolescent contraceptive counseling from that of adults. Adolescents, because of their age, have not yet fully developed executive functioning, including decision-making and the ability to delay reward-seeking. This may translate into an overestimation of immediate effects, such as side effects, and an underappreciation of long-term effects, such as prevention of unintended pregnancy. While it is important to give adolescents autonomy over contraceptive decision-making, presenting the options in a structured way that guides teens through the decision-making process is developmentally appropriate. Giving equal weight and time to each contraceptive method can result in ‘information overload’ and lead to poorly informed choices [1].

A practical approach to contraceptive counseling

Several authors have advocated a practical approach to contraceptive counseling for adolescents [1,8]. The steps of this approach are rule out medically contraindicated methods, determine whether side effects preclude use of certain methods, assess whether the adolescent or her peers are interested in a particular method and present remaining options in order of efficacy. The goal is to narrow the menu of possible contraceptive methods to a short list of methods that will be safe and not result in unacceptable side effects for the teen, while providing the best contraceptive efficacy possible. It is important to recognize provider biases and not to dismiss any method without collecting necessary information from the adolescent. Provider comfort and misperceptions about certain methods may prematurely limit the number of options discussed; for instance, a provider might assume that an adolescent would be prefer to take birth control pills rather than have an implant inserted. The adolescent, rather than the provider, should make the judgment call about what options appeal to her.

For the average, healthy adolescent, medical contraindications to contraception are usually associated with estrogen-containing methods. Among the more common contraindications to an estrogen-containing method are migraine with aura, untreated hypertension and personal history of deep venous thrombosis or stroke. The WHO has published a list of medical eligibility criteria which assigns a safety grade of 1–4 to each available contraceptive method. A ‘4’ indicates that risks greatly outweigh benefits, which a ‘1’ indicates that the method is generally considered safe in the given population. This reference is a valuable tool for investigating potential contraindications in the setting of less common medical conditions [12].

The side effect profiles of contraceptive methods have great impact on adolescent method selection and continuation. Specific side effects to contraceptive methods are common reasons for adolescents to discontinue method use and should be addressed upfront as part of method selection. Menstrual regularity differentiates combined hormonal methods, which generally produce a regular menstrual/withdrawal bleed, from progesterone-only methods, which often result in unpredictable bleeding patterns or amenorrhea. Other personal factors might sway an adolescent toward/away from certain methods, such as comfort with inserting a device into one's vagina or comfort with medical procedures. These factors, together with side effects, are often discussion points during a counseling session. For instance, an adolescent who believes it is unhealthy not to have monthly menses may be open considering another perspective after education is provided. Similarly, education about the IUD insertion process may make this method more appealing.

Duration of method use is of particular importance for adolescents, many of whom desire delaying pregnancy by years. Long-acting methods, such as the IUD or implant, may therefore be ideal for teens. However, many adolescents also display ambivalence about pregnancy intention [13] and providers must not fall into the trap of assuming that long duration of method efficacy is always positive. Reversibility of methods must be stressed; lack of control over removal of long-acting methods of contraception may be a barrier to their use [14].

When other factors have been addressed, remaining methods should be considered in order of efficacy. Contraceptive efficacy is can be understood in terms of perfect use or typical use. A gap between perfect use and typical use typically emerges when methods are ‘user-dependent’, in other words, the user's behavior affects how well the method works. Methods requiring the user to engage in a certain behavior – for instance, taking a medication, using a device, or returning for frequent office visits – display lower typical use efficacy compared with perfect use efficacy. In contrast, long-acting reversible contraception, which includes intrauterine devices and implants, are both inserted and removed in the provider's office, making them user-independent. However, no matter what contraceptive method is selected, contraceptive counseling should aim to help users move from typical use efficacy rates toward perfect use efficacy rates by improving method adherence and trouble-shooting errors in method use (Figure 1).

Figure 1.

Contraceptive efficacy: typical use versus perfect use.

Quick start & follow-up

Contraceptive method selection is not the conclusion of the contraceptive counseling session. In addition to method specific anticipatory guidance (i.e., what to do if a method is forgotten or unacceptable side effects are experienced), the provider and patient together need to discuss when to initiate the selected method. Some methods are started in the office (injections, implants, IUDs) while other methods can be started by the patient on her own outside the office, but all methods can and should be ‘quick-started’, or begun on the same day as method selection. This stands in contrast to a protocol of initiating hormonal birth control with menses (the traditional ‘Sunday start’) in order to rule out pregnancy. Studies show that adolescents who quick start contraception are more likely to initiate contraception and more likely to continue method use [15,16]. A same day method start is appropriate if the adolescent's pregnancy test is negative, emergency contraception is offered if the last unprotected sex was in the last 5 days and the adolescent agrees to use a back-up method for the first week of method use (condoms) and to return for a pregnancy test in 3 weeks if pregnancy cannot be reliably excluded (i.e., unprotected sex in the last 2 weeks). In the case of IUD insertion, pregnancy should be reliably excluded with a negative pregnancy test and no unprotected intercourse within the 2-week period preceding insertion. If the first day of the adolescent's period was less than 5 days prior to method initiation, the contraceptive method can be started without the need for backup method use. Hormonal contraception has been shown not to adversely affect a pregnancy and would be only need to be discontinued, with no additional action taken, in the event that a pregnancy were diagnosed at the follow-up visit [17]. The copper IUD is an exception to the above algorithm, as it can be used as emergency contraception and is effective immediately, without the need for back-up method use for the first week.

At the end of a contraceptive counseling session, it is important to establish a plan for follow-up. There are many reasons to schedule a follow-up visit 3–6 weeks after method initiation: to perform a repeat pregnancy test if a method was quick-started, to trouble-shoot problems that have arisen with method use, to assess for both serious and bothersome side effects, to encourage method continuation, to transition to a new method if the current method proves problematic for the adolescent. Some providers prefer to follow-up with an adolescent sooner by phone, though studies have not shown that this strategy improves adherence [18].

Conclusion & future perspective

Contraceptive counseling for an adolescent should take into account adolescent behavior and development in order to guide the adolescent in selection of an appropriate, efficacious and acceptable contraceptive method. After a contraceptive method is selected, attention should be paid to helping the adolescent achieve correct method use, good adherence and ongoing follow-up care. Future adolescent contraceptive counseling will likely be conducted by interdisciplinary teams of medical providers and may well rely on patient feedback received in real time, made possible by technology.

Executive summary

• The purpose of contraceptive counseling is to educate about contraceptive options and to guide patients in selection of an appropriate method.

• Not all contraceptive methods have equal efficacy; counseling should highlight the most efficacious methods that are safe and acceptable for the adolescent patient.

• Adolescents may be particularly bothered by side effects of certain methods; it is important that they are counseled about these side effects prior to method initiation.

• The developmental stage of an adolescent impacts his/her receptivity to counseling.

• Failure to ensure confidentiality is an obstacle to adolescents accessing contraception and contraceptive counseling.

• More evidence is needed to inform contraceptive counseling practices for adolescents.