Setting the Agenda for Full Contraceptive Choice for Youth

Like young people themselves, the field of adolescent and youth sexual and reproductive health is ever-changing and maturing. While in some settings even breathing the words “youth and contraception” in the same sentence can stop the conversation, we know that:
• In many low- and middle-income countries, youth account for more than 50 percent of the population, unintended pregnancies, and unplanned births, and yet they are not using contraception.
• Many programs to reduce the rate of unplanned pregnancies among youth still implement interventions that are not evidence-based or have been shown to be ineffective.
• Cost, provider biases, misconceptions, and social norms often limit access to quality, age-appropriate information, services, and contraceptive methods for young people.
There is a growing body of knowledge on effective strategies for reaching youth and addressing many of the barriers that prevent youth from using effective contraception. Further, we know that the most effective form of contraception is the least used by youth globally. I am referring to long-acting reversible contraceptives or LARCs. The term “LARCs” seems to imply a broad range of methods, but in truth, we are talking about implants and IUDs.

Where we started
Since 2015, a small group of dedicated global health professionals has been discussing how to expand contraceptive options for youth to include LARCs. What started as an ad hoc assembly of colleagues has evolved into an organized working group led by the U.S. Agency for International Development (USAID), FHI 360, Pathfinder International, Evidence to Action (E2A), Population Services International, Marie Stopes International, and FP2020. Our goal is to identify existing best practices and call attention to research and programming gaps for expanding access to contraceptives for youth. Among our first accomplishments was the development of the Global Consensus Statement for Expanding Contraceptive Choice for Adolescents and Youth to Include Long-Acting Reversible Contraceptives (“consensus statement”). Launched at the 2016 International Conference on Family Planning, it has been endorsed by more than 50 organizations and hundreds of individuals. This important advocacy tool is being used to advance the discussion within countries and programs on the value of access to and use of LARCs. 
Building on the momentum around the consensus statement, the working group, with leadership from Pathfinder/E2A, is hosting a four-part webinar series. Participants are discussing actionable strategies and solutions for expanding contraceptive method choice to make LARCs available to adolescents and youth.

The Missing Links 
On May 18, the second webinar, entitled The Missing Links and led by FHI 360, outlined some of the research related to expanding method choice for youth to include LARCs while highlighting the additional evidence needed. Dr. Caitlin Parker of the CHOICE Project explored how evidence from research in the United States can be applied to programs that expand contraceptive choice for adolescents and youth around the world. Dr. Holly Burke of FHI 360 used examples from low- and middle-income countries to discuss considerations for conducting research on expanding contraceptive choice for adolescents and youth, as well as evidence gaps and future research and programmatic directions. Their presentations will soon be available on the E2A project site.

A question-and-answer period followed the presentations, during which a research and programmatic agenda was debated. Some the questions that were proposed by participants include: 
• How can we ensure that youth are considered as we address the key elements of new product introduction and scale-up? 
• How can we include youth perspectives in demand creation? 
• How does provider stigma, provider bias, and discrimination influence uptake?
• What is the role of church and government in the provision of information about LARCs, and could a collaboration increase uptake? 
• Is there any established training for providers or discussion of coercion as a part of counseling when adolescents are seeking information on contraception? 
• To what extent should effectiveness be emphasized when counseling adolescents about their contraceptive options? Some fear that adolescents would equate an emphasis on effectiveness and long duration with compromised future fertility; others think that, all other things being equal, effectiveness should be emphasized. 
• A study in the United States was remarkable in its use of school nurses and referral systems for LARC provision. Is it possible to develop similar programs in low- and middle-income countries, using either secondary schools or colleges? 
• How do young people best learn about LARCs and other contraceptives? Through one-on-one counseling, mobile technology, from friends and family?
One participant’s comment says it all — “I think more research needs to be done.”

Looking to the future
As a global health community, we have a responsibility to use our evidence, practice, and experiences to create a pathway forward and we will continue to wrestle with these questions. For our next step, I propose we begin to identify priority areas for research and develop a learning agenda. USAID has encouraged the use of learning agendas as a “powerful tool to focus learning efforts on knowledge or evidence gaps.”
While there are still many unanswered questions, research demonstrates that when presented with accurate information about the full range of contraceptive methods — including effectiveness, convenience, side effects, duration of effectiveness, etc. — many young people choose LARC methods. With continued research and education, we can better understand and respond to the needs of young people in accessing the contraceptive methods that are best for them.

Stay tuned for information on the next two webinars on this topic. One will focus on The Global Financing Facility and contributions to improve adolescent and youth sexual and reproductive health, and the other will discuss ways to use the Global Consensus Statement as an advocacy tool.

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