abstracts

Abstracts of the presentations at
the 6th ESC
seminar, October 8-9, 2001 Coimbra, Portugal

MOTHERHOOD IN ADOLESCENCE

Adolescent Pregnancy – Overview

G. Creatsas, Greece

The consequences of increased adolescent sexuality
worldwide include: an increased rate of adolescent pregnancies and abortions; a high
prevalence of sexually transmitted diseases; and a significant number of
psychosocial problems.

Adolescent pregnancy is increasing in many countries where
people marry at younger ages. The adolescent pregnancy rate is also high in
rural areas of the same country where marriage also takes place at a young age.

Although adolescent sexual activity in the USA is not
significantly higher than in other industrialized countries, the adolescent
pregnancy rate is significantly higher. On the other hand, abortion rates are
similar. In Europe the figures are more encouraging. Adolescent pregnancy rate
was found to be low in girls aged 12- 14 years.

As updated multinational statistics take time to be recorded,
information can be taken only from national sources in countries which keep the
records.

In Greece i.e., the adolescent pregnancy rate has been
reduced from 7.5 in 1990 to 5.6 in 1995. This is partly due to the information
provided to adolescents and the fear of STDs, mainly that of AIDS. Data from
Europe also show that most adolescents prefer abortion instead of becoming an
adolescent mother, as they are concerned about the social, psychological and
legal problems of adolescent motherhood. From the medical point of view the
question on whether adolescent pregnancy is safe has been evaluated by several
authors. It has been reported that complications, such as toxemia of pregnancy,
anemia and Down syndrome in babies born to adolescent mothers are more frequent
compared to adult women. In a study performed in our Institution, we compared
three different age groups of primigravidas. A special protocol for the
evaluation and follow up of teenage pregnancies was followed. The protocol
included frequent clinical examinations, biochemical and hormonal tests, such as
alfa – fetoprotein, estriol and β-HCG, sonograms and an interview with a
social worker or/and a psychologist. Following this protocol, adolescent
pregnancies were characterized by a lower incidence of complications i.e.
toxemia as compared with older women. A lower incidence of intrauterine deaths
was also found. The above findings were associated with good perinatal outcome.

Improvement of adolescent sexual behavior should be one of
the primary goals of the 21^st century. This includes development of
new contraceptive techniques, providing protection from sexually transmitted
diseases, improvement of contraception compliance and the correct use of mass
media. As adolescents seek advice on sexual matters, it is our responsibility to
provide them with accurate consultation as well as free family planning services
in well organized adolescent units, where they may be counseled on the
prevention of unwanted pregnancy, and sexually transmitted diseases. This will
assist in a better fertility outcome and a safe motherhood.

Medical issues of adolescent pregnancies

M.O. Silva, Portugal

No
abstract available

Adolescent Parenting

Ana Guedes (Júlio
Dinis Maternity, Porto – Portugal)

The aim of this work is to report the most important data and
experiences of follow-up of adolescent mothers’ neonates at Júlio Dinis
Maternity.

One hundred and eighty five cases occurring during the year
2000 (4.9% of liveborns), are analyzed retrospectively, so as to get a global
vision of this phenomenon.

It is worth to note the
unfavourable social-economic factors
in the group studied as well as a high percentage of adolescent mothers coming
from dysfunctional or monoparental families. The prematurity incidence and the
perinatal and neonatal morbidity were not found to be more significant in this
population comparatively to the non-adolescent women neonates.

A long-term follow-up study will be necessary to evaluate the
future consequences of a so precocious and unfavourable social conditions
maternity.

ADOLESCENT SEXUALITY AND CONTRACEPTION

An overview of adolescent contraceptive methods

V. Bruni (Italy)

Hormonal contraception
Non hormonal contraception The natural regulation of fertility

The characteristics of an ideal contraceptive method for
adolescents are high efficiency, easy availability, low costs, the possibility
of an occasional use, the absence of any repercussions on the reproductive
health as well as the absence of side effects, the protection towards STDs, and
the minimum involvement of the adults and the health operators.

Hormonal contraception

Pharmacological research has introduced new formulations
with progressive reduction in EE Dose (21 day regimen with EE 20 µg and GSD 75
µg or Lng 100 µg and 24 day regimen with EE 15 µg and GSD 60 µg) or with New Progestogens with a peculiar metabolic characteristic:

– Dienogest a 19-norprogestin without ethinyl group in the 17alpha
position characterized by high bioavailability of approximately 90%, a half-life
of about 9 hours, with no bindings to SHBG, and little effects on lipid and
carbohydrate metabolism;

-Drospirenone a progestin with light antimineralcorticoid and
antiandrogenic activity.

It has been introduced a new Progestogen only pill (POP) with
75 µg of DSG, characterized by a good ovulation
inhibition, and low incidence of subjective and metabolic adverse events

Other formulations have been proposed for possible use during
adolescence.

– Injectable methods (monthly contraceptive injection with
MAP and Estradiol Cypionate

– Injectable Suspensions:
DMPA in injection use every (2
weeks)

– Implantable methods: all these long-acting progestin
methods for contraception have benefits in terms of minimal or absent user
failure, but they do not protect against STDs and are burdened by several side
effects.

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Non hormonal contraception

–
Male condom: with
perfect use there is a significant reduction in STDs including HIV. It is
important to stress that the simultaneous use of O.C. and condoms is a method
for preventing unwanted pregnancies and STDs.

–
Female condom: there
are few studies regarding STD prevention and the compliances.

–
Concerning diaphragm
the use among adolescents is inconsistent and the discontinuation rate after one
year is very high (50%).There could be better compliance for the Fem Cap, a new
vaginal Barrier contraceptive device, made of silicone rubber, available in two
sizes (regular and small). Durable and easy to clean; it should be inserted long
before any sexual arousal.

–
Local spermicidal
contraception : good acceptability and good local safety for the benzalkonium
chloride vaginal capsule.

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The natural regulation of fertility

can be found wide role in educational programs on health and
in the knowledge of ones own body.

The
Persona® method is not reliable
enough to be used as contraceptive method in adolescence or when a couple
absolutely wants to prevent a pregnancy , but represents a real support for the
adolescent in orders to obtain information about her own cycle.

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Les facteurs sociaux
liés à la survenue d’une grossesse et
au recours à l’ivg chez les adolescentes: analyse comparative dans 5 pays
industrialisés

Nathalie Bajos (Inserm U 292, France), on behalf the AGI
group research

A l’initiative de l’Institut Alan Guttmacher
à NYC, une
recherche comparative sur les grossesses adolescentes a été entreprise pour
essayer de comprendre les différences observées entre plusieurs pays
industrialisés. Le taux de grossesse chez les 15-19 ans est de 84 °/°° aux USA tandis qu’il est de l’odre de
20°/°° en France et en Suède. Le Canada et
la Grande-Bretagne présentent un profil intermédiaire avec un taux qui se
situe autour de 45°/°°.

Une analyse statistique secondaire des
enquêtes sur les
comportements sexuels, sur la contraception et l’ivg a été entreprise. Par
ailleurs, une analyse des contextes nationaux en matiére de législation sur la
sexualité, la contraception et l’avortement et de politiques de santé
reproductive a été entreprise, ainsi qu’un recueil des données socio-économiques
sur la scolarisation et l’activité professionnelle.

Les
données démographiques sur les grossesses adolescentes
et le recours à l’ivg ont été mises en perspective avec les caractéristiques des contextes nationaux pour mettre
à jour les facteurs
sociaux à l’origine des différences observées entre les pays.

Les
résultats de cette analyse comparative seront présentés et discutés lors du colloque de Coimbra.

Emergency Contraception for Adolescents

E. AubÈny (France)

Adolescence is the age of first loves and first sexual
encounters. Despite the fact that adolescent pregnancies are by and large
undesirable, adolescents’ use of contraceptive methods is imperfect for a number
of reasons. Lack of knowledge about contraception, technical difficulties
employing contraception, and sheer enthusiasm contribute to unplanned,
unprotected acts of intercourse. As a result, an interest has arisen in
contraceptive methods that operate after unprotected sex has taken place:
emergency contraception (EC). Adolescent use of EC depends on it being
reasonably priced and easily accessible. The French government has implemented
three initiatives towards this end:

– 1999: Implementation of over-the-counter distribution of
levonorgestrel-only EC (Norlevo®) in pharmacies, based on the absence of
contra-indications. 800,000 boxes have been since sold, and 60% of users are
under 18 (according to a study conducted among pharmacists). No serious side
effects have been reported, and there has been no reduction observed in use of
regular birth-control pills.

– 2000: Decision that EC would be provided free of cost to
minors (to come into being in October, 2001).

– 2000: Authorization for school nurses to distribute EC in
cases of emergency.

In theory these measures should contribute to a reduction in
adolescent abortions, but it is still too soon to determine whether this is
true.

In either case, the widespread use of EC by adolescents
demonstrates that EC responds to a genuine need.

Medico-legal aspects of
abortion in Europe

Pinter B, Department of Ob/Gyn, University Medical Center,
Ljubljana, Slovenia

Introduction: Abortion is a response to unplanned and
unwanted pregnancy. The practice of abortion in a particular country reflects
culture, economic status, religion and the law. Religious beliefs are one of the
most influential factors affecting abortion issue. But no matter the cultural,
religious or legal status of abortion, women who do not want to be pregnant will
end the pregnancy in any way, even for the price of their lives and health.
Every year about 210 million women throughout the world get pregnant, 15% of
pregnancies end in miscarriages and stillbirths, 22% in induced abortions and
63% in live births. Worldwide approximately 50 million abortions occur annually,
and 20 million or more are performed under unsafe, unusually illegal
circumstances. Every day more than 200 women die of unsafe abortion! Various
aspects of abortion in Europe – laws, rates and practices – are presented.

Abortion laws: Abortion is completely prohibited in
Ireland and Malta. In Poland it is allowed only to save the woman’s life or
protect her physical health. On the grounds to protect also woman’s mental
health is allowed in Northern Ireland, Portugal, Spain and Switzerland. Despite
of the fact that abortion is legal in Portugal, the woman cannot obtain it
because it is inaccessible. On socioeconomic grounds abortion is allowed in
Finland, Great Britain and Hungary. In the other European countries it is
allowed on a demand. Most countries with the liberal laws set the gestational
limits for abortion on a demand from 10 to 12 weeks (except Netherlands to 22
weeks). In some countries (Austria, Denmark, Germany, Greece, Italy,
Netherlands, Norway, the republics of former Soviet Union, Sweden, Turkey)
written parental consent must be obtained for adolescents. In Turkey there is
also a requirement for partner consent to abortion. Some countries (Belgium,
France, Germany, Hungary, Netherlands and Poland) have mandatory counseling with 3-8 day waiting period. Abortion is mostly free of charge, except in some
former Soviet Union republics.

Abortion
rates: Eastern Europe has the highest abortion
rate (Romania 78/1000 women 15-44), and Western Europe has the lowest one
(Netherlands 65./1000); the disparity exists despite little difference in the
legal status of abortion, and may be attributable to differences in availability
and use of effective contraceptives.

Abortion practices: The safest abortions are those
performed early in pregnancy by well-trained practitioners using surgical or
medical methods in legal settings. Within the first 12 weeks of gestation vacuum
aspiration has replaced dilatation and curettage. In the last years medical
abortion (mifepristone with prostaglandins) early in pregnancy has been used in
several European countries. Medical abortion holds the potential to substantially
change the character of abortion provision and the cultural meaning of abortion.

Conclusion: In every country, reduction of the need for
induced abortion and prevention of unsafe abortion through the provision of
appropriate legislation and good family planning services should be an integral
part of health care.

ADOLESCENT PREGNANCY IN PRIMARY HEALTH CARE

What’s happening in Fernão de Magalhães Health
Center?

Filipa Vieira

Fernão de Magalhães Health
Center, Coimbra

Having in mind the real problem of pregnancy in adolescence
we have made a serious approach to this question in what concerns Primary Health
Care.

We are going to present what is happening in the Fernão de
Magalhães Health Center in Coimbra.

We think that prevention, contraception, sexual education,
articulation and cooperation with maternity hospitals, support of the young
pregnant and her family are the first steps to be walked to any kind of success
in this area.

In our Health Center we have bet mostly in the research,
continuous medical education and continuous professional development. We have
also made all the efforts to catch on the children so that later on as
adolescents they may trust and look for help with us. Whenever the adolescents
come to the Health Center by some reason we have to profit from that opportunity
and lead them to healthy life styles. As healthy life styles we mean to make
them responsible for their sexual life as to attain maturity and happiness.

Furthermore all the staff has to be attentive and available
and we have to show them confidence, competence, respect and confidentiality.

We have also implemented a Familiar Planning Consultation
where all the young adolescents may go without any restrictions. It’s an ideal
place to talk about sexual education, contraception, sexual transmissible
diseases, unwanted pregnancies and to clarify any doubts they have.

Over the last ten years we have been witnessing, with a
rather pleasant feeling, that the young people are coming more and more to the
Familiar Planning Consultation and sometimes with their partners who have been
involving in that question.

Our Health Center is engaged in continuing the strategies of
taking these policies of health care outside the walls of the Health Center.
These strategies aim at several groups, at several contexts as for instance
schools, professional schools, informal meetings and others where we can catch
the adolescents’ attention.

It is important to emphasize that we already know how
important are some tools to call on the young people like interactive
communication, youth leaders’ opinions and their active participation.

Whenever an adolescent becomes pregnant we give her all the
health care she needs and the psychological support not only to her but also to
her family, who sometimes has difficulty to deal with the problem.

As these adolescent pregnancies are risk ones we send them to
one of the two maternities in our town, where they will be followed in a special
adolescent consultation.

This care articulation is very important not only during the
pregnancy but also after the baby birth when the bridge between the family and
the Health Center is always open, to help to build a new family.

Adolescent Pregnancy in Primary Health Care: What can we do?

Nunes Berta and Ema Parada

Health Center of Alfândega da
Fé

Even if they have access to safe contraceptive methods and
information, teenagers still get pregnant, also in our region.

In our Health Center (situated in Alfândega da
Fé , a
rural region in the northeast of Portugal), we looked at the number of
adolescents (<<19 years) who got pregnant from 1995 to 2000 and we found 17
cases, 7% of all pregnancies on that period.

Because we recognize the problem and want to prevent these
(mostly unwanted) pregnancies, we created in 1999 a space in the secondary school
where a nurse inform the students and if they want to initiate contraception
they have an appointment with the same nurse at the Health Center and if
necessary they are also seen by a doctor. This year a psychologist, from an Association
is going to collaborate in this space in the school.

We also cooperate with a youth Association that works in this
area and we use the opportunity of the global examination we do to all 11-13
years students, to inform them about contraceptive methods and sexually
transmitted diseases and how they can use the Health Center if they want, for
getting information and contraceptive methods freely.

We also cooperate with the basic and secondary schools,
informing students and teachers about these themes, trying also to involve
parents and all health professionals of the Health Center, in order to create a
culture that encourage young people to have responsible sexual behaviour: this
means also that adults recognize the adolescents the right to express their
sexuality.

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