Impacto do planejamento familiar na vida sexual e reprodutiva de adolescentes / Impact of family planning on the sexual and reproductive life of adolescents

Introdução: O programa de planejamento familiar é uma importante ferramenta na redução dos índices de gravidez na adolescência, que é considerada uma questão de saúde pública. Objetivos: Compilar as publicações científicas nacionais e internacionais acerca do impacto do planejamento familiar na prevenção da gravidez em adolescentes. Métodos: Foi realizada uma revisão de literatura nos bancos de dados da Biblioteca Virtual de Saúde (BVS), Google Scholar, SciELO e PubMed, no período de agosto a dezembro de 2020, a partir de estudos experimentais e observacionais. Resultados: Dos 20 artigos incluídos, foi realizado agrupamento dos dados que possibilitou a construção de três unidades temáticas: programa de planejamento familiar-potencialidades e fragilidades; fatores determinantes e condicionantes da gravidez na adolescência; educação sexual como ferramenta de prevenção da gravidez na adolescência. Conclusão: A eficácia dos programas de planejamento familiar, dependem de vários fatores: treinamento adequado dos profissionais envolvidos, fornecimento gratuito de insumos, metodologia de educação sexual aplicada, local da instalação da sede física do programa e o público-alvo atingido.

Introduction: The family planning program is an important tool in reducing teenage pregnancy rates, which is considered a public health issue. Objective: To compile national and international scientific publications on the impact of family planning on pregnancy prevention in adolescents. Method: A literature review was carried out in the databases of the Virtual Health Library (VHL), Google Schoolar, Scielo and PubMed, from August to December 2020, based on experimental and observational studies. Results: Of the 20 articles included, data were grouped, which enabled the construction of three thematic units: family planning program - strengths and weaknesses; determining and conditioning factors of teenage pregnancy; sex education as a tool to prevent teenage pregnancy. Conclusion: The effectiveness of family planning programs depends on several factors: adequate training of the professionals involved, free supply of inputs, applied sex education methodology, location of the program's physical headquarters and the target audience reached.

Bahamas project receives midterm evaluation.

PIP: This paper presents the findings of the midterm evaluation of the Adolescent Reproductive Health Education Project in the Bahamas. An independent evaluation team, consisting of international and local evaluators, carried out interviews with project stakeholders and conducted other activities to assess the progress made in the project's two major components. These components are information, education and communication (IEC) in the schools and the community, and the institutional strengthening of the executing agency, the Bahamas Family Planning Association (BFPA). Most of the professionals trained by the project indicated that the workshops provided new information and knowledge on adolescent reproductive health and helped them overcome their lack of confidence in talking about sexual issues, in particular to adolescents. The evaluators noted this as one of the major achievements of the project so far. The evaluator underscores some areas to be improved, which include IEC component delays, institutional strengthening of BFPA, strategic planning, and data monitoring.^ieng

Give choice a chance: new report on Guatemala.

PIP: This paper provides an overview on the research report entitled "An Unfulfilled Human Right: Family Planning in Guatemala," by Bonnie Scott Jones, Staff Attorney of Center for Reproductive Law and Policy. The research examines Guatemala's reproductive health care networks. It also presents the factors influencing the high rates of maternal mortality, unwanted pregnancy and extreme poverty. The information gathered from indigenous women, traditional birth attendants, nongovernmental organizations and government officials revealed an appalling lack of support from the Guatemalan government for promoting and protecting its citizens' right to family planning information and services. In addition, the research indicated the role of the Catholic Church in the country's family planning programs.^ieng

Mexican press tour helps raise public awareness.

PIP: In an effort to increase public awareness in Japan of global population and reproductive health issues, 5 Japanese journalists from Japan Broadcasting Corporation (NHK), Kyodo News, Nihon Keizai Shimbun, Yomiuri Shimbun, and FM Hokkaido traveled with a JOICFP team in Mexico for 12 days in October 1988. It is hoped that, following their experience in Mexico, the journalists will help to create favorable public opinion in Japan toward development assistance in population. The UNFPA Mexico office, the Japanese embassy, JICA, central and local ministries of health, and nongovernmental organizations (NGOs) in Mexico City and rural areas were visited during the tour. Specific sites and programs visited include a NGO in Catemaco, Veracruz state, a junior high school sexuality education program funded by the Packard Foundation, a community guest house for child deliveries in Puebla State, and a MEXFAM clinic funded by the owner of a towel factory. As a result of the study tour, an 8-minute program was aired on NHK, featuring an interview with the director of MEXFAM. The journalists learned from the tour.^ieng

Bahamas project update.

PIP: In August 1998, JOICFP agreed with the Inter-American Development Bank (IDB) and the Bahamas Family Planning Association (BFPA) to help BFPA implement a nationwide, adolescent reproductive health education project over a 3-year period. As part of that cooperative agreement, 3 JOICFP experts visited the Bahamas from October 4 to November 1, 1998. Since the BFPA project team had limited experience managing projects and was unfamiliar with the framework upon which projects would be implemented and evaluated, Project Cycle Management (PCM) training was provided. That training enabled the BFPA team to draft its own logical framework as an alternative to the IDB's framework. The project team now believes that it can implement the project on its own. The project being implemented in the Bahamas is unique in that a nongovernmental organization is responsible for building part of a school curriculum.^ieng

Guatemala -- strength is NGO cooperation.

PIP: In early 1999, representations of the UN Population Fund, JOICFP, and APROFAM met in Guatemala to monitor progress of an integrated program promoting reproductive health (RH) and family planning (FP) among Mayans in the Department of Solola. The team observed field activities, such as training, and assessed information, education, and communication (IEC) promotion; service delivery; institutional coordination; and adolescent health programs. The program is training traditional birth attendants (TBAs) to provide RH/FP and general medical services. At one site, a TBA acquires counseling for her clients from a physician via the telephone. This activity will be facilitated with the addition of radio receivers. Resources have been maximized by increasing collaboration among the project, the government, and local nongovernmental organizations. Referrals are being facilitated with improved communication tools and provision of a boat and ambulance for transporting clients. Cooperative efforts are also being made to promote community health and development, health education, and adolescent health.^ieng

Leaving machismo behind.

PIP: A study, which was conducted in Colombia's five largest cities, determined men's, women's, and health care provider's knowledge, attitudes, and needs regarding sexual and reproductive health services for men. Data were collected through 60 focus groups, 720 surveys of service users and nonusers, 45 interviews with health care staff, and 5 couple's life histories. The study found that, due to the inadequate service facilities offered to men, it was difficult for men to achieve the goal of being responsible about their own and their partner's sexual and reproductive health. Only 9 of the 14 health care facilities surveyed rendered services such as vasectomy, health care promotion or prevention, and educational programs aimed at men. According to providers, one reason for lack of services is the low utilization rate even if such services are available. In addition, existing services focus on disease management rather than preventive protocols. The AVSC will work with health care facilities, the Ministry of Health, and health insurance companies in establishing sexual and reproductive health services for men in Bogota, Cali, and Medellin.^ieng

Taking health to the high Sierra. Millennium trailblazers 4: Jambi Huasi.

PIP: The article features the Jambi Huasi or Health House in Otavalo that provides quality reproductive health services to people living in poor urban settlements and remote rural areas. The Jambi Huasi is unique in that it furnishes both modern and traditional medical treatment, as well as family planning advice and services. This unique combination of services has made it a very popular clinic in the communities of Otavalo. In 1998, close to 10,000 people were using the clinic's services on a yearly basis and about half of Jambi Huasi's clients use the services of traditional healers. Moreover, the clinic has a full-time communication and education specialist who speaks to Quechua women and men in an attempt to increase awareness of reproductive health issues provided by the clinic and its satellite operations. Outcome of the efforts of the staff in Jambi Huasi is seen in the increase of the contraceptive prevalence rate from 10% to 40%, and both infant and maternal mortality rates have fallen in Otavalo. One of the keys to the success of Jambi Huasi is the totally community-based way of health services it offers that matches the need of traditional communities.^ieng

Timing of onset of contraceptive effectiveness in Depo-Provera users: Part I. Changes in cervical mucus.

OBJECTIVE: To evaluate the changes in cervical mucus within the first hours or days after depot medroxyprogesterone acetate (MPA) injection so as to estimate the time at which cervical mucus becomes hostile enough to prevent pregnancy. DESIGN: Multicenter, clinical descriptive study. SETTING: Family planning clinic. PATIENT(S): Thirty women who were between days 8 and 13 of their menstrual cycle and who had requested Depo-Provera were enrolled in the study. INTERVENTION(S): Cervical mucus and blood samples were obtained; transvaginal ultrasonography was performed. MAIN OUTCOME MEASURE(S): Cervical mucus scores, sperm penetration distances, ovarian follicular size, and serum levels of progesterone and estradiol. RESULT(S): From 6 to 24 hours after injection, there was a sharp decline in the cervical mucus score for most of the subjects. All subjects exhibited poor mucus on day 3 after injection, and by day 7, all subjects had zero scores, with the exception of two outliers on each day. Sperm penetration, as measured by the vanguard sperm distance, was already poor (< 1 cm) in 7 of the 30 subjects at the time of injection and was reduced progressively up to 24 hours after injection, when only four subjects had a sperm penetration of > 1 cm. A rapid decline in the estimated number of sperm was observed at 12 hours and more so at 24 hours in the majority of subjects. CONCLUSION(S): The data presented in this report confirmed that depot MPA causes profound changes in cervical mucus after injection. Although very little change was seen at 6 hours, alterations were observed subsequently, with 90% of the subjects showing a poor cervical mucus score 24 hours after administration of the progestin. No reliable clinical marker is available to identify in which women depot MPA might exert its effect on cervical mucus within 3 days. Thus, we believe that at present, women should be informed of this uncertainty and should use a backup method of contraception for 7 days when the first injection of depot MPA is provided after the seventh day of the menstrual cycle.

PIP: More accurate knowledge of the time of onset of cervical mucus changes after Depo-Provera injection would enable family planning providers to counsel new acceptors to use a backup method only for the amount of time it is really needed. To obtain such data, 30 women from a family planning clinic in Campinas, Brazil, who requested Depo-Provera in 1995-96 were recruited. At baseline, 11 women had a poor cervical mucus score (0-4), 12 had a fair score (3-8), and 7 scored in the good range (9-12). Between 6 and 24 hours after injection, a sharp decline occurred in the cervical mucus score in all but 3 patients (each of whom had a "good" score at baseline). On day 3, 29 women had "poor" mucus and the remaining woman had a cervical mucus score in the fair range. By day 7, 29 women had zero mucus scores; the score in the last woman was 1. 24 hours after injection, sperm penetration (measured by vanguard sperm distance) had decreased to under 1 cm in all but 4 women. At day 3, 1 of the 2 women with good penetration at 24 hours maintained a vanguard sperm distance of 2.5 cm and an estimated sperm count of 15,363. By day 7, sperm penetration was zero in all but 1 woman (0.5 cm). These findings confirm that depot medroxyprogesterone acetate causes profound changes in cervical mucus after injection. The lack of a more complete hostility to sperm penetration at day 3 was unexpected, however. Given the nonavailability of a reliable clinical marker to verify a contraceptive effect at 3 days, it seems prudent to advise new Depo-Provera acceptors to use a backup method for the first 7 days.

Contraception and culture: the use of yuyos in Paraguay.

The use of herbs (yuyos) as contraception is common practice in Paraguay. This report analyzes data from the 1995-1996 Paraguayan Reproductive Health Survey. The analysis reveals that women are more familiar with yuyos (88%) than any other method of family planning. Modeling the determinants of ever having relied on yuyos as contraception demonstrates that older women (OR = 1.043) and women with more children (OR = 2.283) are significantly more likely to have used yuyos, but an interaction between older women with more children shows they are less likely to have used this method (OR = .982). Women living in rural areas (OR = .664) and those with more education (OR = .883) are less likely to have used the method. These findings show widespread acceptance and use of yuyos for contraception in Paraguay. More research into the chemical properties of yuyos is needed to determine their contraceptive efficacy and to prevent harmful effects from their misuse.

PIP: According to the 1995-96 Paraguayan Reproductive Health Survey of 6465 reproductive-age females, women are more familiar with herbs (yuyos) than any other method of contraception. These herbs are prepared most frequently as teas and drunk every day. 88% of respondents were aware of yuyos. Bivariate analysis indicated that current yuyo users were geographically isolated, older, less educated, poorer, and more likely to speak Guarani in the home than non-users. In the multivariate analysis, ever-use of yuyos was significantly associated with older age (odds ratio (OR), 1.043) and more children (OR, 2.283), while high education (OR, 0.883) and urban residence (0.664) were inversely related to ever-use. Since no protocol exists for yuyo use for contraception, indigenous women rely on word-of-mouth advice and may be at risk of toxic side effects from improper use. Needed, to reduce this risk, are research studies on the use of herbs in other countries for contraceptive purposes and more rigorous testing of the chemical agents found in plants used for fertility control. If efficacy is discovered, additional research is recommended to identify the conditions under which and for how long yuyos should be taken for contraception or menstrual regulation. Any program that builds on yuyo use to promote use of modern contraceptive methods must proceed in a culturally sensitive way.

Cost analysis serves many purposes.

PIP: This article discusses the utility of performing cost analysis of family planning (FP) personnel resources by relying on a system analysis framework in developing countries. A study of a national provider that distributes 16% of all FP services in Mexico found that more efficient use of staff would increase the number of clients served. Nurses and doctors worked slightly more than 6 hours/day, and 38% of a nurse's time and 47% of a physician's time was spent in meetings, administrative duties, unoccupied work time, and personal time. The Mexican government proposed increasing the work day to 8 hours and increasing to 66% the portion of the work day spent on direct client activity. With this change, services would increase from 1.5 million couple-years of protection (CYP) to 1.8 million CYP in 2010, without additional staff, and CYP cost would decline. CYP costs could potentially be reduced by increasing the number of contraceptive units provided per visit and switching from a 1-month- to a 3-month-duration injectable contraceptive. A Bangladesh study found that CYP costs could be reduced by eliminating absenteeism and increasing work time/day by 1 hour. Cost studies can address specific human resource issues. A study in Thailand found that Norplant was more expensive per CYP than injectables and the IUD, and Norplant acceptors were willing to switch to other effective modern methods. The Thai government decided to target Norplant to a few target groups. Staff time use evaluations can be conducted by requiring staff to record their time or by having clients maintain records of staff time on their health cards. The time-motion study, which involves direct observations of how staff spend their time, is costly but avoids estimation error. A CEMOPLAF study in Ecuador found that 1 visit detected almost as many health problems as 4 visits. Some studies examine cost savings related to other services.^ieng

Integrating services involves cost issues.

PIP: This article discusses the integration of sexually transmitted disease (STD) care within family planning (FP) programs and the cost effectiveness of integrated services in development countries. Examples are taken from experiences in Colombia, India, the US, and Kenya. The 1994 International Conference on Population and Development urged the integration of reproductive health care within FP. The more than 330 million annual new STD cases increase HIV transmission and cause pain and infertility. Women are biologically more susceptible to STDs, are more likely to be asymptomatic, and face harsher consequences, including death. Women with STDs should avoid the IUD and use barrier methods. Maintaining laboratories, training staff, and supplying drugs can overburden strained health budgets, but may lower long-term medical costs, increase productivity in employment, and decrease pain and suffering. STDs are viewed by some US health professionals as a "best buy" for being one of the least expensive of the reproductive health options. A Kenyan study found that treating STDs and providing oral contraceptives saved money by collapsing treatment into one instead of two visits. The savings were in overhead and staff costs. Evaluations of cost effectiveness should consider local STD prevalence, cultural setting, client needs, and available resources. In some cases, referral of cases to STD clinics may be the most cost-effective. A US study found that chlamydia screening for all FP clients was more cost-effective than screening selectively. Another US study found that universal screening for chlamydia would provide long-term medical savings even if prevalence was only 2%. Developing countries have the lower-cost option of offering syndromic management of STDs for symptomatic women rather than lab tests. A program in India cut costs by educating and encouraging barrier methods.^ieng

Fees for other services help pay for family planning.

PIP: This article discusses useful, currently operational strategies for setting fees for family planning (FP) services in Ecuador. CEMOPLAF in Ecuador generates income and recovers costs by charging client fees for some FP services. The fees are used to increase client access to FP and to improve quality of care. CEMOPLAF also gains income from selling ultrasound diagnostic services and offering other health services. Sustainability does not mean an end to services. The ultrasound service was implemented in 1992 at a clinic in Quito after a study determined potential costs to the clinic for providing this service, the demand for this service, and expected income over 5 years. This service was appropriate at this clinic due to its high volume of gynecology and prenatal clients. The ultrasound service provision was expanded to CEMOPLAF's 20 clinics and 12 satellite clinics due to its profitability. Because of the high cost of equipment, training, and materials, CEMOPLAF studied costs/benefits and found that some sites were unsuitable for the inclusion of ultrasound services. This study saved the operation considerable money. CEMOPLAF examined the fee structure and found that 40% of clients owned homes and 35% had completed secondary school or university. 33% sent their children to private schools. Prices for FP services varied between clinics by as much as 65% among its 21 clinics. One of the clinics with the highest fees had the greatest number of low-income clients. CEMOPLAF is pursuing studies of program sustainability due to the high potential for severe declines in donor support. Managers must be wary of assuming that provision of a new service automatically ensures a demand for this service. In 1997, CEMOPLAF generated 75% of its operating budget from client fees. The financial returns from ultrasound services are small in the short run but contribute to long-term cumulative gains.^ieng

The Mexico City Policy: a "gag rule" that violates free speech and democratic values.

PIP: With the support of the Republican leadership of the US House of Representatives, Representative Chris Smith of New Jersey continues to attempt to limit provision of US family planning (FP) funding to foreign nongovernmental organizations (NGOs) who agree to enforce absolute prohibitions on engaging in abortion-related activities. Despite the fact that the House is withholding funds to meet US obligations to the UN and to support the International Monetary Fund, US President Clinton refuses to give in to pressure to enforce what amounts to a "gag rule." The Secretary of State explains that Clinton has no intention of punishing organizations engaging in free-speech protected democratic activities in foreign countries. Smith has offered a self-styled "compromise" that would allow Clinton to waive disqualification for a foreign NGO offering abortion services with its own funds in compliance with the laws of its country. This waiver would penalize the international FP program by $44 million and would not apply to the broad prohibitions against abortion lobbying (including lobbying for changes in laws, sponsoring conferences and workshops on "alleged" defects in abortion laws, and drafting and distributing materials or public statements on "alleged defects"). Smith's emphasis on the "lobbying" ban has widened the issue from a debate on abortion to a debate on democracy and free speech. Opposition to Smith's proposal is, thus, rising in many quarters. Smith also endorses withholding US contributions to the UN Population Fund because the fund has resumed work in China.^ieng

Expanding beyond "mother-child" services.

PIP: Several reproductive health programs in Bolivia have attempted to reduce institutionalized gender inequalities through efforts ranging from consciousness-raising courses to national legislation against domestic violence. It has been found that a maternal-child health-oriented approach to reproductive health eliminates many of those who require services, including childless women, women who have completed childbearing, and men. Moreover, the traditional exclusion of men from family planning decision-making often exacerbates women's vulnerability to abuse. La Casa de la Mujer in Santa Cruz, Bolivia, conducts family planning workshops for couples, works with young men and women, and seeks to involve male partners of its clients in center activities. Gender awareness not only helps couples to improve their relationships, but also improves the quality of interactions between family planning clients and providers. The widespread tendency of clinic doctors and staff to dismiss women's questions and concerns about contraceptive methods undermines providers' ability to counter misinformation and urge user compliance. The Center for Research and Development of Women in El Alto, Bolivia, has developed an approach to communication in which providers and clients discuss options in a collaborative manner. This approach has led to improved provider-client cooperation, more accurate diagnoses, and improved client health.^ieng

Women who made history.

PIP: Named after the first female doctor in the Dominican Republic and established in 1987 with the goal of providing high-quality services in a welcoming atmosphere at low prices, the Evangelina Rodriguez Maternal and Child Health Clinic now serves 80% of all residents of north Santo Domingo city. The center's 6 physicians and 3 nurse's aides provide maternal and child health care, including family planning and gynecological services, to 300 people daily in a marginalized area of the city where people live in overcrowded neighborhoods. The Director of Services in the southern region of PROFAMILIA, the family planning association in the Dominican Republic, supervises the clinic's services. Another of PROFAMILIA's clinics is named after an advocate of women's rights in the country, Rosa Cisneros, a lawyer who was murdered in her home, in San Salvador, on August 18, 1981, in the context of a civil war in the country. The Rosa Cisneros Clinic in Santiago de los Caballeros has 16 employees, including administrative staff, counselors, doctors, and nurses who serve almost 300 people per day.^ieng

Sexuality education on the job.

PIP: The Asociacion Demografica Salvadorena (ADS) has been working with the UN Population Fund (UNFPA) in El Salvador since November 1995 to provide sexual and reproductive health services to the country's working classes. UNFPA funding is provided through the Salvadoran government. ADS has entered the commercial and labor sectors to provide sexual and reproductive health services, and expand related public education programs to marginalized working class urban residents of El Salvador's Zona Central. The project has thus far created 25 Reproductive Health Units (UDESAR) in a number of companies, overseen by trained personnel who offer family planning and counseling services, including family planning methods, and the detection of cervical/uterine cancer, breast self-examination, HIV/STD prevention, and the determination of reproductive risk. Volunteers trained by ADS in sexual and reproductive health from a gender perspective, including decision-making and raising women's levels of self-esteem and decision-making capabilities in family planning, safe sex, and general sexual health, help project leaders by educating and motivating co-workers. ADS's involvement in promoting reproductive health in El Salvador has also given the organization an opportunity to broaden its relationship with international agencies.^ieng

Combating sexually transmitted diseases.

PIP: Lack of funding forced APROFAM, the International Planned Parenthood Federation (IPPF)/Western Hemisphere Region (WHR) affiliate in Guatemala, to close its sexually transmitted disease (STD) diagnosis and treatment center, CODETS, in December 1995. CODETS was then the only center in the country providing HIV testing and counseling, STD diagnosis and treatment, and educational programs. Rather than attempting to secure funding to continue operating the CODETS clinic on an emergency basis, APROFAM decided to integrate the clinic's services into its family planning clinics. In April 1996, a 2-year integrated program was launched in APROFAM's Central Clinic, with funding from the Canadian International Development Agency. In 1997, integrated services were extended to other APROFAM clinics. All APROFAM clients at the Guatemala City clinics now receive HIV/STD education as part of the family planning counseling process, as well as free condoms. STD diagnosis and treatment services are also provided in a confidential and caring environment. The overall increased knowledge about STDs among APROFAM staff has helped them to identify STDs in many women who may have never known they were infected. The process of transition toward the provision of integrated services is described.^ieng

INPPARES uses Internet to provide Peruvians with sexuality information and counseling.

PIP: The Peruvian Institute for Responsible Parenthood (INPPARES) has incorporated the Internet into its national sexuality information and counseling service. The idea for an Internet site devoted exclusively to the sharing of sexuality information originated in 1995 with the Institute's youth services staff. More than half the requests for information and advice come from adolescents and young adults. The Internet service is publicized through its Web site, listservs and bulletin boards, and word of mouth. Questions most frequently pertain to sexuality, contraceptive methods, sexually transmitted diseases, HIV/AIDS, sexual problems, and pregnancy. When INPPARES staff reply to the e-mail, they include a brief questionnaire to enable the organization to keep track of the age, gender, educational level, and geographic location of those who use the service. This strategy offers an opportunity to reach groups (e.g., students and workers) who are often not available during regular clinic hours and, because of its anonymity, those who might be uncomfortable assessing reproductive health services directly.^ieng

No added STD protection from spermicidal condoms.

PIP: An epidemiologic study conducted by Family Health International and Profamilia (Dominican Republic) found that condoms treated with the spermicide nonoxynol-9 offer no greater protection against sexually transmitted diseases (STDs) than regular condoms. Enrolled in the randomized controlled study were 635 female sex workers recruited from STD clinics in Santo Domingo. Participants were scheduled to return for follow-up visits every 2 weeks for 24 weeks or until gonorrhea or chlamydial cervicitis developed; only about 17% of women in both the nonoxynol-9 condom group and the plain condom group completed the study. Although nonoxynol-9 condoms did not cause irritation, they were not associated with significant reductions in cervical or vaginal infections. This study was limited, however, by the potential for selection bias associated with the high drop-out rate and the small amount of spermicide used in the treated condoms. A nonoxynol-9 gel for gonorrhea, chlamydia, and HIV protection is under development. Since current nonoxynol-9 condoms are more expensive than regular condoms and have a shorter shelf-life, family planning programs may want to reconsider their use until more research evidence is available.^ieng