Rising unintended pregnancies in SA emphasise the need for effective contraceptive use, particularly among the country’s adolescent population.

Approximately 40% of all pregnancies globally are unintended, a scenario the World Health Organisation (WHO) says occurs when a pregnancy is either mistimed or unwanted. In SA, many of these pregnancies occur among adolescents, with teen pregnancies increasing dramatically between 2011 and 2013. Statistics SA figures show that close to 100 000 schoolgirls fell pregnant in 2013 compared to 81 000 in 2012 and 68 000 in 2011.

Cause and effect

Rising teen pregnancies in SA may be attributed to a number of factors including: dysfunctional families (parents either have little or no time to talk to their children about sex and sexuality or to discuss the use of contraceptives), poverty (girls exchange sexual favours for money, clothes, and other goods), lack of information about sex and contraception and the media (in 2014, 26% of television programmes screened explicit sex scenes). Alcohol abuse, which often leads to risky behaviour, has also been implicated as a cause of unintended pregnancies – especially among teens.

Unintended pregnancy is also linked to a higher risk of problems for both mothers and the babies they carry, including a higher risk of maternal and infant morbidity and mortality, higher risks of infanticide (child under one-year-old is killed) and neonaticide (child is killed within the first 28 days following birth) and an increased number of abortions. Figures released in March this year by the South African Medical Research Council, show that in 2009, 454 children under the age of five died due to homicide. More than 50% were 28 days old or younger.

According to the National Department of Health, at the end of January 2016, 155 624 abortions had been performed in public hospitals and clinics since the law legalising abortion came into effect in February 1997. Girls under 18 accounted for 80 873 abortions. It should be noted that these figures do not take into account the number of illegal abortions performed in SA. It is estimated that this number is similar to those preceding the Choice of Termination of Pregnancy Act.

Dr Gregory Petro, Head of Department: Obstetrics and Gynaecology at the New Somerset Hospital and Metro West in the Western Cape said while a number of factors contribute, unintended pregnancies among both adults and adolescents mainly occur as a result of sexually active people not using contraception, or due to inconsistent or incorrect use of effective contraceptive methods.

Contraceptive choice

There are two main methods of contraception; namely hormonal and non-hormonal methods. Hormonal methods are further divided into long acting (e.g. implants, injectibles or intrauterine devices [IUDs], female sterilisation or vasectomy) and short acting methods (e.g. oral contraceptives or ‘the pill’, barrier methods such as condoms as well as the patch and vaginal ring).

According to Dr Petro, short-acting contraception is suitable for women who wish to conceive within a period of time shorter than two years. The long acting reversible contraceptive (LARC) is ideal for women who wish to prevent pregnancy for three to ten years. LARC is the most effective form of contraception and also has the fewest contraindications. These methods can be used for shorter periods as well, explained Dr Petro.

“Women should be advised that an inter-pregnancy interval of less than two years is associated with adverse maternal and new born outcomes”, he stressed.

Dr Mala Panday, an Obstetrician and Gynaecologist in the Family Planning Services Department, Department of Health, KwaZulu-Natal, noted that each method has indications and contraindications. One method may be safe for a particular woman, while another might not be as ideal. Therefore, it is important to consult with a healthcare professional who will weigh up the risks and benefits of the different methods before recommending a contraceptive.

According to Dr Panday, the benefits of contraceptive use far outweigh the risks. Apart from birth control, she said contraceptives have other benefits as well. Oral contraceptives can help to clear up acne and protect women against ovarian and uterine cancer.

Risks associated with combined hormonal contraception include venous thromboembolism; IUDs are contraindicated in women with a current genital tract infection and progesterone-only contraceptives may be contraindicated in someone who is allergic to a particular ingredient, said Dr Panday. Risks can be minimised by adhering strictly to prescribing guidelines, which are summarised in the WHO’s Medical Eligibility Criteria published in 2015.

Dr Petro recommended that healthcare professionals discuss the following with patients before prescribing a contraceptive: the method, what it contains, route of administration, how often it should be taken, how it works, how long it works for, common side effects, how to stop the method, return to fertility on stopping and where to go if problems are encountered.

According to Dr Panday, implants are one of the most effective contraceptive methods because they are long-acting and reversible and do not require any action from the user. Implants have a more than 99% efficacy rate with ‘perfect use’ and an almost similar ‘typical use’ efficacy.

Other benefits associated with an implant include: easily available and accessible, discreet, no need for follow up visits to healthcare providers every few months, low side effect profile and few contraindications. Implants are especially ideal for adolescents, noted Dr Panday.

While oral contraceptives boast an efficacy rate of 99%, this is only with ‘perfect use’. ‘Typical use’ efficacy is between 85%-97% because it requires daily action by the user. Pills might be forgotten or not absorbed if the user vomits, she added.

While concerns have been raised about side effects caused by LARCs, slight changes in the amount and frequency of bleeding can be expected with any hormone-based contraceptive method.  According to the results of recent studies, infrequent bleeding was present in approximately 30% and prolonged spotting occurred in 20% of women using e.g. Implanon NXT, said Dr Panday.

Similar rates of infrequent bleeding have been reported in women using oral contraceptives. A study has shown that after four injections (one year) 50% of women reported infrequent bleeding. With ongoing use, this figure rose to 75%.

Headaches can be attributed to fluctuating hormones, also a common side effect of other hormonal contraceptives.  Not all women experience side effects, notes Dr Panday. Many women feel better on it than off it.