Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 3 - Jul/Sep - 2018

Original Article Imprimir 

Páginas 101 a 110


Pregnancy recurrence in young women who had access to highly effective contraception

Recurrencia de embarazo en mujeres jóvenes que han tenido acceso a la anticoncepción de alta eficacia

Recorrência de gravidez em mulheres jovens que tiveram acesso a contracepção de alta eficácia

Autores: Aléxia Lavinia Holanda Gama1; Gilka Paiva Oliveira Costa2; Thuany Bento Herculano3; Rayanne Pereira Cabral4; Felipe Alencar Mayer Feitosa Ventura5

1. Medical Student by the Federal University of Paraíba (UFPB). João Pessoa, PB, Brazil
2. Doctor in Health Sciences from the Federal University of Rio Grande do Norte. Natal, RN, Brazil. Associate Professor of Medical Psychology, Medical Training and Patient Physician Relationship - Center of Medical Sciences - Department of Internal Medicine - UFPB and professor of gynecology at the Nova Esperança School of Nursing and Medicine (FACENE / FAMENE). Medical at the Family Planning outpatient clinic of Lauro Wanderley University Hospital. João Pessoa, PB, Brazil
3. Medical Student by the Federal University of Paraíba (UFPB). João Pessoa, PB, Brazil
4. Medical Student by the Federal University of Paraíba (UFPB). João Pessoa, PB, Brazil
5. Medical Student by the Federal University of Paraíba (UFPB). João Pessoa, PB, Brazil

Aléxia Lavinia Holanda Gama
St. José Firmino Ferreira, n° 767 - apto. 203 -Jardim São Paulo
João Pessoa, PB, Brasil. CEP 58053-022
(alexialavinia6@gmail.com)

PDF Portuguese      


Scielo

Medline


How to cite this article

Keywords: Pregnancy in adolescence, Pregnancy, Unplanned, intrauterine devices, contraception, recurrence.
Palabra Clave: Embarazo en la adolescencia, embarazo no planeado, dispositivos intrauterinos, anticoncepción, recidiva.
Descritores: Gravidez na adolescência, gravidez não planejada, dispositivos intrauterinos, anticoncepção, recidiva.

Abstract:
OBJECTIVE: Evaluate the adherence to contraception in resumption of sexual activity and recurrence of pregnancy.
METHODS: We carried out a descriptive, exploratory, retrospective study with a quantitative approach in the obstetric wards of a University Hospital in João Pessoa, Paraíba, Brazil. The sample consisted of adolescents and young adults (14 to 21 years old) who had delivery assistance to natural or cesarean birth and received guidance on intrauterine device (IUD) use from August 2015 to January 2016. Data collection was made by telephone after the completion of one year of obstetric occurrence that led to hospitalization.
RESULTS: 26.8% (30) of the sample reported being discharged without contraceptive guidance and 22.3% (25) affirmed restarting sexual life after gestation, without any type of protection. In one year, the recurrence of pregnancy occurred in 10.7% (12) of the participants and 100% was unplanned. Although 71.4% (80) of the participants were motivated to use an IUD, only 16.1% (18) did insert the device. The main reason for non-use was the social difficulties of returning to the hospital for insertion (56.7%). It was demonstrated a significant association between lower monthly income and occurrence of new gestation (p = 0.02).
CONCLUSION: Despite free access and interest in using an IUD, few returned for insertion after four weeks of delivery. These findings reinforce the importance of contraceptive counseling in prenatal care and IUD insertion immediately after postpartum, considering as a fundamental resource for changing this social reality.

Resumen:
OBJETIVO: Evaluar la adhesión a la contracepción en el reinicio de la actividad sexual y recurrencia del embarazo en el primer año de post-parto.
MÉTODOS: Realizamos un estudio de corte descriptivo, exploratorio y retrospectivo con abordaje cuantitativo en las enfermerías obstétricas de un Hospital Universitario de João Pessoa, Paraíba, Brasil. La muestra consistió en adolescentes y adultos jóvenes (14 a 21 años de edad) que recibieron asistencia al parto normal o cesáreo y recibieron orientación sobre uso de dispositivo intrauterino (DIU) de agosto de 2015 a enero de 2016. La recolección de datos fue hecha por teléfono después de la conclusión de un año de episodio obstétrico que llevó a la hospitalización.
RESULTADOS: 26,8% (30) de la muestra relataron haber recibido alta hospitalaria sin orientación anticonceptiva y 22,3% (25) afirmaron reiniciar la vida sexual después de la gestación, sin ningún tipo de protección. En un año, la recurrencia del embarazo ocurrió en el 10,7% (12) de los participantes y el 100% no fue planeada. Aunque el 71,4% (80) de los participantes se motivó a utilizar un DIU, sólo el 16,1% (18) hizo la inserción del dispositivo. El principal motivo para el no uso fue la dificultad social de regresar al hospital para inserción (56,7%). Se demostró asociación significativa entre renta mensual más baja y ocurrencia de nueva gestación (p = 0,02).
CONCLUSIÓN: A pesar del acceso gratuito y del interés en usar un DIU, pocas regresaron para inserción después de cuatro semanas del post parto o post aborto. Estos descubrimientos refuerzan la importancia del asesoramiento anticonceptivo en el prenatal y la inserción del DIU inmediatamente al post-parto, considerando este recurso como fundamental en el cambio de esa realidad social.

Resumo:
OBJETIVO: Avaliar a adesão à contracepção no reinício da atividade sexual e recorrência da gravidez no primeiro ano de pósparto.
MÉTODOS: Realizamos um estudo de corte descritivo, exploratório e retrospectivo com abordagem quantitativa nas enfermarias obstétricas de um Hospital Universitário de João Pessoa, Paraíba, Brasil. A amostra consistiu em adolescentes e adultos jovens (14 a 21 anos de idade) que receberam assistência ao parto normal ou cesariana e receberam orientação sobre uso de dispositivo intrauterino (DIU) de agosto de 2015 a janeiro de 2016. A coleta de dados foi feita por telefone após a conclusão de um ano de episódio obstétrico que levou à hospitalização.
RESULTADOS: 26,8% (30) da amostra relataram ter recebido alta hospitalar sem orientação contraceptiva e 22,3% (25) afirmaram reiniciar a vida sexual após a gestação, sem qualquer tipo de proteção. Em um ano, a recorrência da gravidez ocorreu em 10,7% (12) dos participantes e 100% não foi planejada. Embora 71,4% (80) dos participantes tenham sido motivados a utilizar um DIU, apenas 16,1% (18) fizeram a inserção do dispositivo. O principal motivo para o não uso foi a dificuldade social de retornar ao hospital para inserção (56,7%). Demonstrou-se associação significativa entre renda mensal mais baixa e ocorrência de nova gestação (p = 0,02).
CONCLUSÃO: Apesar do acesso gratuito e do interesse em usar um DIU, poucas retornaram para inserção após quatro semanas do pós parto ou pós aborto. Essas descobertas reforçam a importância do aconselhamento contraceptivo no pré-natal e à inserção do DIU imediatamente ao pós-parto, considerando este recurso como fundamental na mudança dessa realidade social.

INTRODUCTION

Adolescent pregnancy rates remain high, mainly in countries such as Brazil. Women who become pregnant in this phase are more likely to have a greater number of children throughout their lives1. In Brazil, about 30% of newborns are children of adolescent mothers and 25% of all pregnant women between 15 and 19 years old already have a child, where the majority refers that the new pregnancy wasn´t planned2. In addition to being a situation of vulnerability, pregnancy in youth is one of the main factors for the perpetuation of intergenerational cycles of poverty and exclusion1. It is also verified that the younger, the greater the possibility of a new gestation in a short space of time3.

About 30% of adolescent girls become pregnant in the first year after childbirth and between 25-50% during the second year4. These repetitive pregnancies are associated with an increase in maternal and neonatal morbidity5,6, as well as a cycle of economic deprivation for adolescents and their families7.

One fact that explains the growing incidence of pregnant adolescents, to the detriment of the fall in the birth rate in Brazil, is the low adherence to contraceptive methods in adolescence2,8. About 90% of adolescents who don´t consistently use a contraceptive method can become pregnant again in the first year after delivery2. Contraception in postpartum is one of the most efficient strategies to prevent a new unwanted pregnancy6,7.

These evidences require measures that encourage the use of contraceptive methods (MC) of high efficiency, bringing them as an important ally in the prevention of a new pregnancy. Long-acting reversible contraceptives (LARCs - LongActingReversibleContraceptives), such as the intrauterine device (IUD), have been shown to be quite effective and well accepted among young women3,5-7,9.

The increasing incidence of pregnant adolescents raises questions about what are the real impediments to the use of high-efficiency contraceptive methods by young people who experienced an unplanned pregnancy, what factors are related to a new pregnancy even in adolescence and what is the relationship of the appropriate post-partum counseling with adherence to the use of LARC.

In view of this, the present article proposes to evaluate the use of MCs, especially of the IUD, by adolescents who, after a pregnancy, received guidance and access to these methods, evaluating the adherence to contraception in the resumption of sexual activity and the recurrence of pregnancy.


MATERIALS AND METHODS

A descriptive, exploratory and retrospective study was carried out with a quantitative approach, developed in the obstetric clinics of a University Hospital in João Pessoa (Paraíba - Brazil). The sample was composed of adolescents and young adults (14 to 21 years old) who attended natural childbirth, cesarean section or abortion in the aforementioned service, received guidance on the LARCs in the period from August 2015 to January 2016, and who accepted Participate in research by signing a Free Consent Term and clarifying it together with your legal representative. Occurrences whose contact wasn´t possible after one year of enrollment in the service, adolescents who had inter-occlusion after postpartum and post-abortion who prevented the use of LARCs or situations that have evolved with complications that culminated in infertility were excluded from the sample.

The data collection was done by telephone contact at the end of one year of the obstetric occurrence that motivated the hospitalization. The collection instrument was a questionnaire constructed specifically for the study, in which its items contemplated the variables of the investigation.

For sociodemographic characterization variables were considered: age, schooling, family income and marital status. The reproductive life was characterized by the variables: parity, desire of current pregnancy and previous pregnancies and planning of previous and future pregnancies.

The data related to sexual health were accessed through the variables: age of menarche and sexarca; restart of sexual activity after discharge from maternity; use of contraceptive method (MC) in the resumption of sexual intercourse; contraception advised at hospital discharge; contraceptive methods in use; the motivations for use and/or not of IUD, time of use, perceived side effects, satisfaction with the method and recurrence of pregnancy.

The quantitative data were represented by mean and standard deviation, when they had normal distribution. The qualitative variables were demonstrated by frequency and absolute numbers. In the inference statistics, the Chi-square test of independence was used to compare categorical variables and the Yates correction, when necessary. The statistical analysis was performed with the StatisticalPackage for Social Sciences (SPSS) version 21.0 and the level of significance adopted was 5%.

The study followed all the established ethical recommendations for research involving human beings, in accordance with the Declaration of Helsinki (2008) 10. The research was submitted and approved by the Ethics Committee of Lauro Wanderley University Hospital, linked to University

Federal of Paraíba, with an opinion under the number 1795675. A descriptive, exploratory and retrospective study was carried out with a quantitative approach, developed in the obstetric clinics of a University Hospital in João Pessoa (Paraíba - Brazil). The sample was composed of adolescents and young adults (14 to 21 years old) who attended natural childbirth, cesarean section or abortion in the aforementioned service, received guidance on the LARCs in the period from August 2015 to January 2016, and who accepted Participate in research by signing a Free Consent Term and clarifying it together with your legal representative. Occurrences whose contact was not possible after one year of enrollment in the service, adolescents who had inter-occlusion after postpartum and post-abortion who prevented the use of LARCs or situations that have evolved with complications that culminated in infertility were excluded from the sample.


RESULTS

There were 225 obstetric occurrences with adolescents and young adults in the period from August 2015 to January 2016. After one year, telephone contact was possible with 112 (49.7%) women, who made up the final sample. Two cases were excluded from the sample according to the occurrence of death of the adolescents in the interval of one year after the obstetric event.

The average age of the participants at the time they received obstetric care was 18.9 ± 1.9 years. Of these, 58% (65) were adolescents between 14 and 19 years old and 42% (47) were young adults between 20 and 21 years old. Regarding marital status, 58% (65) lived in a stable union, 18.8% (21) were married and 23.2% (26) were single. With regard to the monthly rent, 63.4% (71) claimed to receive income less than or equal to a minimum wage, 34.8% (39) receive between one and three minimum wages and barely 1.8% (2) income above three minimum wages. At the time of the interview, only 35.7% (40) had finished high school.

With regard to reproductive and sexual history, menarche occurred on average at 12.5 ± 1.5 years and sexarca at 15.5 ± 1.6 years. At age 16, 70.3% (78) already had an active sex life. The average age of the first pregnancy was 17.8 ± 2.0 years. Of these, 78.6% (88) became pregnant between 14 and 19 years old and 21.4% (24) between 20 and 21 years old. For 68.8% (77), the pregnancy wasn´t planned, but it was desired by 93.8% (105) of the girls.

In the high hospital, 26.8% (30) stated that they had not received any type of contraceptive orientation, while 51.8% (58) stated that they had received a prescription with a hormonal contraceptive. For 4.5% (5), the IUD was inserted in the immediate postpartum, while 11.6% (13) inserted ambulatory at least four weeks after delivery.

The sexual resumption occurred without any type of protection for 22.3% (25) of the participants, while 45.5% (51) reported having used some type of hormonal contraceptive, 20.5% (23) used a condom, 8% (9) were already with the IUD and a woman used the emergency pill.

After contraceptive guidance during obstetric care, 71.4% (80) of the participants were motivated to use the IUD, although only 16.1% (18) did the insertion of the device. Of these, 22.2% (4) discontinued the use after an average time of 5.5 ± 3.4 months due to: side effects (1), expulsion of the device (1), lack of access to the ultrasound examination (1), preference for the quarterly injectable (1). With regard to the occurrence of side effects related to the IUD, 71.4% (10) reported having experienced some type of side effect, highlighting the increase in menstrual flow in 70% (7) and menstrual colic 30% (3).

Among those who expressed interest, however, didn´t return for insertion (77.5%), the reasons alleged were: 1- Fear of pain during insertion, side effects or possible complications (21.7%); 2- Option for another contraceptive method (15%); 3- Lack of knowledge about the method, its effectiveness and myths (6.6%); 4- Social difficulties that prevented the return for insertion of the device (56.7%).

For 28.6% (32) of the participants, the IUD wasn´t accepted as a contraceptive option and the stated reasons were: 1-Fear of the insertion procedure and possible complications (18.7%); 2- Lack of knowledge in relation to the method and myths (40.6%); 3- Insecurity in relation to the effectiveness of the IUD (21.9%); 4- Desire to get pregnant again in a short period of time (9.4%); 5- Preference for another contraceptive method previously used (9.4%).

After one year of pregnancy, 28.6% (32) of the participants didn´t use any method and among the users the most used CM was the oral hormonal contraceptive (25.9%) and the condom (21.4%). Dissatisfaction with CM was predominantly indicated by condom users (75%), while the IUD had a lower percentage of unsatisfied women (7.1%) (Table 1).




The recurrence of pregnancy occurred for 10.7% (12) of the participants in the period of follow-up of the investigation, and in all cases the pregnancy wasn´t planned. By correlating the recurrence of pregnancy in the first year after pregnancy with some sociodemographic and reproductive variables (Table 2) was shown a significant association between monthly income equal to or less than a minimum wage and the occurrence of new pregnancy (χ2 = 9.6, p = 0 , 02).




By correlating the motivation to use the IUD after orientation in the postpartum period with some sociodemographic and reproductive variables (Table 3), it was shown that women with unplanned pregnancy were more motivated to use the IUD (χ2 = 5.0 ; p = 0.04). Nonetheless, the use of the IUD was significantly associated with the age group, so that adolescents were the most affected by the device at the expense of young women (χ2 = 5.3, p = 0.021) (Table 4).     






DISCUSSION

The sample of this study was composed of women who became pregnant primarily during adolescence, who had low monthly income and who had pregnancy recurrence in the first year after pregnancy. Another study that was also conducted in northeastern Brazil found recurrence of pregnancy in 25.9% of cases, 11 verifying, in both studies, a positive relationship between recurrence of pregnancy and low family income. This relationship has several determining factors that imply less access to information, contraceptive methods and health services, which only reinforces the social exclusion of these girls12. Such conditions are especially present in developing countries and deserve special attention, since they represent an important factor in the maintenance of the condition of poverty. It is therefore presented as a challenge to social and health policies in these countries13.

However, it isn´t a problem only of poor countries. In the United States, 17% of pregnancies among girls aged 15 to 19 were repeat offenders in 201514, which is similar to the 10.7% found in our study. The data corroborate the evidence that a gestation among young girls is a risk factor for a new pregnancy even in that phase15.

The recurrence of early pregnancy also occurs due to the non-use or inadequate use of contraceptive methods. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend that counseling on safe and effective methods occur from prenatal16. In this case, long-term contraceptives represent the best option in terms of high efficacy that is independent of the user, as well as being able to be inserted in the immediate postpartum period, as in the case of the IUD14.

The incentive to use CM after postpartum avoids the lack of continuity of care that occurs in the period between hospital discharge and the return to puerperal consultation14, a fact frequently observed in ours and in other studies. In addition, it is observed that although 51.8% of the puerperal women claim to have received discharge with a hormonal contraceptive prescription, 22.3% (25) of them reinitiated unprotected sexual intercourse, considering that this frequency is even more in other studies in which an index of 52% was observed 7.

During the first postpartum year, it is observed that the sporadic use of low efficacy methods occurred for 45.5% (51) of the sample. The percentage of puerperal women who wanted to insert the postpartum IUD was low (4.5%), a value similar to that found in the United States in 2004 (5.3%), whose use of the device obtained a significant increase to 25.3% in 201314.

The evaluation of the consistency in the use of contraception, it is perceived that the study participants remained using methods of less consistency and low efficiency or not yet using any CM. Furthermore, considering the dissatisfaction with CM as a determining factor in the interruption of contraception, condom users of the present study were the most dissatisfied with the method (75%), while the IUD had a lower percentage of dissatisfaction (7.1%) which corroborates with the results found in other surveys17,18.

Despite the guidance on high-efficiency contraceptive methods such as the IUD, of 71.4% (80) of the patients who claimed interest in using the IUD, only 16.1% (18) performed their insertion. The event is also verified in other studies in which it is emphasized that the time between the choice of method and the day of insertion is the main impediment to the use of long-lasting contraceptives. In this sense, immediate postpartum is presented as an excellent opportunity for the insertion of the device19.

According to the WHO election criteria, if insertion of the IUD doesn´t occur in the first 48 hours after delivery, it should only be done after four weeks. It is in this period that the fear of pain, side effects and possible complications arises and the puerperal women begin to use the methods prior to pregnancy for convenience19. It was what was presented in this study, where only 16.1% of the participants who showed interest in inserting the IUD did so. The fear of the efficacy and safety of the device and the social difficulties for the ambulatory return, presented as lack of transportation and support for the return to the ambulatory were the reasons indicated for the non-use.

Other evidence that reinforces the IUD as a method of high efficiency and consistent use is the continuity rate at the end of 12 and 24 months when compared to the use of a low-efficiency contraceptive method. Women who used IUDs had a continuity rate of 87% at the end of the first year and 57% at the end of the second, while for other methods continuity of use was 77% and 41%, at the end of the first. and of the second year respectively20.

Despite being a cohort study, where the difficulty of contact with patients after one year of obstetric experience excluded slightly more than half of the expected population, which limited the sample size, some relationships deserved to be observed, such as: with the positive correlation between an unplanned pregnancy and the motivation for the use of the IUD, the young women returned to the ambulatory and introduced the IUD; the possibility of using the unplanned pregnancy as an incentive to use the IUD. In addition, it was also the adolescents who returned to the outpatient clinic and adhered to the IUD. In this case, it is possible that adolescents have found more support to return to the outpatient clinic in post-partum than young adults, as it is known that one of the resources for the prevention of recurrence of pregnancy in adolescence is family support19.


CONCLUSION

The recurrence of pregnancy in adolescence is a reality to which these girls are exposed. Counseling, as well as access to high-efficiency contraceptive methods, is the main resource to combat this event.

Among the reversible, high-efficiency and long-term contraceptive methods, the IUD should be considered, since this method is available free of charge in the Brazilian public health network.

However, despite showing interest and having free access to the IUD, few adolescents and young adults returned to the outpatient postpartum for insertion of the IUD. Among several reasons are the fear, myths and social difficulties that arise in the interval between delivery and the time of return for the insertion of the IUD.

In this way, it is clear that only free access to the IUD isn´t capable of transforming the reality of the recurrence of pregnancy in adolescence. We must consider the issues that arose as impediments to the use of the IUD by these girls, especially in regard to the time between motivation and insertion that is sufficient to assess the other difficulties. In this sense, contraceptive counseling during prenatal care and the insertion of the device in the immediate postpartum period represent the resources with the most immediate effects that can be used in response to these difficulties.

In the long term, it is expected that there will be an increase in IUD users, as well as educational campaigns to deconstruct the myths and support for return to the family planning clinic, which should favor effective contraception and reflect on the reduction of unplanned pregnancy. in adolescence


THANKS

We thank our colleagues from the Study Group on Reproductive Health and Humanities of the Federal University of Paraíba who contributed to the data collection and critical review of the research. We also thank the social service of Lauro Wanderley University Hospital for the support given to adolescents who expressed interest in inserting the IUD, as well as all support given by the hospital management and the obstetrics and gynecology service for the development of the research.


REFERENCES

1. Sedgh G, Finer LB, Bankole A, Eilers MA, Singh S. Adolescentpregnancy, birth, and abortionratesacrosscountries: Levels and recenttrends. J AdolescHealth 2015;56:223-30.

2. Rodrigues ARS, de Moraes Barros W, Soares PDFL. Reincidência da gravidez na adolescência: percepções das adolescentes. EnfermagememFoco2017;7:66-70.

3. Teal SB, Romer SE. Awareness of long-acting reversible contraceptionamongteens and youngadults. J AdolescHealth 2013;52:S35-S39.

4. Fortier E, Foster AM.  Exploringyoungmothers' experienceswithpostpartumcontraception in Ottawa: Resultsfrom a multi-methodsqualitativestudy. Contraception. 2018.

5. Greenberg KB, Makino KK, Coles MS. Factorsassociatedwithprovision of long-acting reversible contraceptionamongadolescenthealthcareproviders. J AdolescHealth 2013;52:372-374.

6. Darney BG, Sosa-Rubi SG, Servan-Mori E, Rodriguez MI, Walker D, Lozano R. Therelationship of age and place of deliverywithpostpartumcontraception prior to discharge in Mexico: A retrospectivecohortstudy. Contraception 2016;93:478-484.

7. Baldwin MK, Edelman AB. Theeffect of long-acting reversible contraceptiononrapidrepeatpregnancy in adolescents: a review. Journal of AdolescentHealth 2013:52, 47-53.

8. Azuike EC, Ikeako LC, Ezeobi I, Ezebialu IU, Umeobika JC, Obi KN, Anene JO, Azuike ED. Predictors of discontinuation of contraceptive use amongNigerianwomen: Results of 2013 Nigeria Demographic and HealthSurveys. Journal of ScientificResearch and Studies 2017:4,171-176.

9. Kavanaugh ML, Jerman J, Ethier K, Moskosky S. Meeting thecontraceptiveneeds of teens and youngadults: Youth-friendly and long-acting reversible contraceptiveservices in U.S. familyplanningfacilities. J AdolescHealth 2013;52:284-292.

10. World Medical Association. World Medical AssociationDeclaration of Helsinki: ethicalprinciplesfor medical researchinvolving human subjects. JAMA 2013;310:2191-2194.

11. Nery IS, Gomes KRO, Barros IC, Gomes IS, Fernandes ACN, Viana LMM. Fatoresassociados à reincidência de gravidez apósgestação na adolescência no Piauí, Brasil. Epidemiologia e Serviços de Saúde 2015;24:671- 680.

12. Rosenstock JR, Peipert JF, Madden T, Zhao Q, Secura GM. Continuation of reversible contraception in teenagers and youngwomen. Obstetrics&Gynecology 2012; 120, 1298-1305.

13. UnitedNationsChildren'sFund- UNICEF. O direito de ser adolescente - Oportunidade para reduzir vulnerabilidades e superar desigualdades, 2011. [AcessoDez 20 2017]. Disponívelem: http://www.unicef.org/brazil/pt/br_sabrep11. pdf>

14. Dee DL, Pazol K, Cox S, Smith RA, Bower K, Kapaya M, Fasula A, Harrison A, CD Kroelinger, D'Angelo D, Harrison L, Koumans EH, Mayes N, Barfield WD, Warner L. Trends in RepeatBirths and Use of PostpartumContraceptionAmongTeens-UnitedStates, 2004-2015. MMWR. Morbidity and MortalityWeeklyReport 2017;66,422-426.

15. UnitedNationsChildren'sFund- UNICEF (2011). Thestate of theworld'schildren 2011: Adolescenceanage of opportunity. [AcessoDez 20 2017]. Disponívelem: http://www.unicef.org/adolescence/files/SOWC_2011_Main_Report_EN_02242011.pd;

16. Romero LM, Olaiya O, Hallum-Montes R, Varanasi B, Mueller T, House LD, Middleton D. Efforts to increaseimplementation of evidence-basedclinicalpractices to improveadolescent-friendlyreproductivehealthservices. Journal of AdolescentHealth. 2017;60:S30-S37.

17. Kaunitz AM. Contraceptivecounseling and selection [UpToDate]. 2017. [AcessoDez 20 2017]. Disponívelem: https://www.uptodate.com/contents/contraceptive-counseling- and-selection>.

18. Secura GM, Madden T, McNicholas C, Mullersman J, Buckel CM, Zhao Q, Peipert JF. Provision of No-Cost, Long- ActingContraception and TeenagePregnancy. The New EnglandJournal of Medicine 2014;371,1316-1323.

19. Borovac-Pinheiro A, Surita FG, D'Annibale A, Pacagnella RC, Pinto E Silva JL. Adolescentcontraceptionbefore and afterpregnancy-choices and challengesforthefuture. RevBrasGinecolObstet2016;38:545-551.

20. Machado RB, Monteiro IMU, Magalhães J, Guazzelli CAF, Brito MB, Finotti MF, JN Lubianca, Sakamoto LC, Franceschini AS. Long-ActingReversibleContraception. RevBrasGinecolObstet2017;39:294-308.










[1] Salário mínimo no Brasil custa em torno de US$ 284,00.
adolescencia adolescencia adolescencia
GN1 © 2004-2018 Revista Adolescência e Saúde. Fone: (21) 2868-8456 / 2868-8457
Núcleo de Estudos da Saúde do Adolescente - NESA - UERJ
Boulevard 28 de Setembro, 109 - Fundos - Pavilhão Floriano Stoffel - Vila Isabel, Rio de Janeiro, RJ. CEP: 20551-030.
E-mail: revista@adolescenciaesaude.com