This equates to roughly 88 million pregnancies. In South Africa, ~1 960 000 pregnancies occurred annually between 2015 and 2019, with ~1 270 000 being unintended and ~461 000 ending in abortion.1,2
Globally 121 million unintended pregnancies occurred between 2015 to 2019. A significant proportion (61%) of these pregnancies ended in abortions each year.3
In LMICs, teenage (15- to 19-years) pregnancies, are highly prevalent, accounting for ~21 million unintended pregnancies annually and leading to ~12 million births. As of 2022, ~4% of South African teenage girls reported experiencing various stages of pregnancy in the past 12 months.4,5
The prevalence of pregnancy exhibited an upward trend with age, starting at 0.3% among 14-year-olds and exceeding 10% among 19-year-olds. Additionally, there was a 1.1% increase in the incidence of pregnancy among girls aged 14- to 19-years compared to the figures from 2021.5
Consequences of unintended pregnancy
Unintended pregnancy refers to a pregnancy that is either unwanted, occurring when no children are desired, or mistimed, happening earlier than desired.3
Recent research indicates that globally, about 20% of pregnancies resulting in live births were unintended at conception. The research also shows that 37% of women reported no contraceptive use before pregnancy, a figure that decreased to 24% after pregnancy.1
Notably, 54% of women who reported no contraceptive use before pregnancy adopted modern contraceptives afterward, with higher rates among those experiencing unintended pregnancies (73.4%) compared to mistimed (58.8%) and wanted (53.4%) pregnancies.1
Mistimed pregnancies were associated with a higher likelihood of maintaining no contraceptive use and switching to less effective methods compared to transitioning to more effective contraceptives.1
Unintended pregnancies correlate with adverse maternal and child health outcomes, including increased maternal and child mortality. It also often compels women to grapple with complex decisions, such as undergoing abortion, considering adoption, or navigating the responsibilities of raising a child without adequate financial, physical, and emotional support.3
The health implications of unintended pregnancies are substantial, and include inherent risks associated with pregnancy, potentially exacerbated by pre-existing medical conditions, as well as the hazards of experiencing multiple pregnancies.3
Complications such as haemorrhage, infection, and hypertensive disorders contribute significantly to maternal mortality, particularly in developing regions.3
Each unintended pregnancy elevates the risk of substantial morbidity and mortality for women, stemming from factors like poverty, malnutrition, limited access to healthcare, and insufficiently trained healthcare providers.3
Negative sentiments about pregnancy are more pronounced among women facing repeat unintended pregnancies, characterised by short birth intervals, a high number of births, undernutrition, and complications from prior unintended pregnancies.1
Access to contraceptives crucial to prevent repeat unintended pregnancies
The adverse consequences of unintended pregnancies are substantially higher in women with repeat unintended pregnancies. Although the successful implementation of Millennium Development Goals led to a substantial increase in contraceptive use in LMICs (from 52% to 62% in 2015), ~50% of married women of reproductive age in these countries still lack proper access to modern contraception methods.1
Factors influencing contraceptive use include future fertility preferences and socio-demographic characteristics such as women's age, education levels of women and their partners, socio-economic status, and exposure to mass media.1
Obstacles to openly discuss and make contraceptive decisions has been identified as an obstacle for teenage girls, especially those with older partners. In specific scenarios, societal expectations may compel girls to marry and bear children after marriage.4
These scenarios involve social and peer pressures to engage in sexual activities, conceive, coercion from familial influences, and restricted autonomy in choosing and using contraceptives, all contributing to the incidence of teenage pregnancies.4
Overcoming these challenges and ensuring proper access to effective contraceptives post-birth are crucial to prevent repeat unintended pregnancies and their associated adverse consequences.1,4
Prevention strategies
Mohamed et al identified three potential strategies that may be effective in preventing unintended pregnancies:4
- Primary prevention strategies involve efforts aimed at averting unintended pregnancies from occurring initially. These may involve fostering a supportive family environment, implementing comprehensive sexuality education, promoting contraceptive use, and addressing the prevention and detection of sexual and gender-based violence.
- Secondary prevention strategies involve early pregnancy diagnosis and counselling on various pregnancy options, including facilitating access to safe abortion care.
- Tertiary prevention strategies focus on preventing adverse events associated with unintended pregnancies. This includes treating incomplete abortions, providing services for psychosocial trauma, and offering antenatal care and maternity services to prevent maternal morbidity and mortality.
Contraceptives options, patient selection, safety and efficacy
The use of contraception has been hailed as a game-changer in preventing unintended pregnancies. The ideal choice of contraception should consider the values and preferences of patients. Available options include:6,7
Intravaginal gel
A new barrier method inserted an hour before intercourse. Maintains acidic pH to inhibit sperm motility and provides a physical barrier. The AMP002 Phase III Contraceptive Study or AMPOWER study demonstrated 86.3% contraceptive efficacy with typical use. Adverse events include vaginal burning (18%) and itching (14.5%). Suitable for those desiring non-hormonal birth control on-demand.
Combined vaginal ring
A 13-cycle combined vaginal ring containing segesterone acetate and ethinyl oestradiol. Provides one year of birth control. Effectiveness in pregnancy prevention noted to be 97.3% with typical use. Complete expulsions occur in ~7% of cycles. An option for those seeking longer-acting, reversible contraception without a daily regimen.
Progestin-only pill (drospirenone 4mg)
An option for women with contraindications to oestrogen-containing contraceptives. Studies found that 4mg drospirenone has anti-mineralocorticoid and antiandrogenic properties. Shows effective suppression of ovulation for up to 24 hours after a missed or delayed dose. Provides a 24/4-day regimen with a regular withdrawal bleed. Offers a desirable safety profile with minimal impact on metabolic parameters.
Newer oestrogen options
Oestradiol valerate and oestetrol are alternatives for those intolerant to ethinyl oestradiol. Oestradiol valerate is a quadriphasic combined oral contraceptive (COC) with lower oestrogen doses. Oestetrol is a novel oestrogen with minimal impact on metabolic parameters. Both provide contraceptive efficacy comparable to ethinyl oestradiol-containing COCs.
Transdermal options
A transdermal patch containing 30μg ethinyl oestradiol and 120μg levonorgestrel. Addresses poor adherence associated with oral contraceptives. Concerns about venous thrombo-embolism risks associated with transdermal patches. May be beneficial for those with difficulty remembering daily pills.
Self-administered DMPA-SC
Offers an option for self-administration of depot medroxyprogesterone acetate (DMPA-SC) for improved contraceptive access. Shown to have a higher continuation rate than provider-administered DMPA. Patients find it easy to administer, with high satisfaction rates. Barriers include fear of needles, incorrect administration, and insurance coverage.
What options are available for male contraception?
There are currently no approved contraceptive options for men except condoms. Behavioural contraceptive methods include penile withdrawal and fertility awareness-based methods, such as natural family planning or the rhythm method. The effectiveness of withdrawal and fertility awareness relies on patient education, cycle regularity, and commitment to daily evaluation of symptoms.7
A meta-analysis reported fertility awareness method failure rates of 22 pregnancies per 100 women-years. Barrier methods like condoms and diaphragms prevent sperm entry and have a first-year typical use effectiveness of 13 pregnancies per 100 women. Current male contraceptive methods currently under evaluation include attempts to suppress sperm count to <1 million/ml and include a testosterone plus progestin topical gel.7
Emergency contraception
Emergency contraception (EC) reduces pregnancy risk after unprotected intercourse. The copper intrauterine devices (IUD) are the most effective EC method, reducing risk to 0.1% when placed within five days. Levonorgestrel (LNG) IUDs are now considered for EC. Oral EC, using progestin (LNG) or anti-progestin (ulipristal acetate), blocks or delays ovulation.7
LNG EC is available over the counter, while ulipristal acetate requires a prescription. Both should be taken as soon as possible after unprotected intercourse, with ulipristal acetate remaining effective up to 120 hours. Clinicians should discuss EC options with patients starting user-controlled methods and may prescribe oral EC for immediate use if needed.7
The pill still the most widely used reversible contraceptive
Oral contraceptives are still the most widely utilised reversible contraceptives.
Choosing a contraceptive pill should be based on patient experience due to the absence of comparative effectiveness studies clearly indicating the superiority of one formulation over another.7
Monophasic regimens, featuring consistent hormone doses in each pill, offer advantages over biphasic and triphasic regimens. The flexibility of extending cycles by skipping the placebo week is more feasible with monophasic regimens, preventing breakthrough bleeding common in multiphasic regimens.7
For ethinyl oestradiol, a dose exceeding 35µg per day is rarely necessary, with starting at 30µg to 35µg providing the best chance of a regular bleeding pattern without added risks. Adjusting ethinyl oestradiol may be considered if oestrogen-associated adverse effects arise.7
Various progestins options are available and differ in terms of androgenicity, metabolic effects. Despite structural differences, no evidence supports the superiority of one progestin over another. Patients may prefer a previously used pill, and if suitable, prescribing it is reasonable.7
COCs can be dosed cyclically or continuously. Originally, a 21-day active drug cycle with a seven-day placebo trigger for withdrawal bleeding was common. However, extended and continuous dosing, with shorter or no placebo periods, has become popular due to improved efficacy and fewer adverse effects associated with the placebo week. A new vaginal ring (segesterone acetate/ethinyl oestradiol) offers a yearly prescription with monthly removal for seven days.7
IUDs and subdermal implants have the highest effectiveness
Long-acting reversible contraceptives (LARCs eg IUDs, copper -IUD, and subdermal implants) provide at least three-year continuous pregnancy protection and do not require any input from users. LARCs have demonstrated greater efficacy in preventing unintended pregnancy among all women in comparison with short-acting methods.8
Typical use pregnancy rates for the copper IUD are ~1% per year, with no impact on the user's hypothalamic-pituitary-ovarian axis, allowing uninterrupted ovulation and menstrual cyclicity.7
The primary mechanism of action involves spermicidal effects, attributed to copper salts and induced endometrial inflammatory changes. A notable challenge associated with the copper IUD is the potential increase in the amount, duration, and discomfort of menstrual periods, particularly during the initial three to six months of usage.7
Importantly, IUD utilisation does not elevate the subsequent risk of tubal infertility. In cases where sexually transmitted infection (STI) testing is deemed necessary, it can be conveniently conducted alongside IUD placement.7
This streamlined approach to STI testing during IUD insertion does not amplify the risk of pelvic inflammatory disease. The absolute risk of pelvic inflammatory disease post-IUD insertion remains low, ranging from 0% to 5% in patients living with gonorrhoeal or chlamydial infections and 0% to 2% in those without such infections.7
Subdermal implants are progestin-only contraceptives inserted under the skin, delivering hormones steadily and bypassing hepatic metabolism. They lack oestrogen, thus preventing plasma progestin peaks.8
The LNG 6-capsule subdermal implants were pioneering reversible contraception methods, demonstrating lower failure rates and one-year pregnancy rates compared to oral contraceptives and IUDs. Bleeding irregularities were the primary cause for discontinuation and the most reported side effect.8
Etonogestrel (ENG) implants are a single-rod contraceptive containing 68mg of ENG. Post-removal, normal menses returned in most patients. Despite common side effects like abnormal bleeding, the evidence did not associate higher body mass index (BMI) or weight with hormonal contraceptive effectiveness, making it a first-line option regardless of BMI.8
Research suggests extending the approved three-year period for ENG implants, positioning them as discreet alternatives to IUDs for teenage girls. Immediate postpartum implant insertion and post-abortion placement were deemed safe and effective.8
The ENG implant shows promise in managing symptomatic endometriosis, offering pain relief comparable to other progestins. The insertion of ENG implants immediately after a surgical abortion do not increase pregnancy risk, further establishing their versatility and efficacy in various reproductive health scenarios.8
Conclusion
South Africa faces what some has called a teenage pregnancy epidemic, with rising rates and associated challenges.9 Unintended pregnancies, prevalent in LMICs, can lead to adverse maternal and child health outcomes, necessitating effective prevention strategies.
Repeat unintended pregnancies pose higher risks, highlighting the need for proper access to contraceptives. Contraceptive options, including innovative methods and male contraception, play a crucial role.
Overcoming societal barriers and ensuring access to contraceptives post-birth are essential for preventing unintended pregnancies. Implementation of primary, secondary, and tertiary prevention strategies can contribute to mitigating the impact of unintended pregnancies, fostering better reproductive health outcomes in South Africa.
References
- Khan MN, Islam MM. Women’s experience of unintended pregnancy and changes in contraceptive methods: evidence from a nationally representative survey. Reprod Health, 2022.
- Guttmacher Institute. Unintended pregnancy and abortion. 2022. South Africa. Available at: https://www.guttmacher.org/regions/africa/south-africa#:~:text=In%20South%20Africa%20in%202015,Africa%20is%20legal%20on%20request.&text=Notes%3A%20These%20are%20model%2Dbased,we%20are%20of%20these%20trends
- Ayele A, Abdurashid N, Hailu M, Tefera B. Unintended Pregnancy and Associated Factors among Pregnant Women Attending Antenatal Care Unit in Public Health Facilities of Dire Dawa City, Eastern Ethiopia, 2021. Obstetrics and Gynecology International, 2021.
- Mohamed S, Chipeta MG, Kamninga T, et al.Interventions to prevent unintended pregnancies among adolescents: a rapid overview of systematic reviews. Syst Rev, 2023.
- Cowling N. Share of teenage pregnancies in South Africa 2018-2022, by age. 2023. [Internet]. Available at: https://www.statista.com/statistics/1115755/share-of-teenage-pregnancies-in-south-africa-by-age/#statisticContainer
- Fiffick AN, Iyer TK, Cochran T, et al. Update on current contraceptive options: A case-based discussion of efficacy, eligibility, and use. Cleveland Clinic Journal of Medicine,
- Teal S, Edelman A. Contraception Selection, Effectiveness, and Adverse Effects: A Review. JAMA, 2021.
- Rocca ML, Palumbo AR, Visconti F, Di Carlo C. Safety and Benefits of Contraceptives Implants: A Systematic Review. Pharmaceuticals (Basel), 2021.
No author listed. The ‘epidemic’ of adolescent pregnancy in SA. 2023. [Internet]. Available at: https://www.iol.co.za/dailynews/opinion/the-epidemic-of-adolescent-pregnancy-in-sa-e262e87b-7c50-4a21-a91b-2b58178802b7
