The Dutch success explained: Context The quality of sex education both within school and the family The general openness about sexuality and the acceptance of teenage sexuality as a fact. The availability and accessibility of primary healthcare services Less patronizing attitudes of service providers and a tendency of demedicalisation Method high rates of reliable contraceptive use (OC, sterilization) User The communication skills of teenagers enabling them to make their own responsible choices. High compliance rates (Pearl index of OC for instance 10 times lower than US)

Contraceptive use in The Netherlands/age category   age none CHC* PO IUD steril. condom** other 15–19 45 53 0 0 0 2 0 20–24 20 76 0 0 0 2 0 25–29 28 59 1 2 4 6 0 30–34 32 42 1 4 18 6 0 35–39 21 34 1 4 30 8 0 40–44 21 32 1 3 44 7 1 45–49 19 26 1 3 45 4 0 * combination with condom included; ** condom as contraceptive, not in combination with other method. CHC=combined hormonal(OC =Nuvaring) PO=longacting progestagen only(injectables and implants

Age Profile OC Use

Sterilization in The Netherlands 15-50y: 19.2% 45-49y : 32.0% 15-50y : 8.9% 45-50y : 16.6%

Subjective reliability estimate (n= 5000) 3.Method actually used Van Dalen & van Lunsen, 2004, submitted

Abortion is there to stay In an ideal world, contraceptives would be 100% effective, and they would be used correctly every time. But, like most things in life, birth control isn't perfect. Pills are missed; condoms break, are put on improperly, and sometimes are not used at all. And, unfortunately, situations occur in which women are forced to have intercourse against their will.

Determinants of inadequate preventive behaviour Lack of Motivation Mistakes are Human (user dependent factors) 3. Bad Luck (100% reliable does not exist) (method dependent factors) Unexpected sexual encounters (situative factors) 5. Contextual factors(partner and/or society related

1.Lack of Motivation (user dependent factors-1) The motivation to use contraception is determined by the fact that it enables sexual activity without fear for pregnancy. When the expected outcome of sex is not positive, both sexual and contraceptive motivation will be lacking When expected and/or experienced side effects outweight the benefits contraceptive motivation will decrease and non-compliance will increase van Lunsen et al ,proceedings ISSWSH 2004

2. Mistakes are Human (user dependent factors-2) Nobody is perfect The method is not suitable for the situation (lack of tailor-made approaches)

3. Bad Luck (method dependent factors) 100% reliable does not exist Irrational subjective reliability assessment

4.Unexpected sexual encounters (situative factors) Starters Serial Monogamous Restarters Substances

5.a. Contextual factors (partner related) partner communication lack of male responsibility partners’ preferences abusive relationships partner abandonment and other situations that turn a desired pregnancy into an unwanted pregnancy

A lack of communication between partners as well as relational problems negatively influence consistent use of contraceptives Women and men who are satisfied with their relationship more frequently use reliable contraceptives than those who experience relational problems. .Sundby et al.Patient Education and Counseling 1999,38:11-10. .Ingelhammer I, et al. Contraception 1994;50:142-52.

5.b. Contextual factors (society related) social attitudes about sex educational climate patronizing attitudes of service providers medicalisation scares lack of accessible services limitations in availability of certain methods lack of availability of emergency contraception financial barriers

Contrary to the belief of many policy makers in more repressive societies a pro-sexual attitude of society, educators and care-givers is one of the major determinants determining the success of prevention programs.

Abortionrate/1000 1970-2004 * pillscare € NHS * *

Abortions/ age category(1992-2000)

Frequency/age category(% of total number of abortions)

Causes increase in abortion rates since 1996 Increased numbers of non-European immigrants Decrease OC use related to : - Negative Publicity on OC’s - Changed health beliefs and decreased acceptability of side effects Changed risk perception/increased risk behaviour (simultaneous increase STD) Less investments in prevention programs Changes in refunding system

A small decrease in 2003 by: Sharp decrease numbers of new immigrants Renewed prevention campaigns in schools, media (including several websites) and for special groups