A Request for Confidential Contraception by a 16-Year-Old
A 16-year-old girl comes alone to a midwife-led clinic and asks for contraception. She is unmarried and says her parents must not know. She is in school and is worried about pregnancy. She has no medical history of note, takes no medicines, and has no allergies. Her last menstrual period was 12 days ago and is regular. She has never been pregnant. She asks specifically for "the injection" because her friend uses it. The clinic policy requires parental consent for clients under 18, and the midwife is the only staff member present. The girl becomes tearful and says she will not come back if anyone is told.
1. How should the midwife balance confidentiality, clinic policy, and the girl's best interests?
Read the worked answer
Ethical and legal analysis:
- Best interests and competence: a 16-year-old can often understand contraceptive information and its consequences. The midwife should assess her understanding, not her age alone. Refusing care because of a blanket policy may expose her to unprotected sex and pregnancy, which is worse for her health.
- Confidentiality: the midwife should explain the limits of confidentiality honestly, including what the clinic policy says and what she can and cannot promise. She should not promise secrecy she cannot keep.
- Policy conflict: a policy requiring parental consent for all under-18s conflicts with the principle of acting in the young person's best interests. The midwife should not simply break confidentiality or simply obey the policy. She should seek advice from a supervisor or the clinic's ethics or legal lead, and document the reasoning.
- Safety: ask about coercion, violence, and whether the sex is consensual. If there is evidence of abuse or exploitation, safeguarding procedures take priority over confidentiality.
Practical approach: explain options, offer a same-day method, and support her to involve a trusted adult if she wishes, without making it a condition. If the policy truly forbids treatment, refer her to a service that can provide confidential care rather than sending her away with nothing.
2. If she is deemed able to consent, which contraceptive method is most suitable today, and what counselling points and follow-up are needed?
Read the worked answer
Method choice: she asked for the injectable, and a progestogen-only injectable is a reasonable option for a healthy 16-year-old. However, the injectable is not the best method for everyone: it can cause irregular bleeding, and return to fertility may be delayed. A long-acting reversible method such as an implant or an intrauterine device is more effective and does not depend on remembering appointments, but an intrauterine device may be less acceptable to a young nulliparous woman and requires a skilled provider.
If the injectable is chosen:
- It can be given today if pregnancy can be reasonably excluded. With a last menstrual period 12 days ago and regular cycles, she may be in the fertile window, so a pregnancy test or a rule-out is prudent before starting.
- Explain that the injection does not protect against sexually transmitted infections, and offer condoms and information about testing.
- Explain expected bleeding changes, the need for repeat injections on schedule, and the importance of returning if she has unprotected sex or a missed period.
- Give a written appointment date and a way to contact the clinic confidentially.
Follow-up: review at the next injection date, check blood pressure and side effects, and revisit the method choice. Document the counselling, her understanding, and the method given.