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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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25Unintended Pregnancy

The rate of pregnancies among teenagers in the United States currently exceeds that of any other country in the western world. During the year 1990, one in 10 female adolescents in the United States aged 15 to 19 years became pregnant. Of teenage pregnancies, approximately 95% are unintended, and 40% are terminated by elective abortion. Among nonwhite teenagers, the rates of unintended pregnancies are nearly twice those of white teenagers. Young women with the least familial, educational, and financial resources are the most likely to become pregnant. As a result, teenage pregnancies are more likely than adult pregnancies to result in adverse health outcomes for both mother and baby, largely because of prenatal care delays, poor nutrition, and other lifestyle factors.

Recent data reveal a decrease in teenage sexual activity in the United States, with a concurrent increase in the rate of teenage contraceptive use. Previous surveys had demonstrated an increasing trend in teenage sexual activity since the 1970s. In 1995, 50% of females and 55% of males aged 15 to 19 years reported ever having sexual intercourse. These figures represent a decline from prior years (down from 55% of females in 1990 and 60% of males in 1988).

Approximately two-thirds of teenagers report using contraception (almost exclusively condoms) during their first sexual intercourse, and 78% report contraception usage during their most recent sexual intercourse. Younger adolescents are the least likely to use a contraceptive method when compared with either older teenagers or young adults.

See chapter 61 for information on counseling to prevent unintended pregnancy in adults. See chapters 23 and 59 for related information on counseling to prevent sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) infection among adolescents and adults, respectively. See chapters 14 and 48 for related information on hepatitis B in children and adults.

Recommendations of Major Authorities

  • All major authorities, including American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), American Medical Association (AMA), Canadian Task Force on the Periodic Health Examination, and US Preventive Services Task Force (USPSTF) --
  • Primary care providers should routinely counsel adolescents in the prevention of unintended pregnancies. AAP recommends that all pediatricians who choose to see teenagers should be able to provide counseling about sexual behavior, education on contraceptive methods and prevention of STDs, and assistance with access to contraception, preferably in the office or, if necessary, by referral. ACOG recommends that special attention be given to ensure that sexually active adolescents have access to suitable methods of contraception. AMA recommends that all adolescents should be asked annually about involvement in sexual behaviors that may result in unintended pregnancy and STDs, including HIV infection. USPSTF recommends that counseling be based on information from a careful history that includes direct questions about sexual history, current and past use of contraception, level of concern about pregnancy, and past history of unintended pregnancies. The USPSTF also recommends that clinicians inform adolescent patients that abstinence is the most effective way to prevent unintended pregnancy and sexually transmitted diseases; the effectiveness of abstinence counseling has not yet been established. Clinicians should involve young pubertal patients (and their parents, when appropriate) in early, open discussion of sexual development and effective methods to prevent unintended pregnancy and sexually transmitted diseases.

Basics of Counseling To Prevent Unintended Pregnancy

1. Ask all adolescents about their sexual experiences and use of contraceptives. Attempt to maintain a nonjudgmental, empathetic manner. This discussion can begin with questions about the patient's peer group before moving on to more explicit questions about the patient's own sexual behavior. State your willingness to answer any questions and to provide contraceptive advice and prescriptions. Provide adolescents with explicit information about the consequences of pregnancy and STDs and about effective methods to prevent them.

2. Counsel adolescents individually, assuring the patient that you will maintain confidentiality to the maximum extent possible. State laws vary regarding the minimum age at which an adolescent may consent to treatment, receive prescription contraceptives, or both. Become familiar with the laws in your state regarding these issues. Inform adolescents about their legal rights to confidentiality regarding pregnancy prevention and STD testing and treatment.

3. Counsel parents about the role of emerging sexuality in teenagers' lives, desire for privacy, and the options for contraception. Fostering effective communication between adolescents and their families regarding responsible sexual behavior is very important.

4. Support the decision of adolescents who choose to be sexually abstinent.

5. All patients should be encouraged and supported in their efforts to resist unwelcome or coercive sexual relationships.

6. Assist sexually active adolescents in choosing an effective, appropriate primary method of contraception. The choice should take into consideration the patients' personal preferences and motivation, religious beliefs, cultural norms, and relationship with their partner(s).

See Table 61.1 for the pregnancy ("failure") rates of women during the first year of contraceptive use. The two most popular contraceptive methods among adolescents are oral contraceptives and condoms. Oral contraceptives can confer the benefits of less painful menstrual periods and regular, predictable cycles. Implants or injectable contraceptives may also be appropriate choices for teens. In general, diaphragms, cervical caps, withdrawal, and periodic abstinence are technically more difficult methods for teenagers to use effectively. Intrauterine devices (IUDs) are not recommended for adolescents because of the increased risk of pelvic inflammatory disease, which may lead to sterility. Permanent sterilization procedures are not appropriate for adolescents and are prohibited for individuals under age 21 years when Federal funds are involved. In situations of unprotected intercourse, suggesting use of emergency oral contraceptives (morning-after pills) may be appropriate if treatment can be initiated within 72 hours after sexual contact. See chapter 61 for a discussion on emergency contraception.

Table 61.1. Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year, United States.

Table

Table 61.1. Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year, United (more...)

7. Encourage all sexually active adolescents to use condoms as a means of preventing STDs and HIV infection, even if they are using another form of contraception. Stress that latex condoms used consistently and correctly are an effective method for both pregnancy protection and disease prevention. Many teenagers, particularly those at younger ages, are hesitant to purchase condoms. Educating teenagers about their rights to purchase condoms and about access to other sources of condoms can be helpful. Some authorities recommend making condoms available to teenagers during office visits.

8. Encourage adolescents of both sexes to talk frankly with their partners about STDs, HIV, and hepatitis B infection, and the use of contraceptives. Encourage adolescents to be assertive with their partners about using contraception and protective measures against STDs. Also stress that saying "no," is every person's right each and every time.

9. Provide male adolescents with as much counseling as that provided to females about contraception and STD prevention. Instruct young adolescent males about responsible sexual behavior at an early age, particularly regarding the importance of condom use.

10. Provide adolescents with close follow-up after they begin using contraceptives. Adolescents often discontinue contraceptive use unnecessarily because of concerns about side effects and misconceptions about proper technique. Many such concerns and misconceptions can be easily dealt with in follow-up counseling. Table 25.1 provides sample responses to some common concerns of adolescents about oral contraceptives.

Table 25.1. Addressing Adolescents' Common Concerns About Oral Contraceptives.

Table

Table 25.1. Addressing Adolescents' Common Concerns About Oral Contraceptives.

Patient Resources

  • Being a Teenager: You and Your Sexuality; Teaching Your Children About Sexuality, Growing Up. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • Birth Control: Choosing the Method That's Right for You. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org
  • Emergency Contraception Website. The Office of Population Research at Princeton University. Internet address: http://opr.princeton.edu/ec/index.html
  • Emergency Contraception Hotline. The Office of Population Research at Princeton University. (800)584-9911.
  • How to Talk With Your Child About Sexuality, Decisions About Sex; How to Talk to Your Teenagers About the Facts of Life. Planned Parenthood, 810 Seventh Ave, New York, NY 10019; (212)541-7800.
  • Making the Right Choice: Facts Young People Need to Know About Avoiding Pregnancy; Talking to Your Teen About Sex; The Correct Use of Condoms: A Message to Teens. American Academy of Pediatrics, 141 Northwest Point Blvd, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org

Provider Resources

  • The Adolescent and Young Adult Fact Book; Evaluating Your Adolescent Pregnancy Program: How to Get Started; Teenage Pregnancy Prevention Strategies; What About the Boys? Children's Defense Fund, 25 E St NW, Washington, DC 20001; (202)628-8787.

Selected References

  1. Abma J, Chandra A, Mosher W, et al. Fertility family planning, and women's health: new data from the 1995 National Survey of Family Growth. National Center for Health Statistics. Vital Health Stat 23(19); 1997.
  2. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
  3. American Academy of Pediatrics. Counseling the Adolescent About Pregnancy Options. Pediatrics. . 1989; 83:135–137. [PubMed: 2909963]
  4. American Academy of Pediatrics. Committee on Adolescence: Contraception and Adolescents. Pediatrics. . 1990; 86:134–138. [PubMed: 2359670]
  5. American Academy of Pediatrics. Committee on Adolescence: condom availability and youth. Pediatrics. . 1995; 95:281–285. [PubMed: 7838650]
  6. American College of Obstetricians and Gynecologists. Safety of Oral Contraceptives for Teenagers. Washington, DC: American College of Obstetricians and Gynecologists; 1991. ACOG Committee Opinion No. 90.
  7. American College of Obstetricians and Gynecologists. The Adolescent Obstetric-Gynecologic Patient. Washington, DC: American College of Obstetricians and Gynecologists; 1990. ACOG Technical Bulletin No. 145.
  8. American Medical Association. Rationale and recommendations: psychosexual development and the negative health consequences of sexual behavior. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Ill: American Medical Association; 1994: chap 7.
  9. Canadian Task Force on the Periodic Health Examination. Prevention of unintended pregnancy and sexually transmitted diseases in adolescents. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 46.
  10. Canadian Task Force on the Periodic Health Examination. The periodic health examination: 2. 1987 update. Can Med Assoc J. . 1988; 138:618–626. [PMC free article: PMC1267740] [PubMed: 3355931]
  11. Centers for Disease Control. Sexual behavior among high school students: United States, 1990. MMWR. . 1992; 4:885–888. [PubMed: 1727971]
  12. Center for Population Options. Teenage Pregnancy and Too-Early Childbearing: Public Costs, Personal Consequences.5th ed. Washington, DC: Center for Population Options; 1990.
  13. Hatcher RA, Stewart F, Trussell J, et al. Contraceptive Technology 1994-1996 16th rev. ed. New York, NY: Irvington Publishers, 1996.
  14. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th rev ed. New York, NY: Irvington Publishers; 1998, in press.
  15. Healthy People 2000: Midcourse Review and 1995 Revisions. Washington, DC: US Department of Health and Human Services. Public Health Service; 1995.
  16. Spitz AM, Velebil P, Koonin LM, et al. Pregnancy, abortion, and birth rates among US adolescents— 1980, 1985, and 1990. JAMA. . 1996; 275:989–994. [PubMed: 8596256]
  17. US Preventive Services Task Force. Counseling to prevent unintended pregnancy.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 63.
  18. Ventura SJ, Taffel SM, Mosher WD, Henshaw S. Trends in pregnancies and pregnancy rates, United States, 1980-88. Monthly Vital Statistics Report. Hyattsville, Md: National Center for Health Statistics. 1993;41:6(suppl). US Department of Health and Human Services publication PHS 93-1120.

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