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  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.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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61Unintended Pregnancy

Modern contraceptives have enabled women to increase control over their reproductive lives. However, in the United States 60% of all pregnancies are unintended. Unplanned pregnancies affect women of all ages and circumstances; however, their number is higher in certain population groups, such as teenagers (82% of pregnancies unintended) and never-married women (88% of pregnancies unintended). The consequences of these pregnancies in the United States include approximately 1.5 million abortions annually, children who are at increased risk of health and behavior problems in childhood and later in life, and pregnancies that have not benefitted from preconception risk identification and management.

Screening, counseling, and preventive services are particularly needed for older women of childbearing age. For women aged 35 to 39, 56% of pregnancies are unintended. For women aged 40 to 44, the number is 77%, and 59% of these end in abortion, the highest percentage for any age group from age 15 to 44. Pregnancies of women aged 40 to 44 and beyond, while small in absolute numbers, are disproportionately unintended, likely to end in abortion, and likely to entail other adverse outcomes. The large percentage of unintended pregnancies for women approaching age 44 suggests that both women and their care givers underestimate the potential for, and fall short of, adequate protection against pregnancy during these years when fertility is expected to decline.

Modern contraceptives marketed in the United States have been shown to be safe and effective (Table 61.1). Although most are relatively inexpensive, their costs vary.

See chapter 25 for information on counseling to prevent unintended pregnancy in adolescents. See chapters 23 and 59 for information on counseling to prevent sexually transmitted diseases and HIV infection among adolescents and adults, respectively.

Recommendations of Major Authorities

  • American College of Obstetricians and Gynecologists and US Preventive Services Task Force —
  • Primary care providers should obtain a history of sexual practices and provide counseling on the prevention of unintended pregnancy and contraceptive options to all sexually active women who do not want to become pregnant and men who do not want to have a child. Counseling should also be provided regarding high-risk sexual behavior and the prevention of STDs and HIV infection.

Basics of Counseling to Prevent Unintended Pregnancy

1. The main goal is to make sure family planning is a part of primary care for all sexually active patients. Assess sexual practices and the need for contraceptive counseling for every patient, including women in their forties and men. This can be done as a part of periodic health examinations or during acute care visits for issues of a related nature, such as STDs, postpartum care, or family stress. As with all counseling of patients regarding sensitive topics, address this issue with openness and a nonjudgmental attitude.

2. Determine each patient's level of knowledge about contraceptive options. What methods have they tried in the past? Have these methods been acceptable and effective for the patient and partner or partners? What medical and life-style factors could influence the patient's choice of an appropriate contraceptive?

3. Educate patients about the important characteristics of different contraceptive methods (Table 61.2). Present the patient with a range of contraceptive options. Assist patients in carefully choosing a contraceptive method that is appropriate for their abilities, motivation, and life-style, thereby increasing the likelihood that it will be used correctly and consistently. Encourage patients who are already using a method correctly and successfully to continue to do so.

Table 61.2. Complications, Side Effects, and Benefits of Major Methods of Contraception.

Table

Table 61.2. Complications, Side Effects, and Benefits of Major Methods of Contraception.

4. Discuss the ability of different contraceptive methods to protect against sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) infection. Latex condoms, used consistently and correctly, are effective for both birth control and reducing the risk of disease. Other forms of birth control, such as IUDs, diaphragms, cervical caps, and oral contraceptives, do not give the same protection. Stress to patients that even if they use another form of birth control, if they are not involved in a mutually monogamous relationship with a person known to be free of infection, they also need to use condoms to reduce the risk of STDs.

5. Contraception is a responsibility of both partners. If possible, involve both partners in counseling and discussion of contraceptive options. See Table 61.1 for an evaluation of the effectiveness of various contraceptive methods. Also discuss ways in which males can participate in family planning.

6. After patients choose a method, conduct an in-depth discussion of:

  • How it works
  • Theoretical and actual effectiveness
  • Advantages/benefits
  • Disadvantages/risks
  • How to use the method
  • Nuisance side effects
  • Warning signs
  • Back-up methods.

Provide patients with printed material about the contraceptive method chosen (Patient Resources).

7. Follow-up counseling is particularly important in the first few weeks of contraceptive use to deal with any difficulties associated with use and side effects. Ask patients how they are using the method, correct misinformation, and discuss any impediments to proper use of the method. Continue counseling during each patient visit, especially until patients are very comfortable with use of the contraceptive method. Many compliance problems can be resolved relatively simply with reassurance and changes in dose or technique of use.

8. Oral contraceptives (OCs) can also be prescribed as a postcoital ("morning after") method to prevent pregnancy (Table 61.3). The Food and Drug Administration announced in February 1997 that certain combined oral contraceptives containing ethinyl estradiol and norgestrel or levonorgestrel were safe and effective for use as postcoital emergency contraception . This approach to emergency contraception has been reported to reduce the risk of pregnancy by 55.3% to 94.2% after unprotected intercourse if treatment is initiated within 72 hours.

Table 61.3. Oral Contraceptives for Use as Postcoital Emergency Contraception.

Table

Table 61.3. Oral Contraceptives for Use as Postcoital Emergency Contraception.

Instruct the patient to take the first dose as soon as possible (but no more than 72 hours) after unprotected intercourse; the second dose is taken 12 hours after the first dose. The most common side effects of these regimens are nausea and vomiting.

Patient Resources

  • 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
  • Barrier Methods of Contraception; Contraception (in English and Spanish); Family Planning by Periodic Abstinence; The Intrauterine Device; Oral Contraceptives; Postpartum Sterilization; Sterilization by Laparoscopy; Sterilization for Women and Men. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • Drugs and Pregnancy: Often the Two Don't Mix; Choosing a Contraceptive. FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.
  • Emergency Contraception Website. The Office of Population Research at Princeton University. Internet address: http://opr.princeton.edu//ec/hotline.html
  • Emergency Contraception Hotline. The Office of Population Research at Princeton University. (800)584-9911.
  • Facts About Birth Control. Planned Parenthood, 810 7th Ave, New York, NY 10019; (212)541-7800; Internet address: http://www.igc.org/ppfa

Provider Resources

  • Hormonal Contraception. (ACOG Educational Bulletin #198). American College of Obstetricians and Gynecologists. 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • Emergency Contraception. (ACOG Practice Pattern #3). American College of Obstetricians and Gynecologists. 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • Food and Drug Administration. Prescription Drug Products; Certain Combined Oral contraceptives for Use as Postcoital Emergency Contraception; Notice. Federal Register. 1997; 62(37)8610-8612.
  • The Intrauterine Device (technical bulletin 164). American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • Managing Contraceptive Pill Patients. EMIS Publishers, Dallas, TX; (800)225-0694.
  • Oral Contraceptive User Guide (Second Edition). EMIS Publishers, Dallas, TX. (800)225-0694.
  • Planned Parenthood. Planned Parenthood at 810 7th Ave, New York, NY 10019; (212)541-7800. Internet address: http://www.igc.org/ppfa

Selected References

  1. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care. Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  2. Baird D, Glasier AF. Hormonal contraception. N Engl J Med . 1993; 328:1543–1549. [PubMed: 8479492]
  3. 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]
  4. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology 1994-1996. 16th rev ed. New York, NY: Irvington Publishers, 1996.
  5. Hatcher RA, Stewart F, Trussell J, et al. Contraceptive Technology . 17th rev ed. New York, NY: Irvington Publishers; 1998, in press.
  6. Trussell J, Stewart F. The effectiveness of postcoital hormonal contraception. Family Planning Perspectives . 1992; 24:262–264. [PubMed: 1483529]
  7. Trussell J, Stewart F, Guest F, Hatcher RA. Emergency contraceptive pills: a simple proposal to reduce unintended pregnancies. Family Planning Perspectives . 1992; 24:269–273. [PubMed: 1483531]
  8. US Department of Health and Human Services, Public Health Service. Healthy People 2000 Progress Review: Family Planning . Washington, DC: US Department of Health and HumanServices, Public Health Service; March 26, 1996.
  9. 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.

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