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Letters to the Editor

Primary Care May 2002

Contraception and Antibiotics
Congratulations on an excellent article (Zieman M, Nelson A. Combination OCs and Prescribed Antibiotics. The Female Patient. 2002;27(3):40-41). I wish you had written it 20 years ago when I was doing student health. Although my assessment of the problem was the same as yours, some back up from experts would have been helpful. My solution was to advise students to take vitamin C 500 mg when taking antibiotics with oral contraceptives. Vitamin C about doubles the estrogen level. I read this in the British Medical Journal probably some time in the 1980s.

Roger Roof, MD
Greencastle, Ind

Adolescent Pregnancy and the Provider's Role
Close to 1 million teens become pregnant each year in the United States. Ninety-five percent of these pregnancies are unintended, and at least one third will end in abortion.¹ The United States has the highest teen pregnancy rate of all developed countries. Although the sexual activity rate among all developed countries is the same, the lack of contraceptive counseling and effective contraceptive use here in the United States results in the higher teen pregnancy rate.² I believe that health care providers have the potential to aid in the reduction of adolescent pregnancy by providing contraceptive counseling at all visits, including well visits and acute care visits.

The national teen pregnancy rate did decline from 101.1 in 1995 to 97.3 in 1996 per 1,000 women aged 15 to 19 years of age.³ The slight decline in teen pregnancies can be attributed to better contraceptive use and more abstinence by the teens.⁴ However, there are still more than 484,000 teens giving birth per year.³ These births have negative outcomes for the mother, her baby, the baby's father, and society as a whole.³ The adolescent mother is at an increased risk for depression, physical abuse, failing to achieve her educational, financial, and career goals. The child of an adolescent mother is more likely to have low birth weight, abuse, neglect, and social behavioral problems. Daughters of teen mothers are at risk for becoming teen mothers themselves. Adolescent pregnancy also impacts the father negatively by decreasing his likelihood of graduating from high school and he is more likely to abuse alcohol and drugs. Public costs from teen pregnancies totaled $120 billion from 1985 to 1990. If these teens had postponed motherhood until their 20s, $48 billion could have been saved.⁵

Physicians, health care providers, nurses, psychologists, and social workers are in a unique position to educate young men and women about contraceptive care.

Adolescents aged 11 to 20 years made 60 million visits to private physicians' offices (pediatricians and family physicians) in 1990 alone. During these visits, contraceptive counseling took place less than 2% of the time. The small rate of counseling occurs despite large percentages of sexually active adolescents and high rates of adolescent pregnancy and sexually transmitted infections. In 1991, a national survey of 9th through 12th graders found that 54% had had sexual intercourse at least once. The same study found that 55% of these individuals did not use a condom during the latest sexual encounter.6 A survey of 343 internists, family physicians, gynecologist, and pediatricians in California showed that 40% of these physicians did screen for sexual activity or counsel their adolescent patients regarding contraceptive care. However, less than 5% of the physicians surveyed provided condoms to sexually active clients, while 81% have never provided condoms.⁸ Results from another study of 331 family physicians, gynecologist, pediatricians, internists, and psychiatrists showed that pediatricians, psychiatrists, and internist were less likely than family physicians and gynecologists to provide family planning counseling to adolescents aged 11 through 19 years.⁷ Women physicians, gynecologists, and newly graduated physicians are the ones who report higher rates of counseling and preventive care.⁸

Although contraceptive counseling should be addressed at each well visit, one should not let the opportunity pass during acute care visits. The more an individual hears about contraception, the more likely they are to remember and practice safer sex. Lipkin suggests that practitioners should not overcomplicate contraceptive information that is presented to patients. The information presented should be straightforward and concise with a review of the patient's understanding afterwards. Patient involvement in the decision-making process will also facilitate compliance.⁹

With the limited time a provider has to spend with each patient, information on different types of contraception can be presented in a pamphlet and placed in the waiting area or provided to each new reproductive-aged woman when she is completing her new patient paperwork. Another opportunity to inform patients about the different types of contraception would be in the form of a poster in each exam room. Patients will undoubtedly be in the exam room alone before the provider enters. This offers the patient another opportunity to review the poster in private and ask any questions during the exam.

Providers can also ask all adolescents and childbearing-aged women if they are sexually active and what type of contraception is used during gynecological and genitourinary problem visits, and especially during all well checks. This will open the door for timid patients to ask questions that they may have been afraid to bring up.

Previous studies have shown that contraceptive counseling does indeed decrease adolescent pregnancy by as much as 25%.⁷ With parental involvement and provider counseling, adolescents will have the knowledge and power necessary to make the decision that is best for them regarding abstinence or safer sexual practices. The ability to make an impact on an adolescent's life and aid in decreasing the national teen pregnancy rate falls in the hands of all individuals who come into contact with adolescents, especially health care providers, regardless of specialty.

Ana Khoune
UNC-Chapel Hill

References

1. Teen Pregnancy. Centers for Disease Control and Prevention Web site. Available at: www.cdc.gov/nccdphp/teen.html. Accessed November 20, 2001.
2. Moore PJ, Adler NE, Kegeles SM. Adolescents and the contraceptive pill: The impact of beliefs on intentions and use. Obstet Gynecol. 1996;88:S41-S47.
3. Reducing teen pregnancy. Planned Parenthood Web site. Available at: www.plannedparenthood.org/LIBRARY/TEEN-PREGNANCY/reducing.html. Accessed November 20, 2001.
4. Hellerstedt WL, Smith AE, Shew ML, Resnick MD. Perceived knowledge and training needs in adolescent pregnancy prevention. Arch Pediatr Adolesc Med. 2001;154:679-683.
5. Pregnancy and childbearing among US teens. Planned Parenthood Web site. Available at: www.plannedparenthood.org/LIBRARY/TEEN-PREGNANCY/childbearing.html. Accessed February 27, 2002.
6. Igra V, Millstein SG. Current status and approaches to improving preventive services for adolescents. JAMA. 1993;269: 1408-1412.
7. Orr DP, Weiser SP, Dian DA, Maurana CA. Adolescent health care: Perceptions and needs of the practicing physician. J Adolesc Health Care. 1987; 8:239-245.
8. Millstein SC, Igra V, Gans J. Delivery of STD/HIV preventive services to adolescents by primary care physicians. J Adolesc Health. 1996;19:249-257.
9. Lipkin M. Physician-patient interaction in reproductive counseling. Obstet Gynecol. 1996;88:S31-S40.

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