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Contraception Corner

Challenges to Preventing Unintended Pregnancy in Teenagers and Young Adults

Pablo Rodriguez, MD; Barbara Clark, RN, MSN, MPH

The media and society convey mixed messages about sex. We teach abstinence in schools and parents often avoid the subject at home, but teenagers and young adults are bombarded with sexual messages in entertainment and advertising. Society fears that if sex is discussed openly, teenagers will do it—but they already do.

Comprehensive sex education programs (as opposed to abstinence-only programs) have positive effects on teenage sexual behavior, according to a 2007 evaluation report.1 Despite years of government funding for abstinence-until-marriage programs ($176 million in 2007), comprehensive programs delayed the initiation of sex, reduced the number of sexual partners, and increased condom/contraceptive use.1-3 Lending support to this comprehensive approach are the experiences of developed countries like the Netherlands and France, which teach teenagers responsible sexual behavior and contraceptive use.4 They have dramatically lower rates of teenage pregnancy and HIV/AIDS than the United States.

Lack of education about healthy sexuality and contraception is a major cause of unintended pregnancy in young women, but there are other causes as well—including lack of insurance coverage, inadequate physician education about contraception, and outdated provider beliefs and practices. A combination of public policy and provider strategies is needed to address such barriers.

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UNINTENDED PREGNANCY RATES

Following a 14-year decline, teenage birth rates in the United States rose by 3% in 2005.5 Even with the years of decline—attributed to increased use of contraceptives, not sexual abstinence—the United States still has one of the highest teenage pregnancy rates among developed countries.4 Its rate is more than 9 times higher than the rate in the Netherlands, and nearly 4 times higher than the rate in France. Unintended pregnancy rates have also been rising among women in their 20s. In 2001, the unintended pregnancy rate for women aged 18 to 24 years was twice that for other age groups—ie, more than 1 unintended pregnancy for every 10 US women.6 The rate has also risen among women aged 25 to 29.

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SEX EDUCATION

A study on programs to reduce teenage pregnancy and sexually transmitted infections (STIs) found that 66% of 48 programs supporting both absti- nence and contraception for sexually active teenagers had positive behavioral effects.1 However, 10 rigorous studies on abstinence-only programs demonstrated no delay in the initiation of sex, increase in abstinence, or decrease in the number of sexual partners.1

Today, many teenagers and young adults are not being educated about healthy sexuality and contraception. According to 2002 data, 33% of teenagers had not received any formal instruction about contraception, and 20% have received abstinence-only education with no instruction in birth control.2 Because teenagers and young adults are not receiving this formal education, it is even more important for health care providers to discuss healthy sexuality and contraception with their patients, according to members of an advisory committee of reproductive health providers.7 In 2007, the National Campaign to Prevent Teen and Unplanned Pregnancy and the Association of Reproductive Health Professionals cosponsored a meeting of this committee to obtain health providers’ perspectives on the barriers to preventing unintended pregnancies in teenagers and young adults.

Inadequate sex education has contributed to patient barriers such as unintended sex associated with alcohol abuse, ambivalence or complacency about contraception and pregnancy, fears about contraception safety, and ignorance concerning long-term contraceptive methods and the importance of using contraceptives consistently and correctly (Table 1).7 According to a 2007 report, many teenagers do not use contraception either carefully or consistently.1

Table 1. Patient Barriers to Preventing Unintended Pregnancy Alcohol. An unrecognized contributor to unintended sex and unintended pregnancy; 75% to 80% of unintended pregnancies in the college population are related to alcohol use.7 Fear of harm from contraception. Fear of potential infertility or cancer. Ambivalence and complacency about pregnancy and contraception. Most young women who have an unintended pregnancy do not think they can get pregnant, comprising a form of magical thinking.

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PROVIDER EDUCATION AND TRAINING

Even though much of the responsibility for sex education and contraceptive counseling falls on providers, many are unprepared for this task. As the advisory group noted, medical students only receive 1 hour of pharmacology training in all forms of birth control,7 whereas they should be told that contraception is one of the most important subjects they will study during their career; regardless of their specialty, they will need to discuss sexuality and birth control with their patients. In nursing and nurse practitioner programs the level of training varies widely, but specific data on these programs are lacking.

Outdated provider beliefs and practices further impede contraceptive use and counseling. For example, some providers still believe that oral contraception is the best method for all women; others do not provide contraception after an abortion, and are reluctant to sterilize patients due to concern over patient regret.7

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INSURANCE COVERAGE

Poor insurance coverage is another barrier to women obtaining contraceptive services. Some do not have health insurance, while others have insurance that does not cover contraception. According to the advisory committee, lack of insurance is a major issue for women in their 20s who seek care at clinics but do not qualify for government programs; these women cannot even afford the lower prices offered by nonprofit organizations such as Planned Parenthood.7 Lack of insurance coverage or access to contraceptive care particularly affects Hispanic women, who are at higher risk for unintended pregnancy than women from other cultures.7 In fact, Latina teenagers have a pregnancy rate that is twice the national average: 51% of Latina women have been pregnant at least once by the age of 20.8

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PROVIDER REIMBURSEMENT

Even if providers are trained and willing to counsel their patients about sexuality and contraception, they are seldom adequately reimbursed for this service or even basic contraceptive services. The advisory committee reported that although a Planned Parenthood clinic may pay $200 to $360 for intrauterine contraception, Medicaid reimburses only $98 for the cost of the device, insertion, and staff time.7 Health centers for college students are also underfunded and have been eliminated from the 340B government-sponsored drug discount program, so they can only provide oral contraceptives—excluding transdermal patches, vaginal rings, or intrauterine devices.7

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PROVIDER STRATEGIES

To overcome barriers to reducing unintended teenage pregnancy, sweeping changes are needed in society’s views, public policies on healthy sexuality and contraception, contraceptive coverage and access, and provider education. Nonetheless, there are some proven strategies that health care providers can implement within their own practices to increase contraceptive use in young women (Table 2).9,10

Table 2. Strategies to Increase Contraceptive Use Arrange longer appointment times to accommodate counseling with other physicians, nurses, or other trained staff Provide a structured education component or supplemental educational materials Give reproductive health counseling during the patient’s first visit, with a pelvic examination during the second visit Use the "quick start" method for starting hormonal contraception; women start oral contraceptives the same day as their office visit, while the directions are fresh in their minds Offer long-term contraceptive methods to patients Teach patients about reproductive health skills, such as condom use

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CONCLUSION

Research shows that comprehensive sex education programs—rather than abstinence-only programs—are needed to tackle the high rate of unintended pregnancy among US teenagers and young adults. It is clear that society’s negative attitudes and misdirected public policy toward healthy sexuality and contraceptive use must change. Policymakers, parents, educators, and individual health care providers must recognize the terrible consequences of unintended pregnancies in young women and work together to reverse this trend.

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Pablo Rodriguez, MD, is Chief Executive Officer and physician, Women's Care, Pawtucket, RI, and Associate Professor of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI. Barbara Clark, RN, MSN, MPH, is a freelance writer in Arlington, VA.

References

1. Kirby D. Emerging Answers 2007: Research Findings on Programs to Reduce the Problems of Teen Pregnancy and Sexually Transmitted Diseases. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; 2007. www.teenpregnancy.org/product/pdf/6_11_2007_13_14_8Fullreport_EmergingAnswers2007.pdf. Accessed December 30, 2007.
2. Lindberg LD, Santelli JS, Singh S. Changes in formal sex education: 1995-2002. Perspect Sex Reprod Health. 2006;38(4):182-189.
3. A brief history of federal abstinence-only- until-marriage funding. Sexuality Information and Education Council of the United States web site. www.siecus.org/policy/states/2006/explanation.html. Accessed December 30, 2007.
4. Adolescent sexual health in Europe and the U.S.ãwhy the difference? 2nd ed, October 2001. Advocates for Youth web site. www.advo catesforyouth.org/PUBLICATIONS/factsheet/fsest.pdf. Accessed December 30, 2007.
5. Births: Final data for 2005. National Vital Statistics Reports, 54(2), 56(6). Hyattsville, MD: National Center for Health Statistics; December 5, 2007. www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf. Accessed December 30, 2007.
6. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-96.
7. Providersê Perspectives: Perceived Barriers to Contraceptive Use in Youth and Young Adults. Meeting cosponsored by The National Campaign to Prevent Teen and Unplanned Pregnancy and the Association of Reproductive Health Professionals, Washington, DC, October 13, 2007.
8. The National Campaign Latino Initiative. The National Campaign to Prevent Teen and Unplanned Pregnancy web site. www.teen pregnancy.org/espanol/initiative.asp. Accessed December 30, 2007.
9. Burlew, R, Philliber, S. The National Campaign: What Helps in Providing Contraceptive Services for Teens. http://teenpregnancy.org/resources/data/pdf/WhatHelps.pdf. Accessed December 30, 2007.
10. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 342. Intrauterine device and adolescents. Obstet Gynecol. 2007;110(6):1493-1495.

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