Adolescent Pregnancy and Contraception
Maria Trent
Unplanned pregnancy is a major public health problem facing pediatric and adolescent health. In the 2001 Youth Risk Behavior Survey of high school students, 42.9% of girls and 48.5% of boys reported having ever engaged in sexual intercourse. Currently, more than 800,000 pregnancies occur in the United States each year, of which 80% are unplanned, 51% result in a live birth, 35% in abortion, and 14% in miscarriage. These figures represent a significant reduction in adolescent pregnancies over the last few decades. Some of this reduction can be attributed to the finding that fewer adolescents are having sexual intercourse; however, research by the Alan Guttmacher Institute using the 1995 National Survey of Family Growth data demonstrated that the reduction is primarily the result of increased access to and use of highly effective forms of contraception. Despite the finding of no significant differences in sexual behavior among adolescents across industrialized countries, the United States continues to be a leader in this area. Rates of pregnancy and childbearing in the United States are approximately twice that of Great Britain and Canada and are four times higher than Sweden and France. Levels of sexual activity and age of initiation among teenagers in these countries do not differ significantly from those of teenagers in the United States; however, teens in those countries appear to select more reliable methods of contraception. In addition, young people growing up in socially and economically disadvantaged environments are more likely than their less-disadvantaged peers to engage in risky sexual behavior and to bear children during adolescence. The United States, which has the highest per capita income of these countries, also has the greatest proportion of disadvantaged families. European communities have also been able to provide the clear message that childbearing is an adult behavior reserved for persons who have completed their education and vocational training, whereas sexual expression as seen as a normal part of adolescent development. This view appears to foster an expectation of sexual responsibility that is supported by comprehensive sexuality education promoting responsible sexual behavior.
CONSEQUENCES OF ADOLESCENT PREGNANCY
The potential consequences of teenage parenthood include the medical complications of pregnancy, unintended births, physical discomfort and emotional distress associated with abortion, reduced educational attainment, fewer employment opportunities, increased likelihood of welfare reliance, and poorer health and developmental and social outcomes for their children. Experiencing an unplanned pregnancy indicates that a young
woman has been involved in sexual contact that has not been protective for sexually transmitted infections (STIs). Central to the adolescent focused goals within the Healthy People 2010 Objectives are the reduction of unplanned pregnancies and STIs in adolescents. The goals of contraceptive management in adolescents are therefore twofold—the prevention of unintended pregnancy and the prevention of STIs and their sequelae. With consistent use, dual methods such as a hormonal method with condoms can prevent unplanned pregnancy as well as the acquisition and spread of STIs.
woman has been involved in sexual contact that has not been protective for sexually transmitted infections (STIs). Central to the adolescent focused goals within the Healthy People 2010 Objectives are the reduction of unplanned pregnancies and STIs in adolescents. The goals of contraceptive management in adolescents are therefore twofold—the prevention of unintended pregnancy and the prevention of STIs and their sequelae. With consistent use, dual methods such as a hormonal method with condoms can prevent unplanned pregnancy as well as the acquisition and spread of STIs.
DIAGNOSIS OF PREGNANCY
Although pregnant adolescents may present for a variety of complaints, late or missed menstrual period is the most common presentation. Other symptomatic presentations include mild abdominal discomfort, constipation, urinary frequency, dizziness, fatigue, nausea, breast tenderness, headaches, or a combination of symptoms. Although some adolescents may express concern about the possibility of pregnancy, many adolescents have not really considered the possibility of pregnancy and believe that their symptoms are representative of another medical problem. Adolescents may also not provide sufficient detail related to sexual activity, and this can further delay diagnosis. For this reason, it is not unusual for adolescents to be diagnosed with pregnancy at an urgent care visit, family planning appointment, or even well physical examination.
Clinical assessment and evaluation of the pregnancy should be initiated at the time of presentation to delay intervention further. Inexpensive urine pregnancy tests can be used to diagnose pregnancy within 7 days of implantation. These tests vary in sensitivity, ranging from 5 to 50 mIU/mL of human chorionic gonadotropin. This is usually sufficient given that most women have human chorionic gonadotropin levels between 50 and 250 mIU/mL at the time of missed period. In general, there is no advantage to use of radioimmunoassay (serum) tests in diagnosing a pregnancy unless a concern exists about threatened abortion and/or ectopic pregnancy.
Pelvic examination, including testing for STI and uterine sizing and dating, is an important aspect of the clinical evaluation. Pregnancies are dated from the first day of the last menstrual period. Given that some adolescents are unsure of date of the last menstrual period, the bimanual examination allows the provider to assess agreement between dates and uterine size. On bimanual examination, the 8-week uterus is the size of an orange, the 12-week uterus is the size of a grapefruit at the level of the pubic symphysis, the 16-week uterus is midway between the pubic symphysis and umbilicus, and the 20-week uterus is at the level of the umbilicus. Testing for Chlamydia trachomatis and Neisseria gonorrhoeae and a wet preparation for trichomoniasis and bacterial vaginosis are important for the young woman. Infection can threaten the status of the pregnancy of a young woman who plans to continue to term and can complicate a medical abortion. A complete blood count to assess for anemia, syphilis serology, and human immunodeficiency virus (HIV) counseling and testing should also be considered at the time of diagnosis. Quantitative testing and ultrasonography should be considered in women whose uterine size does not correlate with dates or if there are concerns about threatened abortion or ectopic pregnancy.
The approach to counseling the adolescent girl about pregnancy options should be customized depending on the developmental level of the adolescent and the circumstances that resulted in pregnancy. Although the decisions related to the pregnancy rest with the adolescent, she will often need substantial partner and family support. Regardless of the approach used, all options for pregnancy management available to the adolescent should be presented to the adolescent patient for consideration. It is essential that adolescents who present early in pregnancy receive nonjudgmental, accurate, and detailed information about referral options related to prenatal care, adoption, and termination services. Providers who are unable to counsel the pregnant adolescent about all available options should refer her to a provider who can do so. Delaying decision making is commonly seen with younger adolescents who may not have fully grasped the significance of a pregnancy diagnosis or who have real fears related to the availability of parental support. It is important to ascertain the status of the family situation, including her safety at home or potential involvement of a family member in the pregnancy, before assisting the young woman in engaging her family in dialogue. Close follow-up of the pregnant adolescent until a decision is made is important given that the availability of termination is time dependent. The longer that a young woman is undecided about her plans for the pregnancy, the fewer options will remain for her over time.
Adolescents who plan to continue the pregnancy should be referred for prenatal care, prescribed multivitamins with iron, and receive instructions related to use of over-the-counter mediations, avoidance of alcohol and drugs, and common environmental hazards to avoid. Adolescents who opt for abortion should also be counseled regarding self-care before and after the procedure. It is often useful to prepare the young woman before the procedure so she can anticipate how the experience will proceed. Although she will be offered a postprocedure follow-up appointment by the facility providing the procedure, many young girls prefer to be seen by their usual adolescent or gynecologic provider for the follow-up visit. It is important to have a plan in place for long-term contraception before the procedure because hormonal methods can be initiated at the time of termination. Deferring the discussion on family planning until the 2-week postoperative visit will unnecessarily delay initiating an effective contraceptive method, thus potentially making the young woman vulnerable to repeat pregnancy in the coming month when she re-engages in sexual activity.
CONTRACEPTION
General Counseling
Many contraceptive options are available to women in the United States; however, not all options are equal with respect to pregnancy prevention. Obtaining a detailed patient history can often assist in counseling patients on contraceptive options. Important data to obtain during a family planning visit include sexual history, past medical history, family history, and an extensive review of systems. Developmental stage and the availability of parental support related to contraception should also be assessed. Adolescents often select contraception based on their previous experience with a particular method as well as the experiences of relatives and friends. Contraceptive methods are also now advertised in the media, and so this may also drive the selection of a particular type of method or brand. Even if the adolescent has requested a specific type of contraception, it is important to engage the adolescent in a discussion regarding methods the patient has previously used, concerns about a particular method, the experiences of friends and relatives (e.g., sisters and mothers), perceived self-efficacy related to the different methods, and partner involvement and assistance related to using a particular method. Use of the HEADDDS (Home, Education, Activities, Diet, Drugs, Depression, Sexuality) acronym to direct the family planning interview will yield important lifestyle data that can assist providers in guiding patients to select a method that will work best for them. Adolescents should receive routine health care including yearly physical examinations and screening laboratory tests as a part
of preventive clinical services, but not as a requirement for initiating contraception. Pelvic examinations are not required before starting contraception. For preventive services, sexually active adolescent girls, whether using hormonal contraception or not, should have STI screening annually or biannually, depending on risk factors. Pap smear screening should be initiated within 3 years of onset of sexual activity or earlier if the girl is immunocompromised or receives only episodic health care. Adolescents who initiate a contraceptive method should be seen every 3 to 6 months so they can solve problems with their health provider regarding side effects or other problems that may arise.
of preventive clinical services, but not as a requirement for initiating contraception. Pelvic examinations are not required before starting contraception. For preventive services, sexually active adolescent girls, whether using hormonal contraception or not, should have STI screening annually or biannually, depending on risk factors. Pap smear screening should be initiated within 3 years of onset of sexual activity or earlier if the girl is immunocompromised or receives only episodic health care. Adolescents who initiate a contraceptive method should be seen every 3 to 6 months so they can solve problems with their health provider regarding side effects or other problems that may arise.
Methods
The failure rates for current contraceptive methods are shown in Table 92.1.
Abstinence
Primary abstinence is the most effective and least expensive form of contraception in the United States. Adolescents who have never had sexual intercourse and who choose to abstain during adolescence avoid the contraceptive and emotional stressors related to maintaining a sexual relationship while navigating other aspects of adolescent development. Although many more adolescents have chosen abstinence as their primary method of contraception in recent years, the fact remains that most adolescents in the United States have had intercourse before their high school graduation.
Secondary abstinence (secondary virginity or celibacy) and periodic abstinence are two additional possibilities that are often overlooked as family planning methods used by adolescents. In secondary abstinence, an adolescent chooses to abstain from intercourse until a desired life point such as being in a long-term, committed monogamous relationship after having previously engaged in intercourse. Periodic abstinence, during which adolescents have periods of sexual inactivity between periods of sexually activity without making a long-term commitment to abstinence, can be more difficult to manage. Adolescents who are not in a relationship may choose not to have sex during that period, but they may re-engage when beginning a new relationship. Re-engaging in sexual intercourse means reestablishing a contraceptive method, which may have been discontinued during the period of inactivity. Many adolescents in this situation will choose to continue a hormonal method during periods of sexual inactivity to reduce the risk of pregnancy associated with an unanticipated unprotected sexual encounter. Condoms should be used in this situation to prevent STI.
Adolescents who choose any form of abstinence should be encouraged and supported regarding their decision. These adolescents should also receive comprehensive sexuality education and should be well informed of the available contraceptive methods, given that making decisions about sex during adolescence is a dynamic process that may result in intercourse regardless of intention.
Outercourse
Many adolescents use outercourse or noncoital intimacy to fulfill sexual desires while reducing pregnancy risk. Given the array of sexual behaviors that adolescents may engage in without actually having vaginal-penile intercourse, it is important that they understand how to prevent STIs, particularly that they avoid contact of ejaculate with the external female genitalia or vagina; barriers should be used to prevent infection through oral or skin lesions from partners infected with herpes, syphilis, or human papillomavirus.
Fertility Awareness
Fertility awareness (or “natural” family planning) relies on the identification of days during the female partner’s menstrual cycle during which pregnancy is most likely to occur. Signs and symptoms such as the character of cervical secretions and position of the cervix, menstrual calendar calculations, and/or basal body temperature are used to predict fertile times of the month so couples who do not desire pregnancy can abstain or engage in other methods during fertile periods. Use of this method requires training, record keeping, and excellent communication and cooperation within the couple. The major disadvantages of this method are the high failure rate and the lack of protection against STDs, thereby limiting its use among adolescent populations.
Barrier Methods
Male Condoms
The male condom is the most widely available and used method of contraception.
TABLE 92.1. FIRST-YEAR CONTRACEPTIVE FAILURE RATES | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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