Contraception guidelines for adolescents
Teenaged pregnancy rates in the United States continue to be among the highest in the industrialized nations.
T
eenaged pregnancy rates in the United States continue to be among the highest in the industrialized nations. Although the rate has decreased by 51% from its peak in 1990 to the most recent data available in 2010 (116.9 pregnancies per 1000 girls aged 15 to 19 years vs 57.4 per 1000, respectively), estimates suggest 614,000 women aged younger than 20 years still become pregnant each year, indicating that roughly 1 in 4 teenaged girls will get pregnant at least once by age 20 years.1,2
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These numbers highlight the need for more effective use of contraception in this population, especially high school students, of whom nearly half report having had sexual intercourse.3
Pediatricians play a unique and vital role in the lives of adolescents as trusted guides through a myriad of issues including contraception use. This article is intended to provide an easy guide for pediatricians to help facilitate counseling adolescents on contraception use and choice, with a focus on recommendations from the updated guidelines on contraception use in adolescents by the American Academy of Pediatrics (AAP).3
AAP recommendations
Published in 2014, the updated AAP policy statement on contraception for adolescents provides pediatricians and other healthcare professionals who work with adolescents with 11 recommendations for counseling and prescribing contraception for this age group.3
These recommendations are based on the best currently available evidence, which is explained in a technical report that accompanies the policy statement.4The AAP policy statement provides updated data on the efficacy and safety of different contraceptive options for adolescents, and ranks them in order of the most effective to least effective (Table 1).3,4
As shown in Table 1, long-acting reversible contraception (LARC) that includes progestin implants and intrauterine devices (IUDs) is considered the most effective for adolescents and is the first-line choice. Pediatricians are urged to counsel adolescents on contraception choice based on their rank of effectiveness and to use a tiered approach that advises adolescents to use the most effective contraception first.4
Eliminating barriers to LARCs
The need for pediatricians and other healthcare providers to better counsel teenagers on the use of LARCs is highlighted by data showing that despite proven safety, efficacy, and ease of use, the use of
LARCs among adolescent girls remains low.5 Barriers to advising teenagers on using LARCs as reported by providers include a concern over their safety in adolescents, their high up-front costs, and providers’ lack of training in inserting implants and IUDs.
To address these barriers, a number of initiatives are under way to facilitate and increase the use of LARCs among reproductive-aged girls and women).5-8 Strategies used to overcome these barriers include educating providers on the safety of LARCs for teenagers; training providers on how to insert LARCs; training providers on how to provide counseling that is patient focused and that includes discussing with adolescents the most effective contraceptive methods first; and providing contraception and LARCs at either reduced or no cost to the patient.5
For most women, the issue of cost has been ameliorated under the terms of the Affordable Care Act (ACA) that mandates insurers to cover at least 1 form of birth control, including LARCs, that has been approved by the US Food and Drug Administration. Recent tightening of the rules for mandated contraception coverage further helps providers to ensure patients that cost is no longer a barrier to contraception use.9
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Build trust, respect confidentiality
Along with providing the most current data on the efficacy and safety of different contraceptive options for teenagers, the AAP recommendations also address issues that are critical in counseling teenagers about contraception use.
Among the key issues is the need to establish a trusting relationship between provider and patient to improve contraception use. A recent survey of teenagers found that the primary reason they don’t use contraception is fear that their parents will find out.10 Fundamental to establishing a trusting relationship is adherence to legal statutes that protect the confidentiality of teenaged patients (Table 2).4,11,12
Another key issue is the need for pediatricians to undertake a comprehensive history of their adolescent patients that includes a developmentally targeted sexual history, along with assessment of sexually transmitted disease (STD) and pregnancy risk (Table 3).3,4,13,14 Strengthening trust with adolescents in this assessment can be helped by using a matter-of-fact, nonjudgmental approach that shows care and honesty. One suggestion about how to accomplish this is to use motivational interviewing approaches based on open-ended questions and careful listening that focus on the adolescent (Table 4).4
After a careful consultation with adolescents, pediatricians should advise adolescents when appropriate about screening for STDs as well as the use of contraception.3
The AAP policy statement update emphasizes that pediatricians should counsel adolescents with disabilities or medical conditions in the same way as they do healthy adolescents in terms of sexuality and sexual healthcare needs. For example, the AAP discusses issues to keep in mind when counseling an adolescent who is obese because the efficacy and safety profiles of contraceptives may be influenced by the endocrine effects of obesity. Data show that women weighing more than 190 pounds had more excess pregnancies when using the transdermal contraceptive patch than nonobese women.4 However, clear evidence is lacking on the effect of body weight or body mass index on the efficacy of LARCs or combined oral contraceptive pills (COCs).
Some evidence to bear in mind is data showing that obese adolescents who use depot medroxyprogesterone acetate (DMPA) may be more likely to gain weight compared with obese adolescents who use COCs or normal weight users of DMPA.4 A more complete discussion of specific issues to recognize when counseling obese adolescents, as well as other populations such as adolescents with human immunodeficiency virus infection or those who are recipients of solid organ transplantation, are discussed in more detail in the AAP Technical Report.4
Table 5 provides a summary of the current recommendations.4 For a full description, see the AAP Policy Statement.3
Table 6 addresses various myths commonly associated with contraception use for teenagers.2,15-18
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Summary
Despite falling pregnancy rates among adolescents in the United States, thousands of adolescents become pregnant each year. Pediatricians play a vital role in counseling these young women about contraception. To facilitate the conversation, the AAP updated its policy statement on contraception in adolescents to reflect the most current best evidence on contraception choice for this population as well as some best practices for pediatricians to follow to improve the use of and adherence to contraception for adolescents.
REFERENCES
1. National Campaign to Prevent Teen and Unplanned Pregnancy. Fast facts: teen pregnancy in the United States. Available at: https://thenationalcampaign.org/resource/fast-facts-teen-pregnancy-united-states. Published August 2014. Accessed May 12, 2015.
2. Truehart A, Whitaker A. Contraception for the adolescent patient. Obstet Gynecol Surv. 2015;70(4):263-273.
3. Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1244-e1256.
4. Ott MA, Sucato GS; Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1257-e1281.
5. Romero L, Pazol K, Warner L, et al. Vital signs: trends in use of long-acting reversible contraception among teens aged 15-19 years seeking contraceptive services-United States, 2005-2013. MMWR Morb Mortal Wkly Rep. 2015;64(13)363-369. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6413a6.htm?s_cid=mmmm6413a6_w. Accessed May 12, 2015.
6. Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med. 2014;371(14):1316-1323. Erratum in: N Engl J Med. 2014;372(3):297.
7. Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspect Sex Reprod Health. 2014;46(3):125-132.
8. Biggs MA, Rocca CH, Brindis CD, Hirsch H, Grossman D. Did increasing use of highly effective contraception contribute to declining abortions in Iowa? Contraception. 2015;91(2):167-173.
9. US Department of Labor. FAQs about Affordable Care Act implementation (part XXVI). Available at: http://www.dol.gov/ebsa/faqs/faq-aca26.html. Published May 11, 2015. Accessed May 12, 2015.
10. National Campaign to Prevent Teen and Unplanned Pregnancy. Survey says: April 2015: Hide the birth control. Available at: http://thenationalcampaign.org/resource/survey-says-april-2015. Published April 2015. Accessed May 12, 2015.
11. English A, Bass L, Boyle AD, Eshragh F. State Minor Consent Laws: A Summary. 3rd ed. Chapel Hill, NC: Center for Adolescent Health and the Law; 2010. Available at: http://www.cahl.org/state-minor-consent-laws-a-summary-third-edition/. Accessed May 12, 2015.
12. Guttmacher Institute. State policies in brief as of May 1, 2015. Minors’ access to contraceptive services. Available at: http://www.guttmacher.org/statecenter/spibs/spib_MACS.pdf. Accessed May 12, 2015.
13, Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove, IL: American Academy of Pediatrics; 2008.
14.Centers for Disease Control and Prevention. A guide to taking a sexual history. Publication No: 99-8445. Atlanta, GA: Centers for Disease Control and Prevention; 2005. Available at: http://www.cdc.gov/STD/treatment/SexualHistory.pdf. Accessed May 12, 2015.
15. Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM. Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials. Fertil Steril. 2009;91(5):1646-1653.
16. Vickery Z, Madden T, Zhao Q, Secura GM, Allsworth JE, Peipert JF. Weight change at 12 months in users of three progestin-only contraceptive methods. Contraception. 2013;88(4):503-508.
17. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 415: depot medroxyprogesterone acetate and bone effects. Obstet Gynecol. 2008;112(3):727-730.
18. Centers for Disease Control and Prevention. U.S. selected practice recommendations for contraceptive use, 2013. MMWR Morb Mortal Wkly Rep. 2014;62(5):1-59. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm?s_cid=rr6205a1_w. Accessed May 12, 2015.
Ms Nierengarten, a medical writer in St Paul, Minnesota, has over 25 years of medical writing experience, authoring articles for Lancet Oncology, Lancet Neurology, Lancet Infectious Diseases, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.
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