Between and , a small proportion of the decrease in adolescent pregnancy can be attributed to an increase in the age at first intercourse and a decrease in the number of adolescents who reported ever having sex 9, Between and , the number of adolescents ever having sex The most rapid decrease in adolescent pregnancy occurred from to Data suggest that changes in sexual activity are unlikely to have contributed significantly to this rapid decrease 12 , Pregnancy in adolescents has decreased largely because adolescents are becoming more effective contraceptive users 9, Use of LARC methods in contraceptive users who were 15—19 years of age increased from 1.
Although modest, this increase represents a tripling in the use of LARC methods among adolescents. The social and behavioral factors that motivated adolescents to become more effective contraceptive users and less sexually active are unclear. Involvement in school activities, educational and career aspirations, mentoring programs, economic fluctuations, childbearing norms, contraceptive coverage under the Affordable Care Act, and the availability of health information through the Internet and television all have been hypothesized to play a role.
The College supports access for adolescents to all contraceptive methods approved by the FDA. In the absence of contraindications 17 , patient choice should be the principal factor in prescribing one method of contraception over another. To help the patient make this choice, the obstetrician—gynecologist should do the following:. When engaging in shared decision making regarding contraceptive use, obstetrician—gynecologists should be aware of and address their own biases, work to empower patients, and strive for equitable outcomes for all patients regardless of age, race or ethnicity, class, or socioeconomic status Furthermore, it encourages gynecologic health care providers to examine issues of bias and coercion and advocate for equitable access and change Adolescents face unique barriers in accessing contraceptive services, including concerns about confidentiality and cost.
Where allowed, obstetrician—gynecologists should provide adolescents the opportunity to discuss their reproductive goals and contraceptive needs without a parent or guardian present for at least part of the visit. Additionally, obstetrician—gynecologists may refer patients to Title-X-funded clinics for confidential contraceptive services if they are unable to provide confidential care Adolescents who discuss sexuality and contraception with a parent or guardian are more likely to use contraception consistently and are less likely to become pregnant 21 , Although parental involvement should be encouraged when a supportive parent or guardian is available, pregnancy intention and the decision to start or stop contraception are highly individual and complex.
Just as adolescents should have access to the full range of contraceptives, including LARC methods, they should be able to decline and discontinue any method on their own, without barriers. Fear of a pelvic examination may prevent adolescents from seeking contraception A pelvic examination is seldom necessary, except for IUD insertion Whether recent changes in practice guidelines regarding pelvic examination in adolescents have diminished concerns in this population is currently unknown.
National data indicate a decrease in the number of young women who have had a pelvic examination who are using effective contraception eg, oral contraceptive pills [OCPs], depot medroxyprogesterone acetate [DMPA], the patch, or the ring The College supports access for adolescents and young adults to all contraceptive methods approved by the FDA. Satisfaction with and continuation of LARC methods are high among adolescents.
For adolescents who choose a LARC method, initiation should be offered immediately after delivery, pregnancy loss, or abortion 26, 27, As contraindications to immediate placement are uncommon, obstetrician—gynecologists should counsel women about the convenience and effectiveness of immediate postpregnancy LARC, as well as the benefits of lengthening interpregnancy intervals.
Additional College guidance offers strategies to improve access to LARC methods and to all contraceptives under the Affordable Care Act 30 and to immediate postpartum insertion of IUDs and implants Although most clinicians consider LARC methods to be safe, some still do not provide these methods to adolescents. Adolescents themselves have only a modest awareness of LARC methods. Contraceptive counseling programs that engage adolescents in shared decision making show high levels of LARC method selection 27, Guidelines from the CDC on providing quality family planning services can be found at www.
See For More Information for additional relevant resources. Injectable contraception DMPA has a convenient dosage schedule, which makes it a good method for many adolescents. When cost and access barriers are eliminated, women who received repeat injections of DMPA within the recommended 3-month period had very low pregnancy rates, similar to those of LARC methods Losses in bone mineral density appear to be fully reversible and do not contribute to fracture risk.
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However, evidence suggests that DMPA may be used indefinitely by adolescents or older women. Combined hormonal contraceptives contain estrogen and progestin and include OCPs, the patch, and the ring. One-year continuation rates for OCPs are Difficulties with use, in addition to adverse effects, are two of the most common reasons adolescents discontinue combined hormonal methods All contraceptive methods including LARC methods can be started anytime, including on the day of the visit, if there is reasonable certainty that the patient is not pregnant.
Risk of pregnancy can be assessed using patient history eg, less than or equal to 7 days after the start of normal menses or has not had sexual intercourse since the start of last normal menses and urine pregnancy tests When there is uncertainty about pregnancy, the benefits of starting the implant, DMPA, combined hormonal contraceptives, and progestin-only pills likely exceed any risk. Thus, starting a contraceptive method should be considered at any time, and a pregnancy test should be repeated in 2—4 weeks.
If there is uncertainty about pregnancy, an IUD should not be inserted until the health care provider is reasonably certain that the patient is not pregnant. Selected Practice Recommendations for Contraceptive Use Obstetrician—gynecologists should be able to provide anticipatory guidance for adolescents and their parents or guardians regarding expected bleeding effects and possible menstrual changes with various methods.
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Strategies to promote adherence to the pill, patch, ring, and DMPA include cell phone or electronic reminders and online programs that provide the user with daily, weekly, monthly, or quarterly text messages www. Given the familiarity of adolescents with online programs and text messaging, these strategies have the potential to increase adherence. However, more high-quality studies are needed to establish the effectiveness of these programs When provided with structured counseling in which the most effective methods were discussed first and access to all methods was provided at no cost, Overall, sexually active adolescents had a pregnancy rate of The National Campaign to Prevent Teen and Unplanned Pregnancy also maintains a database of effective adolescent pregnancy prevention programs at www.
Title X of the Public Health Service Act is a federal program that provides infrastructure funding to community-based family planning centers, as well as funds for direct client services.
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In , 3. Among low-income residents who lived in counties with a Title X clinic, the observed adolescent birth rate was nearly one-third lower than the projected rate and the number of high-risk births decreased, presumably because of prevention of unintended pregnancy. Condom use requires the ability to communicate and negotiate with a partner, admit to the risk of STI acquisition, and initiate use at time of coitus, which can be challenging for adolescents Dual method use—pairing condoms with more effective contraceptive methods—to protect against STIs and unwanted pregnancy is the ideal contraceptive practice for adolescents.
The rate of dual use among adolescents is When adolescents initiate highly effective methods, the obstetrician— gynecologist should reinforce the role of condoms in preventing STI acquisition. Few behavioral intervention trials have demonstrated success in increasing dual use, which suggests the need for additional strategies The availability of condoms in retail stores and pharmacies without a prescription does not always translate to ready access for adolescents.
Condoms kept behind a counter and requiring assistance from a store clerk are deterrents to adolescents. Obstetrician—gynecologists are encouraged to provide condoms within their offices, teach adolescents how to properly use condoms, and support availability within their communities. See For More Information for relevant resources.
The College and AAP support school-based condom availability programs The effect of school availability programs on condom use is mixed. Some studies show increased use of condoms but others report nonsignificant changes 48 , Studies of school-based condom availability programs have found increased condom use when adolescents can obtain condoms in school through counselors, nurses, teachers, vending machines, or baskets 50 , Concern that these programs will hasten initiation of sex and increase sexual activity are unfounded 50— Comprehensive sexuality education programs, clinic-based programs, school-based health centers, and condom availability programs have all been cited as potential contributors to the decreases in adolescent pregnancy, although none has been implemented on a large enough scale in the United States to be solely responsible for decreases in adolescent pregnancy.
Adolescents who participate in comprehensive sexuality education delay the initiation of sex and have increased condom and contraceptive use Comparatively, abstinence-only programs are ineffective at delaying sexual initiation 54, Most students who have taken abstinence pledges have sex before marriage Those who do have sex before marriage are less likely than similar nonpledgers to use condoms or contraceptives consistently and are more likely to experience nonmarital pregnancy and acquire human papillomavirus infection 56, The College and AAP support the use of evidence-based, medically accurate, age-appropriate sexuality education as an integral part of health education 53, Fewer than one half of all states mandate sexuality education and even in states that do have a mandate, the content varies significantly by county and school.
Clinic-based programs provide comprehensive sexuality education specifically targeted to adolescents in a clinic setting. Most programs involve fewer than 10 contact hours with adolescents and physicians or health educators Most studies of clinic-based programs targeted female-only or male-only participants, although some included both. Clinic-based programs can be one-on-one encounters or may incorporate group sessions. Evaluation of different programs reported variable effects. Although no programs found a delay of sexual initiation, many reported decreased sexual frequency, decreased number of partners, increased condom use, increased contraceptive use, decreased STI acquisition, and decreased pregnancies or births School-based health centers that also supply contraceptives are well-situated to provide convenient, confidential care to males and females.
Studies show that such centers do not increase student sexual activity and may increase the use of contraception among students 48, The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients.
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No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Adolescent pregnancy, contraception, and sexual activity. Committee Opinion No. American College of Obstetricians and Gynecologists.
Obstet Gynecol ;e—9. Women's Health Care Physicians. Recommendations and Conclusions The American College of Obstetricians and Gynecologists the College makes the following recommendations and conclusions: In , the birth rate among U. Pregnancy in adolescents has decreased largely because adolescents are becoming more effective contraceptive users.
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The College supports access for adolescents and young adults to all contraceptive methods approved by the U. For adolescents who choose a LARC method, initiation should be offered immediately after delivery, pregnancy loss, or abortion. The College supports the use of evidence-based, medically accurate, age-appropriate sexuality education as an integral part of health education. Dual method use—pairing condoms with more effective contraceptive methods to protect against sexually transmitted infections STIs and unwanted pregnancy—is the ideal contraceptive practice for adolescents.
Background In , the birth rate among U. Decreases in Adolescent Pregnancy Rates In adolescents, two factors, 1 contraceptive use and 2 sexual activity, can affect the pregnancy rate.
leondumoulin.nl/language/history/chained-chained-to-the-floor.php Depot Medroxyprogesterone Acetate Injectable contraception DMPA has a convenient dosage schedule, which makes it a good method for many adolescents. Combined Hormonal Contraceptives Combined hormonal contraceptives contain estrogen and progestin and include OCPs, the patch, and the ring. Adherence Strategies to promote adherence to the pill, patch, ring, and DMPA include cell phone or electronic reminders and online programs that provide the user with daily, weekly, monthly, or quarterly text messages www.
Education for Adolescent Pregnancy Prevention Comprehensive sexuality education programs, clinic-based programs, school-based health centers, and condom availability programs have all been cited as potential contributors to the decreases in adolescent pregnancy, although none has been implemented on a large enough scale in the United States to be solely responsible for decreases in adolescent pregnancy. Looking Forward Despite positive trends, the United States continues to have the highest adolescent pregnancy rate among industrialized countries with data.
For More Information The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. Births: final data for Natl Vital Stat Rep ; Bethesda MD : Child Trends; Births : Preliminary Data for Klerman JA. Centers for Disease Control and Prevention. CDC fact sheet: Incidence, prevalence, and cost of sexually transmitted infections in the United States.
Accessed August 20, Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Differences in teenage pregnancy rates among five developed countries: the roles of sexual activity and contraceptive use.
Fam Plann Perspect. Thomas A. Three strategies to prevent unintended pregnancy. J Policy Anal Manage.
Albert B. Office of Adolescent Health. Accessed May 14, Scott ME, Wallace I. State and tribal PREP performance measures: findings and implications for program improvement. Child Trends. Accessed May 15, Lieberman L, Su H. Choosing the best program in communities committed to abstinence education. Sage Open. Efficacy of a theory-based abstinence-only intervention over 24 months: a randomized controlled trial with young adolescents.
Arch Pediatr Adolesc Med. LaChausse RG. Am J Health Educ. Adolescent pregnancy prevention: an abstinence-centered randomized controlled intervention in a Chilean public high school. J Adolesc Health.