Updates in Contraception From The XVI World Congress of the International Federation of Gynecology and Obstetrics

David A. Grimes, MD

Disclosures

September 20, 2000

In This Article

World's Lowest Teen Pregnancy Rate: How Do the Dutch Do It?

Teenage pregnancy is a stubborn problem in many countries, both developed and developing. The Netherlands is not one of these, however. This small country boasts of the lowest teenage pregnancy and abortion rates in the world -- lower even than those in Sweden, another success story.[13] Rik H. W. Van Lunsen[14] of the University of Amsterdam, The Netherlands, shared his explanation for this stellar record in the final presentation of the first session on contraception.

Counseling is the key. This leitmotif echoed throughout Dr. Van Lunsen's presentation: education, not medical interventions, had made the difference. He attributed the success in The Netherlands to 4 principal factors: liberal sexual attitudes, excellent sex education, free supplies of contraceptives, and legal abortion. He noted that the first factor was especially important for healthcare providers.

Dr. Van Lunsen emphasized the need to de-medicalize the traditional approach to contraception for teenagers. He reported on survey data from his country, pointing out that fear of a pelvic examination was an important deterrent for young women in need of contraception. Hence, Dutch physicians clearly advise young women that they will not have a pelvic examination on the first visit; it will be exclusively devoted to counseling and provision of contraceptives. He noted that the pelvic examination is medically unnecessary.

Surveys of adolescent women found 3 considerations to be important: nonjudgmental attitudes on the part of providers, confidentiality, and de-medicalization of the encounter. In response, the Dutch approach is to make the first visit for contraception only for counseling. Second, no mandatory follow-up is built in. Third, teenagers have easy access to services at no cost.[15]

The Dutch have a reputation for pragmatism. This certainly applies to their approach to the touchy issue of adolescent sexuality and contraception. In many societies, the approach to adolescent sexuality is schizoid: teenagers are immersed in sexual imagery yet straight talk about sex is scarce. The United States is an example of such a society, and its teenage pregnancy rates, though falling, remain higher than those in other industrialized nations. By contrast, teenagers in Sweden have coitus earlier and more often than do US teenagers, but with 1 important difference: they seldom get pregnant.[13]

The forthright Dutch approach accepts that adolescents are sexual beings and provides them with both information and services in a nonthreatening way.[15] When treated as adults, teenagers respond appropriately. Other nations have much to learn from the Dutch approach: it is hard to fight success. The take-home message for clinicians is that the pelvic examination is not only medically unnecessary before beginning hormonal contraception but also deters some young women from adopting safe, effective contraception. Thus, the traditional requirement of a pelvic examination indirectly leads to unwanted pregnancies and induced abortions. Young women deserve better.

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