American Adolescents and Emergency Contraceptive Pill Access: Moving Beyond Politics

Jacqueline Sedgwick, MD, MPH

Disclosures

April 02, 2010

Introduction

Adolescents in the United States have higher pregnancy and abortion rates than adolescents in other industrialized nations, primarily as a result of intermittent, improper, or nonuse of contraception. Unprotected sexual activity also puts teenagers at risk for sexually transmitted infections (STIs). Public health and clinical actions to improve knowledge of, access to, and use of effective contraceptive methods are necessary to help adolescents avoid unintended pregnancies and STIs.

Scope of the Problem

Studies show that after a 15-year decline, the birth rate in the United States increased 5% from 2005-2007 among young women 15 to 19 years of age. In 2007, the average birth rate was 42.5 per 1000 women in this age group.[1] The birth rate is highest among black and Hispanic teens. Nearly two thirds of teenage mothers reported that their pregnancies were unintended.[2] This increase in teen birth rates has occurred despite a 16% decrease, from 1991 to 2007, in the number of high school students who reported engaging in sexual activity (according to the Centers for Disease Control and Prevention's Youth Risk Behavior Surveillance System).

Teen sexual activity, pregnancy, and childbearing are associated with substantial social, economic, and health costs. Pregnant adolescents have a higher preterm birth rate, and their babies have higher infant mortality rates.[3] Mothers aged 19 years or younger are more likely to drop out of high school and to remain single parents.[4] A 2008 study found that 1 in 4 (26%) sexually active female adolescents in the United States has had at least 1 STI.[5] Even among adolescent girls who report having only a single lifetime sexual partner, 1 in 5 has been diagnosed with an STI.[5]

The increase in US teen birth rates, unintended pregnancies, and frequency of STIs needs immediate attention. All individuals who choose to be sexually active, regardless of age, should have access to safe and effective contraceptive methods. A disconnect exists between common adolescent behavior and the provision of personal health services to adolescents. Many health educators, policy-makers, and clinicians have been reluctant to provide teenagers with ready information about and access to contraceptives.[6] However, the evidence clearly shows that abstinence-only programs are not as effective as comprehensive sex education in the prevention of teen pregnancies.[7] Promoting availability and use of effective contraception is a public health imperative.

Correlates of Prevention of Adolescent Pregnancy and STIs

Condoms are the only contraceptive method that can help prevent the spread of HIV/AIDS, so promoting correct and sustained condom use among sexually active adolescents is essential. Teens are more likely to use condoms if they are worried about becoming infected with HIV, if they feel comfortable accessing and carrying condoms, and if they are not embarrassed to use them. Because condoms can break, they are best combined with a back-up contraceptive method to prevent unwanted pregnancy. Many factors affect acceptability and use of contraceptive options among adolescents. Sexually active teenagers are more likely to use contraception if they have long-term educational goals; are older; perceive pregnancy as a negative outcome; have had a pregnancy scare or been pregnant; and have family, friends, or healthcare providers who support contraceptive use.

Use of Emergency Contraceptive Pills

Emergency contraceptive pills (ECP) are a safe, effective method intended for back-up or occasional use and are an excellent contraceptive method in the event of condom failure or unprotected sexual activity. When taken within 72 hours of intercourse, pregnancy rates after ECP use are between 0.2% and 3%, depending on the timing of the teen's menstrual cycle and the delay between sexual activity and taking the medication. Despite the efficacy, safety, and ease of ECP use, in the United States only about 6% of women of reproductive age have ever used ECPs.[8]

The low use of ECPs in the United States is partially the result of misperception of ECPs as "abortion pills"; however, ECPs do not induce abortion. Implantation of a fertilized ovum does not occur for approximately 5 to 7 days after ovulation, and ECPs are designed to be taken within 72 hours (but no later than 120 hours) of intercourse. A physical examination and laboratory testing are not required before prescribing oral ECPs, and there are no medical contraindications to their use. The sooner that ECPs are taken, the more effective they will be; however, ECPs do not interrupt pregnancy. These medications are not associated with miscarriage, major congenital malformations, pregnancy complications, or adverse pregnancy outcomes if a woman is already pregnant when she takes these pills.[9] The mechanism of action of ECPs in preventing pregnancy varies depending on the stage of a woman's menstrual cycle when the medication is taken. Actions include inhibiting or delaying ovulation, interfering with fertilization, preventing implantation by hormonally altering the endometrium, or causing regression of the corpus luteum. Public education is required to promote understanding, accurate use, and acceptance of ECPs.

Research has shown that advance provision of and ease of access to ECPs does not affect adolescents' sexual behavior or increase their risk for STIs.[10,11] In fact in 2000, the use of ECPs obviated the need for more than 50,000 abortions in the United States.[12]

Access to ECPs

In 2009, a federal court ordered the US Food and Drug Administration to expand access to ECPs, making them available without a prescription from a pharmacist (but not over the counter) for individuals aged 17 years or older. Proof of age with a government-issued identification card is required. Adolescents 16 years of age or younger still require a prescription, which in some states may be obtained from a specially trained pharmacist under a standing order from a healthcare provider. Most states have passed regulatory clauses to the Church Amendment of 1973, which allows pharmacists and healthcare providers to refuse to provide contraceptive pills. In rural or inner-city areas, adolescents may have few options for obtaining ECPs. Clinicians should encourage women to obtain ECPs in advance because they may have difficulty filling their prescription or obtaining ECPs when needed, and the efficacy of this method is directly related to the time from intercourse to treatment.

ECP Options

Several ECP options are available, including levonorgestrel in 1-pill (Plan B One Step) and 2-pill (Plan B) formulations and the Yuzpe regimen (taking specific amounts of oral contraceptive pills designed for cyclic use, containing ethinyl estradiol plus levonorgestrel or norgestrel). Women who choose ECPs should be advised that a risk for pregnancy exists if they have unprotected sexual activity after taking the pills. Women may start barrier and hormonal contraceptive methods the day after the last ECP is taken and will require a back-up method for 7 days if hormonal contraceptives are used. After ECP use, menstruation generally occurs within 1 week of the expected date. If normal menstrual bleeding has not occurred within 4 weeks or if persistent vaginal bleeding or pelvic pain occurs, the patient should have a pregnancy test and clinical evaluation.

Barriers to ECP Use Among American Adolescents

Many barriers to ECP use by teens currently exist, including lack of access to confidential services, fear of undergoing a pelvic examination; concern about side effects, such as weight gain; poor availability; high cost; reluctance to negotiate use with their partner; peer pressure; and abuse. Adolescents do not often plan to have sex and may not ask for advance ECP prescriptions. Shame about incidents of unprotected intercourse may prevent them from seeking postcoital contraceptives. In states where ECPs are available from pharmacists, teens may feel uncomfortable asking for contraception in a local store with limited privacy.

Some teens may not have access to transportation to attend a clinical appointment or visit a pharmacy that provides ECPs. Another barrier to obtaining ECPs is possible confusion among teens regarding confidentiality. Although numerous state and federal laws help ensure access to contraception services, many adolescents, as well as many clinicians, are unaware of the laws and regulations in their own state.[13]

The Healthcare Provider's Role in Enhancing Adolescents' Awareness and Use of ECPs

Healthcare providers and office staff can facilitate discussions about contraceptives with adolescent patients by posting clear policies on confidentiality and spending part of the visit talking with teens without their parents being present. Providers can let the adolescent know that the office is a safe space to ask questions as well as receive health services. Suggestions for creating this safe space include[14]:

  • Bring it up! Open the door to conversation.

  • Keep it private; one-on-one conversations may be best.

  • Be accessible; the conversation should be ongoing and relationship-building.

  • Set aside your personal judgments.

  • Be aware of your body language and nonverbal cues; youths don't want to feel judged by adults.

  • Don't make assumptions based on your personal experiences.

  • Use humor, when appropriate; this can help the adolescent feel comfortable.

Healthcare providers should provide anticipatory guidance on pregnancy prevention and STIs during physical examinations and all visits during which sexual activity is discussed. Among adolescents who are interested in discussing contraception, counseling should always include prevention of STIs, condoms, and ECP use. Clinicians should assist teens who desire contraception with selection of the best method for their needs on the basis of health factors, frequency of use, convenience, and adherence.

Conclusion

Effective public health campaigns are required to stem the tide of increasing pregnancy rates among US adolescents. This will require a change in public sentiment toward supporting education about responsible sexual behavior and promoting easy, private access to effective contraceptive methods before adolescents decide to have sex. Healthcare providers can ensure that teenagers receive accurate information and anticipatory guidance at physical examinations and all visits during which sexual activity is discussed. When providing contraceptive counseling to adolescents, clinicians should provide information about all birth control options and prevention of STIs, including HIV/AIDS. These discussions should include the availability and use of condoms and ECPs. Public education is especially important to teen acceptance of contraceptive methods, and family, friend, and clinician support are predictors of contraceptive acceptance and use by adolescents.

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