Original ResearchAdolescent Self-Reported Use of Highly Effective Contraception: Does Provider Counseling Matter?
Introduction
The American Academy of Pediatrics reports that 750,000 adolescents become pregnant each year, with 80% of these pregnancies unplanned.1, 2, 3 Adolescent pregnancies are more likely than those of adults to result in maternal and child morbidity and mortality.4 Moreover, teen mothers are at risk for school failure,5,6 underemployment, persistent poverty, and reliance on social assistance programs.7 We know that adolescent pregnancy disproportionately affects poor women and women of color, as well as the children of teen parents. These disparities are perpetuated and often amplified in the intergenerational cycle of adolescent pregnancy.8 Hence reducing unwanted teen pregnancy by promoting adolescent use of effective contraception is one of the highest priorities for adolescent medicine, particularly in our community. In Rochester, New York, adolescent pregnancy rates in 2015 were 5.9%, compared with 2.2% nationally.9,10
Although short-acting hormonal contraception (SAC; pill/patch/ring/shot) is moderately effective in preventing pregnancy (approximately 4-7 pregnancies per 100 women per year),11 long-acting reversible contraception (LARC; implants or intrauterine devices) is 99% effective because it requires no regular user action to maintain efficacy.12,13 The American College of Obstetricians and Gynecologists recommends LARC methods an optimal option for adolescent contraception, because they are safe, have higher efficacy and better continuation and satisfaction rates than SAC.14 Use of LARC could radically reduce rates of unintended youth pregnancy, but nationally, only 3.3% of girls in grades 9-12 use this method.15
Reported user barriers include patient factors (eg, lack of knowledge about reproduction and contraception), poor access to health care, and high cost of treatment. Provider barriers also reduce LARC and SAC use. These include personal beliefs, knowledge gaps, shortage of qualified educators, and limited continuing medical education opportunities.16, 17, 18 Studies conducted in California in 2008 and 2015 show that many providers fail to initiate conversations with teens about sexual and reproductive health.16, 17, 18 Clearly, provider counseling barriers and misconceptions are persistent.
To provide a new perspective on provider counseling, we conducted a study to clarify whether high-risk urban teens recalled provider counseling about contraceptive methods and what methods the adolescents used, if any. We added LARC-specific questions to the 2015 Youth Risk Behavior Survey (YRBS) that was administered in urban high schools in Rochester, New York. We also assessed hormonal contraceptive use and counseling in relation to a number of potential barriers or facilitators that were already included in YRBS questions. We hypothesized that provider counseling about specific methods is significantly related to adolescent method choices. Our goal was to hold up a mirror to provider counseling behaviors as reflected by what teens remembered about counseling and what contraceptive method they chose.
Section snippets
Data Source
In this cross-sectional study we analyzed data from the 2015 YRBS, a nationally distributed survey administered to grade 9-12 students by the Rochester City School District (RCSD). The YRBS is sponsored by the Centers for Disease Control and Prevention to monitor health risk behaviors that contribute to death, disability, and social problems in US youth and young adults, including sexual behaviors related to pregnancy and sexually transmitted infections.19,20 The Centers for Disease Control and
Results
The total sample included 1990 female students, of whom 730/1990 (37%) reported that they were sexually active. The response rate was estimated to be 57.4% (1990/3468; total female enrollment = 4071 × 85.2% attendance rate = 3468). Table 3 includes a summary of demographic data of all female respondents, including the sexually active and non-sexually active groups. Sexually active female students comprised our analytic sample. The sexually active group was 353/730 (49%) African American,
Discussion
This study examines provider counseling about contraceptive methods from the unique perspective of adolescent patients. Although subject to bias, the adolescent's recollection of what she heard from the provider might be quite different from what was actually said, and is likely to influence her contraceptive use. Only 29% of participants received memorable LARC counseling and 36% received memorable SAC counseling, although the American Academy of Pediatrics and American College of
Acknowledgments
The authors acknowledge all of the individuals who made a substantive contribution to the study: Andrea Swartzendruber, PhD, MPH, Department of Epidemiology and Biostatistics, University of Georgia College of Public Health, Athens, Georgia, who provided external review of this report; Aloma Y. Cason, RCSD, Office of Accountability Delegated/Entitlement Administrator; and IRB Coordinator and Data Specialists, who provided raw YRBS data. None of these individuals received compensation for their
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The authors indicate no conflicts of interest.
A portion of these data were presented as a poster at the Society for Adolescent Health and Medicine national meeting in Seattle on March 14-17, 2018. An abstract for the poster was published in the Journal of Adolescent Health 2018; 62(2 suppl):S72.