Teenagers need contraceptive advice, not just abstinence counselling

In revised guidelines, the American Academy of Pediatrics has recommended that teenagers receive counselling to postpone sexual activity but also information about and access to contraception, including over the counter emergency contraception without a prescription (Pediatrics 2005;115:281-6). The academy’s 60 000 members provide primary care to infants, children, and teenagers up to the age of 18 or 21.

Jonathan Klein, chairman of the committee that drew up the guidelines, told the BMJ that the new report was a routine update to consider newer options such as emergency contraception, not a reaction to the Bush administration’s programmes promoting abstinence until marriage and monogamy thereafter. The report says that teenage pregnancy poses medical and psychosocial complications, and that children of very young mothers do not do as well as those of adult women.

Although sexual activity and teen pregnancy rates have declined, they remain a concern. More than 45% of girls and 48% of boys at high school (aged 13 or 14 to 17 or 18) have had sexual intercourse. The average age of first intercourse is 17 for girls and 16 for boys, but about a quarter of teenagers report having had intercourse by age 15.

Every year, 900 000 teenage girls become pregnant. Half of teenagers’ pregnancies are within six months of first intercourse. More than 40% of adolescent girls become pregnant at least once before the age of 20, although most pregnancies are in teenagers aged 18 or 19. Education about HIV and sexually transmitted disease has led more teenagers to use barrier contraceptives, but only 63% reported having used a condom the last time they had intercourse.

More than 90% of 15-19 year olds in the United States say that their pregnancies were unintended (as do half of adult women). About 51% of teenagers’ pregnancies result in live births, 35% in induced abortion, and 14% in miscarriage or stillbirths. Nearly 80% of births to teenagers are outside of marriage.

Pregnancy rates in teenagers have declined since the 1950s and 1960s, as abortion was legalised and the pill and other methods of contraception became available. Nevertheless, births to teenagers aged 15 to 19 are far higher than in other industrialised countries: 61 per 1000 in the US, compared with 41 in Canada, 33 in the United Kingdom, eight in the Netherlands, and four in Japan.

Dr Klein, of the University of Rochester School of Medicine, New York, said that the abstinence programme, which costs up to $87.5m (£50.4m; €73.3m) a year and is shared by the federal government and the states, "was not based on medical or health information." He told the BMJ, "The academy believes young people and families ought to have access to comprehensive reproductive health information."

A report to the federal Department of Health and Human Services in June showed that abstinence programmes increased teenagers’ awareness of abstinence but did not decrease teenagers’ sexual activity, pregnancy, or infection with sexually transmitted diseases (http://aspe.hhs.gov/hsp/05/abstinence/report.pdf).

In response to the report, Wade Horn, assistant secretary for children and families at the Department of Health and Human Services, told the Associated Press that the abstinence only message was best because it was clear while the academy’s message confused prevention and intervention. The Planned Parenthood Foundation applauded the guidelines.

The guidelines to pediatricians say that they should encourage teenagers to postpone sexual activity; routinely offer confidential screening for sexual activity, pregnancy risk, and risk of sexually transmitted diseases; make sure that adolescents know about all types of contraception and have access to contraceptives; recommend folic acid supplements to young women; encourage community efforts to delay teenagers’ sexual activity and pregnancies; advocate comprehensive medical and psychosocial support for pregnant adolescents, including information on abortion and adoption; assess teenager mothers’ ability to care for their infants and refer them for help; include the father in prenatal programmes; and serve as a resource for the pregnant teenager, infant, family, and the father.