Helping patients avoid social and health challenges related to unintended pregnancy has a public health value.1 Unintended pregnancies often have more complications (such as prematurity and low birth weight) than intended pregnancies due to delayed prenatal care and unhealthful maternal habits, such as smoking.1
Unintended pregnancy is defined as a pregnancy that was either not desired or was mistimed.2 Although the unintended pregnancy rate is slowly declining in the United States, 45% of all pregnancies are unintended.1 Most of these pregnancies occur in women who did not use contraception or used it incorrectly.2 In fact, about 60% of women who experienced an unintended birth reported not using any type of contraception.3 Many reasons exist as to why sexually active women who do not want to become pregnant do not use contraception. In a survey of 842 women who had unintended pregnancies while not using contraception, the CDC found that the most common reason for not using contraception was that the women simply did not think they could get pregnant.4 This highlights a need for providers to understand patient perspectives and possible misunderstandings so they can better communicate risks and interventions.
When is the best time to provide patient education? Data suggest that teens who use contraception at first intercourse are less likely to ever have an unintended pregnancy, making an argument for education about pregnancy risk and prevention before first intercourse.5 Twenty-two percent of female teens reported not using contraception at first intercourse, and some who had an unintended pregnancy believed they were too young to become pregnant, despite sexual development emerging at age 10 to 14 years.5-7 Therefore, timely discussion is essential for effective prevention.
The Healthy People 2020 initiative, which provides 10-year national objectives for promoting health and well-being, also stresses the importance of preventing unintended pregnancies, and encourages clinicians to integrate reproductive education into much of primary care.8Table 1 contains select Healthy People 2020 objectives related to the subject of unintended pregnancy. How to integrate this education continues to be a challenge, however, as fewer than 40% of healthcare providers actually obtain a sexual history from their patients.9
This article reviews strategies to help clinicians educate patients about preventing unintended pregnancies, including knowing about common patient misunderstandings, adopting the appropriate timing for effective education, considering specific interview techniques, and practical steps for implementation.
COMMON PATIENT MISUNDERSTANDINGS
To deliver patient-centered education, clinicians must actively seek to understand the patient's perspective first. For example, does the patient consider pregnancy as a potential outcome for her? Surprisingly, one survey found that some women may be under the impression that they cannot get pregnant. As mentioned previously, this is the most common reason (36% to 44%) sexually active women ages 15 to 44 years give for not using contraception.3,4,6 One survey found that 42% of women thought that either they could not get pregnant, or that their partner was sterile; others stated that they had been told by a healthcare worker that they could not become pregnant.6 Other common reasons given for not using contraception include:
- Did not mind becoming pregnant, 23% to 30%
- Did not expect to have sex, 14% to 17%
- Worried about adverse reactions to contraception, 14% to 16%
- Male partner did not want to personally use contraception, 8% to 10%
- Male partner did not want female to use contraception, 5% to 7%.3,4,6
A study by the National Campaign to Prevent Teen and Unplanned Pregnancy found that 90% of young adults believe that they “have all the knowledge needed to avoid unplanned pregnancy.”10 However, when questioned about correct use of common types of contraception, many were unable to answer correctly.10 For example, 40% of young adults do not know when a woman is most fertile, even if they are relying on fertility-based methods to avoid pregnancy.10 Interestingly, the same study also reported that 44% of women believe that pregnancy will occur “when it is time,” regardless of whether they use contraception.10
Assess the patient's understanding of fertility and contraceptive options. A useful patient education resource on contraceptive methods and levels of efficacy is available from www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/Contraceptive_methods_508.pdf. In addition, clinicians can discuss how certain forms of long-acting reversible contraception are not patient-dependent for correct and consistent use.11,12 These types of contraceptives may be useful for the 14% to 17% of patients who stated that conception of an unintended pregnancy occurred at a time that they did not expect to have sex.3,4 Clinicians should be encouraged to initiate this discussion with patients because one survey showed that most women (75%) want reproductive information from their healthcare provider, but only half reported a reproductive health discussion with their provider, and fewer than 25% reported actually talking to their provider about specific fertility or reproductive topics.13
APPROPRIATE TIMING FOR EFFECTIVE EDUCATION
The American College of Obstetricians and Gynecologists (ACOG) recommends evaluating and counseling women during annual health assessments to determine if a discussion is needed on preventing unintended pregnancy. The recommendations are divided into four age divisions: ages 13 to 18 years, 19 to 39 years, 40 to 64 years, and 65 years and older, with all age groups, except the oldest, including counseling about prevention of unintended pregnancy.14
Because sexual development usually occurs in the middle-school years, this seems to be an important time to offer education about pregnancy prevention.7 Data also show that discussing pregnancy risks and prevention with teens before first intercourse reduces the likelihood of an unintended pregnancy.5 According to the most recent School Health Policies and Practices Study, about 60% of school districts require teaching on pregnancy prevention in their middle schools, and about 76% require it in their high schools.15 Topics that were covered in more than one-third of middle schools included abstinence; resisting peer pressure; risks and effects of teen pregnancy; relationships between pregnancy, sexually transmitted infections (STIs), and alcohol and drug use; and pregnancy prevention in general.16 Topics that were taught in fewer than one-third of schools included types of contraception, contraception efficacy, how to obtain contraception or find pregnancy care, the value of using a condom in addition to other contraception, and the importance of using contraception correctly.16 A national survey of 4,691 teens and young adults compared sex education that discussed only abstinence with sex education that discussed abstinence and contraception.17 Both types of sex education were associated with increased age at first sex. However, females who received education on abstinence and contraception were more likely to use a condom at first intercourse than those who received only abstinence education.17
According to a 2017 CDC survey, 28.7% of high school students claim to be sexually active, and 3.4% claim to have had intercourse before age 13 years.18 These numbers help illustrate the importance of educating adolescents before high school or early in high school about preventing unintended pregnancy. The American Academy of Pediatrics (AAP) makes the following points about education:
- for patients ages 11 to 14 years: “The safest way to prevent pregnancy and STIs is to not have sex, including oral sex” and “Plan how to avoid risky situations; if sexually active, protect against STIs/pregnancy.”19
- for patients ages 15 to 17 years: “Abstaining from sexual intercourse, including oral sex, is the safest way to prevent pregnancy and STIs; plan how to avoid sex, risky situations,” and “If sexually active, protect against STIs and pregnancy by correctly/consistently using long-acting reversible contraception, such as IUD/contraceptive implant, or birth control pills. Use with a condom.”19
The AAP also recommends that between ages 15 and 18 years, all patients undergo screening for HIV.20 The CDC also recommends the human papillomavirus vaccine for all adolescents at age 11 to 12 years.21 ACOG recommends that girls have their first female reproductive visit between ages 13 and 15 years.22 Considering these data and recommendations, appropriate timing to begin pregnancy risk assessment and education aimed at preventing unintended pregnancy appears to be in early adolescence, before first intercourse. One small survey of 162 physician assistants (PAs) who worked primarily in family practice showed that only 28% frequently provided contraceptive counseling to teenage patients before their first intercourse.23
The CDC recommends that clinicians obtain a sexual history at a patient's first appointment and at all routine preventive appointments.24 However, fewer than 40% of healthcare providers actually obtain a sexual history from their patients.25 The sexual interview is an essential part of the patient's full medical history and opens the door for counseling on prevention of unintended pregnancy. Frequent and proactive inquiries about a patient's sexual health can increase opportunities for preventive care.26
Developing a standard introduction to the sexual history may help clinicians ease into the conversation. For example, after establishing rapport and collecting some of the patient's history, the clinician might begin with: “Sexual health is important to overall health; therefore, I always ask patients about it. If it's okay with you, I'll ask you a few questions about sexual matters now.”26 Providing privacy and ensuring confidentiality may put the patient at ease. States vary in their limitations of confidentiality with adolescents, so knowing state laws will enable clinicians to effectively facilitate the discussion.22 Moving through questions about a patient's sexual history should be done with a respectful, matter-of-fact approach that encourages a question-answer dialogue.27 Although a sexual history includes questions about partners, practices, and STIs and is much broader than just determining a patient's plans for pregnancy, contraception is an essential part of the sexual history.24 In fact, the CDC suggests that all patients who are of reproductive age should develop a reproductive life plan with their healthcare provider.27 The following questions can be used in the sexual history to determine if further discussion on pregnancy prevention is warranted:
- Are you sexually active?
- Do you have any children?
- Are you trying to get pregnant?
- Would you like to have (more) children later?
- Are you concerned about an unplanned pregnancy?
- Do you use any method of birth control?
- Are you satisfied with that method?24,26,27
If further discussion on contraceptive methods is indicated, the goal is to guide the patient toward the most effective method that is appropriate for that patient. Review contraindications and risks with the patient's medical history in mind, using the CDC's Medical Eligibility Criteria chart at www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf. The CDC recommends that clinicians give patients information on the most effective forms of reversible contraception before discussing less-effective methods.28 Data from the CDC suggest that high-efficacy contraceptive methods, such as the implant and intrauterine device, are more than 99% effective.11
A study of 1,965 women in the primary care setting showed that patients often chose the first type of contraceptive a clinician discussed.29 Although many patients may request the type of contraception with which they are most familiar, they may not be familiar with efficacy differences between typical and perfect use for common forms of contraception. An important message is that unintended pregnancy is less likely to occur due to contraceptive failure than from improper use (Table 2).4
While moving through the sexual history or reproductive life plan, continue to seek the patient's perspective and use this information to tailor patient education by addressing concerns, filling in knowledge gaps, and correcting misunderstandings, so that the decision about contraceptive use is made jointly.30 Clinicians are encouraged to present patients with all details about appropriate use, adverse reactions, and troubleshooting the chosen contraceptive method in order to increase the likelihood of consistent and appropriate use.
Primary care providers should be aware of their significant role in helping patients avoid unplanned pregnancies. By understanding common misconceptions and reasons for contraception nonuse, clinicians can offer focused patient education and resources to narrow the gap between patient knowledge and practices about preventing unintended pregnancies. In accordance with CDC recommendations and Healthy People 2020 objectives, obtaining a sexual history and providing timely education about preventing unintended pregnancy should be a priority for all clinicians, in order to deliver quality patient-centered care.8,24
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25. Lanier Y, Castellanos T, Barrow RY, et al Brief sexual histories and routine HIV/STD testing by medical providers. AIDS Patient Care STDS
26. Nusbaum MR, Hamilton CD. The proactive sexual health history. Am Fam Physician
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services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep
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30. Hashim MJ. Patient-centered communication: basic skills. Am Fam Physician
31. Branum AM, Jones J. Trends in long-acting reversible contraception
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32. Trussell J. Contraceptive failure in the United States. Contraception
Keywords:Copyright © 2019 American Academy of Physician Assistants
unintended pregnancy; contraception; reproductive health interview; patient education; misunderstandings; family planning