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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Unplanned pregnancy

Author Dr Annapurna Nori 
Expert reviewer Professor Sherry Saggers

Background

In 2008, almost 19% of all births in Australia were to young women aged 15–24 years.20 In 2003, more than half of pregnancies in young women aged 15–19 years resulted in induced abortions.21 This implies that many pregnancies in young women are unplanned events. In addition, teenage pregnancies are associated with increased risk of pre-term births, small-for-gestational-age babies and neonatal deaths. Teenage mothers often find it difficult to complete their education, can be separated from the child’s father, often have less financial resources than older mothers, and their children tend to have worse health. Children of adolescent parents have increased risk of developmental delay, behavioural problems, substance abuse, early sexual activity and becoming teenage parents themselves.22,23

Aboriginal and Torres Strait Islander young women are more likely to get pregnant and smoke during pregnancy, and are at greater risk of adverse outcomes for themselves and their babies. In 2005, the age specific fertility rate of Aboriginal and Torres Strait Islander young women in the age group 15–19 years and in the age group 20–24 years was 4.3 times and 2.3 times higher than for non-Indigenous young women respectively. In 2008, 20% of Aboriginal and Torres Strait Islander mothers were teenagers compared to 3.5% of non-Indigenous mothers.20 Aboriginal and Torres Strait Islander women of all ages have babies with a three times higher prevalence of low birth weight, and two times higher prevalence of pre-term deliveries. Pregnant Aboriginal and Torres Strait Islander young women are also more likely to have fewer antenatal attendances. In 2004–05, 34% of all hospitalisations for Aboriginal and Torres Strait Islander young people were due to pregnancy related complications. Congenital abnormalities are more prevalent in Aboriginal and Torres Strait Islander than in non-Indigenous babies, particularly for babies born to teenage mothers.24

Evidence of effectiveness of preventive interventions

The clinic visit can be used to engage the young person in a discussion targeting reproductive health, or within the context of broader and more general health issues. Indeed, commencing the consultation with a more general approach is better suited to the needs of a young person.1 The components of routine antenatal health assessments are outlined in Chapter 9: Antenatal care.

Screening and behavioural interventions

Experts in Australia, the USA and the UK recommend three interventions for young people: anticipatory guidance/counselling, screening for sexual activity and at risk sexual behaviour, and appropriate counselling for preventing unplanned pregnancies.1,11,25–28 

Anticipatory or health guidance is defined as a proactive, developmentally based counselling technique that focuses on a young person’s stage of development. It is meant to ‘promote a better understanding of their physical growth, psychosocial and psychosexual development, and the importance of becoming actively involved in decisions regarding their healthcare’.11 There is a paucity of good quality studies assessing the effectiveness of counselling on unplanned pregnancies.25,26,28,29 Consequently recommendations are generally based on expert opinion30 and suggest that counselling should include ‘advice on how to prevent unplanned pregnancies, all methods of reversible contraception, how to get and use emergency contraception, and to provide supporting information in an appropriate format’.27 Parents or guardians should also receive health guidance at least one time each during the young person’s early, middle and late adolescence.11

Barrier methods of contraception, especially male condoms, are effective for both pregnancy prevention and reducing risk of some STIs. While the method specific failure rate for condoms is 2%, the typical use failure rate is around 15% due to improper and inconsistent use.25 Condoms are recommended as a primary prevention intervention but ongoing education with emphasis on consistent and proper use is important.

Chemoprophylaxis

Hormonal contraception includes the oral contraceptive pill (OCP) and long acting reversible contraception (LARC), which is defined as any method that requires administration less than once per cycle or month. Examples of hormonal LARCs include progestogen-only injections, progestogen-only subdermal implants and progestogen-only intrauterine devices (IUDs) while copper intrauterine devices are a form of non-hormonal LARC. Unlike the oral contraceptive pill (OCP), effectiveness of LARC does not depend on daily compliance. There is scant but reassuring literature on the use of IUDs in adolescents.31 Due to the adverse but reversible effect of progestogen-only injections on bone mineral density, this should be used cautiously as first line contraception in young women aged under 18 years.32 Subdermal progestogen LARCS are not known to be associated with reduced bone mineral density.32 On the basis of extrapolated evidence, all other hormonal contraception has the same safety and efficacy profile in young women as in adult women.

According to the 2004–05 National Aboriginal and Torres Strait Islander Household Survey, condoms followed by the OCP were the main methods of contraception reported by young Aboriginal and Torres Strait Islander women aged 18–24 years in 2004–05, 25% and 16% respectively. Implants and injections were reported by 6% each. An estimated 14% of young Aboriginal and Torres Strait Islander women reported not using any contraception.

Hormonal contraception is traditionally commenced with the onset of menses to avoid contraceptive use during an undetected pregnancy. An alternative is immediate initiation if pregnancy can be reliably ruled out. The advantage of this method in young women is to improve the uptake of contraception. However, with the exception of injectable progestogen, there is limited evidence that immediate commencement of contraception reduces unintended pregnancies.33

Emergency contraception can decrease the chance of pregnancy. To date, however, there is no evidence that either advance provision of, or increased access to, emergency contraception reduces unintended pregnancies at a population level.29,34 On the encouraging side, advance provision has not led to increased rates of STIs, increased frequency of unprotected intercourse or changes in contraceptive methods. In particular, women who received advance emergency contraception were as likely to use condoms as women who did not receive this. In a study involving adolescents, experience with emergency contraception was associated with an increased probability of condom use and an increased perceived capacity to negotiate condom use.26 It is therefore reasonable to support young women’s knowledge of, and access to, emergency contraception.

Environmental

There have been a few reviews of the effectiveness of primary pregnancy prevention programs in young people. Interventions studied have been in both low and middle income countries and high income countries. They include school based programs, community based programs, family planning clinics, workplace programs, mass media programs (social marketing) and health facility based programs.31,35-37 Overall, most programs have a positive impact on knowledge and attitudes, and no impact on sexual activity or delaying initiation of sexual intercourse. There is some evidence that programs can be effective in increasing contraceptive use and to a much lesser extent reducing pregnancy rates. In one systematic review of educational interventions to inform contraceptive choice, theory based groups consistently demonstrated favourable results. These included social cognition models (particularly social cognitive theory), motivational interviewing and the aids risk reduction model.38 Community based programs tend to be more effective than school based programs, and clinic based programs more effective than non-clinic based programs. Programs in youth friendly services can improve knowledge, increase contraceptive use and increase use of the service. Abstinence programs were the least successful intervention.

Recommendations: Unplanned pregnancy
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All young people aged 12–24 years Ask if sexually active and identify at risk sexual behaviours (eg. unprotected sexual intercourse: see Chapter 8:  Table 8.1) Opportunistic and as part of an annual health assessment (including psychosocial assessment) GPP1,11
Behavioural All young people Provide anticipatory guidance* and sexual health education, tailoring the information according to whether a young person is sexually active or not (see Chapter 8: Sexual health and bloodborne viruses)
Discussion should include the following:
  • sexual development and sexual feelings
  • prevention of unplanned pregnancies including abstinence
  • resisting sexual and peer pressure
  • methods of reversible contraception, access to and use of emergency contraception
Opportunistic and as part of an annual health assessment GPP1,11,27
Young people who are considering initiating sexual activity or who are sexually active Recommend use of and/or provide condoms
Discuss the proper methods for condom usage
Opportunistic and as part of an annual health assessment IIIC25
Young people engaging in risky sexual behaviour Use individual behaviour change techniques such as brief interventions (eg. information giving, motivational interviewing) and cognitive behavioural therapy Opportunistic GPP27
Offer or refer to theory based pregnancy prevention/education programs to improve knowledge and increase contraceptive use. Examples include social cognitive theory,† motivational interviewing program, AIDS risk reduction model (see Table 3.1) IA31,35–38
Parents or guardians of young people Provide health guidance to parents and other guardians regarding youth sexual health following the principles of anticipatory guidance* At least once at early, middle and late adolescence GPP11
Chemoprophylaxis Young females who are sexually active or considering initiating sexual activity Assess suitability for and offer hormonal contraception. Methods include the oral contraceptive pill and long acting reversible contraception (ie. progestogen only injections, progestogen only subdermal implants, progestogen only IUDs) Opportunistic IIIC31,32
Young females who have had unprotected intercourse Conduct a detailed history to assess the context
Discuss and recommend emergency contraception as necessary
Arrange for appropriate follow up
Opportunistic IIB26
Environmental N/A Promote youth friendly primary healthcare services N/A GPP1
* Anticipatory guidance is a developmentally based counselling technique that focuses on a young person’s stage of development. Counselling is focused towards gaining a better understanding of young people’s physical growth, psychosocial and psychosexual development. It emphasises the importance of the young person becoming actively involved in decisions regarding their healthcare11
† Social cognitive theory is a learning theory based on the idea that people learn by watching what others do and do not do
Table 3.1. The AIDS risk reduction model
This model has three stages and is based on several other behaviour change theories, including the health belief model, ‘efficacy’ theory, emotional influences and interpersonal processes. The three stages outlined below are behaviour labelling, commitment to change and taking action
StageInfluences
1. Recognition and labelling of one’s behaviour as high risk
  • Knowledge of sexual activities associated with HIV transmission
  • Believing that one is personally susceptible to contracting HIV
  • Believing that having AIDS is undesirable
  • Social norms and networking
2. Making a commitment to reduce high risk sexual contacts and to increase low risk activities
  • Cost and benefits
  • Enjoyment (eg. will the changes affect my enjoyment of sex?)
  • Response efficacy (eg. will the changes successfully reduce my risk of HIV infection?)
  • Self efficacy
  • Knowledge of the health utility and enjoyability of a sexual practice, as well as social factors (group norms and social support), are believed to influence an individual’s cost and benefit and self efficacy beliefs
3. Taking action:
  • information seeking
  • obtaining remedies
  • enacting solutions
Depending on the individual, phases may occur concurrently or phases may be skipped
  • Social networks and problem solving choices (self help, informal and formal help)
  • Prior experiences with problems and solutions
  • Level of self esteem
  • Resource requirements of acquiring help
  • Ability to communicate verbally with sexual partner
  • Sexual partner’s beliefs and behaviours
Source: Family Health International 200239

References

  1. Chown P, Kang M, Sanci L, Newnham V, Bennett DL. Adolescent health: enhancing the skills of general practitioners in caring for young people from culturally diverse backgrounds. GP resource kit, 2nd edn. Sydney: NSW Centre for the Advancement of Adolescent Health and Transcultural Mental Health Centre, 2008.
  2. American Medical Association. Guidelines for adolescent preventive services (GAPS) recommendations monograph. Chicago: American Medical Association, 1997. Cited October 2011. Available at www.ama-assn.org/ ama1/pub/upload/mm/ 39/gapsmono.pdf.
  3. Laws P, Li Z, Sullivan EA. Australia’s mothers and babies 2008. Perinatal statistics series no. PER 50. Canberra: Australian Institute of Health and Welfare, 2010.
  4. Grayson N, Hargreaves J, Sullivan EA. Use of routinely collected national data sets for reporting on induced abortion in Australia. AIHW cat. no. PER 30. Sydney: Australian Institute of Health and Welfare, 2005. Cited October 2011. Available at www.npsu.unsw.edu.au/ PRERUWeb.nsf/resources/AMB_2004_2008 /$file/ps17.pdf Accessed February 2011.
  5. Van Der Klis KAM, Westenberg L, Chan A, Dekker G, Keane RJ. Teenage pregnancy: trends, characteristics and outcomes in South Australia and Australia. Aust N Z J Public Health 2002;26(2):125–31.
  6. Klein JD. Adolescent pregnancy: current trends and issues (clinical report). Pediatrics 2005;116:281–6.
  7. Westenberg L vdKK, Chan A, Dekker G, Keane RJ. Aboriginal teenage pregnancy compared with non-Aboriginal in South Australia 1995–1999. Aust N Z J Obstet Gynaecol 2002;42(2):187–92.
  8. Trussell J. Contraceptive efficacy. In: Hatcher RA TJ, Nelson AL, Cates W, Stewart FH, Kowal D, et al, editors. Contraceptive technology, 19th edn. Ardent Media Inc, 2007, p.747–826.
  9. Walker D, Torres P, Gutierrez J, Flemming K, Bertozzi S. Emergency contraception use is correlated with increased condom use among adolescents: results from Mexico. J Adolesc Health 2004;35(4):329–34.
  10. National Institute for Health and Clinical Excellence. One to one interventions to reduce the transmission of sexually transmissible infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups. PHI3. London: National Institute for Health and Clinical Excellence, 2007. Cited October 2011. Available at www.nice.org.uk/ nicemedia/pdf/ PHI003guidance.pdf.
  11. Killoran A, McCormick G. Towards an integrated approach to sexual health services: The contribution of NICE guidance on one-to-one interventions to prevent STIs and under 18 conceptions. Health Education Journal 2010;69(3):297–310.
  12. Centre for Reviews and Dissemination. Population effect of increased access to emergency contraceptive pills: a systematic review (structured abstract). Database of Abstracts of Reviews of Effects serial on the Internet 2001;(1).
  13. Cook P, Corbett K, Downing J, Crossley M, Bellis M. A fieldwork evaluation of NICE guidance on sexual health interventions. Liverpool: John Moores University Centre for Public Health, 2007.
  14. Centre for Reviews and Dissemination. Intrauterine devices for adolescents: a systematic review (structured abstract). Database of Abstracts of Reviews of Effects serial on the Internet 2011;(1).
  15. National Collaborating Centre for Women’s and Children’s Health. Long acting reversible contraception. London: National Institute for Health and Clinical Excellence, 2005. Cited October 2011. Available at www.nice.org.uk/ nicemedia/live/10974/ 29912/29912.pdf.
  16. Lopez LM NS, Grimes DA, Schulz KF. Immediate start of hormonal contraceptives for contraception. Cochrane Database Syst Rev 2008;Apr 16;(2):CD006260.
  17. Polis CB GD, Schaffer K, Blanchard K, Glasier A, Harper C. Advance provision of emergency contraception for pregnancy prevention. Cochrane Database Syst Rev 2007;Apr 18;(2):CD005497.
  18. DiCenso A, Guyatt G, Willan A, Griffith L. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials. BMJ 2002;324:1426–30.
  19. Centre for Reviews and Dissemination. The effectiveness of adolescent reproductive health interventions in developing countries: a review of the evidence (structured abstract). Database of Abstracts of Reviews of Effects (serial on the internet), 2010;(4).
  20. Centre for Reviews and Dissemination. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials (structured abstract). Database of Abstracts of Reviews of Effects (serial on the internet), 2010(4).
  21. Lopez LM, Grimes DA, Chen-Mok M. Theory-based interventions for contraception. Cochrane Database Syst Rev 2009;Jan 21;(1):CD007249.
  22. Family Health International. Behavior change: a summary of four major theories. Durham: Family Health International, 2002. Cited January 2011. Available at www.fhi360.org/ NR/rdonlyres/ei26vbslpsidmahhxc332vwo3g 233xsqw22er3vofqvrfjvubwyzclvqjcbdgexyzl3msu4mn 6xv5j/BCCSummaryFourMajorTheories.pdf.
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