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

Chapter 4. The health of young people
Unplanned pregnancy
☰ Table of contents

Recommendations: Preventing child maltreatment – Supporting families to optimise child safety and wellbeing

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence



All young people aged 12–24 years

Ask if sexually active, conduct a social emotional wellbeing assessment, and identify at-risk sexual behaviours (eg unprotected sexual intercourse – refer to Chapter 14: Sexual health and blood-borne viruses, Box 1)

Opportunistic and as part of an annual health check


1, 10, 37


All young people aged 12–24 years

Provide anticipatory guidance1 and sexual health education (refer to Chapter 14: Sexual health and blood-borne viruses), tailoring the information to the young person’s needs

Discussion should include the following:

  • sexual development and sexual feelings
  • prevention of unplanned pregnancies
  • resisting sexual and peer pressure
  • methods of reversible contraception, access to and use of emergency contraception

Opportunistic and as part of an annual health check


1, 11, 37, 46

Young people who are considering initiating sexual activity or who are sexually active

Provide contraceptive services  


11, 37

Recommend use of and/or provide condoms

Discuss the proper methods for condom usage

Discuss and offer hormonal contraception

Discuss advance emergency contraception

Opportunistic and as part of annual health check


11, 37

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




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 (Box 1)



45, 50, 52, 53

Parents or guardians of young people

Provide health guidance to parents and other guardians regarding youth sexual health following the principles of anticipatory guidance





Young females who are sexually active or considering initiating sexual activity


Assess suitability for, and offer, hormonal contraception. Methods include the oral contraceptive pill (OCP) and longacting reversible contraception (LARC) (ie progestogen-only injections, progestogenonly subdermal implants, progestogen-only intrauterine devices)

Opportunistic and as part of annual health check


45, 46

Offer advance emergency contraception

Opportunistic and as part of annual health check



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






Promote youth-friendly primary healthcare services



1,16, 54

*Social cognitive theory is a learning theory based on the idea that people learn by watching what others do and will not do.
Anticipatory guidance is a developmentally based counselling technique that focuses on a young person’s stage of development. Counselling is focused toward 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 healthcare.17


Box 1. The AIDS Risk Reduction Model55

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.



1. Recognition and labelling of one’s behaviour as high risk

  • Knowledge of sexual activities associated with human immunodeficiency virus (HIV) transmission
  • Believing that one is personally susceptible to contracting HIV
  • Believing that having acquired immune deficiency syndrome (AIDS) is undesirable
  • Social norms and networking

2. Making a commitment to reduce highrisk 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. This consists of three phases:

  1. information seeking
  2. obtaining remedies
  3. 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


Despite improvements in reproductive health outcomes over the last five years, the rates of pregnancy in Australian young women remain high. In 2014, almost 16% of all births in Australia were to young women aged less than 25 years. The fertility rate of teenage Aboriginal and Torres Strait Islander women (57.3 babies per 1000 women) was over four times that of all teenage women (13 babies per 1000). Aboriginal and Torres Strait Islander mothers, compared with non-Indigenous mothers, were over eight times as likely to be teenage mothers (17% compared with 2%).29,30 Not only are Aboriginal and Torres Strait Islander young women more likely to become pregnant, they are also more likely than their non-Indigenous counterparts to smoke during pregnancy, have fewer antenatal attendances, and be at greater risk of adverse outcomes for themselves and their babies. Young mothers have higher rates of not completing their education, separation from the child’s father, and restricted access to financial resources compared with older mothers. Adverse neonatal outcomes include higher rates of preterm birth, small for gestational age, and neonatal death. In 2014, babies born to Aboriginal and Torres Strait Islander mothers were more likely to be admitted to a special care nursery or intensive care unit than babies of non-Indigenous mothers (22% and 15% respectively).29 Adverse health outcomes in childhood include increased risk of developmental delay, behavioural problems, substance abuse, early sexual activity and becoming teenage parents themselves.31,32

There are no recent national data on induced abortions, the last collation being in 2003. Western Australian data from 2012 reveal an induced abortion rate of 29.3 per 1000 women in young women aged 20–24 years, and 14.4 per 1000 in those aged 15–19 years. Young women aged ≤24 years accounted for almost 43% of all abortions. In addition, almost 46% of pregnancies in young women aged 15–19 years and 34% of pregnancies in women aged 20–24 years resulted in induced abortions.33 This implies that many pregnancies in young women are unplanned events. This is strengthened by evidence from several qualitative studies that there is a lack of knowledge among young women and young mothers about consequences of sexual activity, contraception methods, and correct contraceptive use. There is also a suggestion that this lack of knowledge is more marked in young women from minority groups or social disadvantage.11

According to the 2004–05 National Aboriginal and Torres Strait Islander Household Survey, condoms followed by the Oral Contraceptive Pill (OCP) were the main methods of contraception reported by Aboriginal and Torres Strait Islander women aged 18–24 years (25% and 16% respectively). Both implants and injections had a reported usage of 6%. An estimated 14% of young Aboriginal and Torres Strait Islander women reported not using any contraception.34


Evidence of effectiveness of preventive interventions

Most of the evidence on effective interventions is derived from US studies. In addition, there is a dearth of evidence on the effectiveness of interventions in socially disadvantaged or minority groups. Consequently, the evidence base is immature and provides mixed evidence in regard to the effectiveness of preventive practice.11 For example, there is good evidence that the clinic visit can be used to engage the young person in a discussion targeting reproductive health, within the context of broader and more general health issues. Indeed, commencing the consultation with a more general approach rather than with a discussion about sexual health is better suited to the needs of a young person.1,10,11 The evidence is less clear in regard to more specific interventions. These are discussed in detail in the sections below. The components of routine antenatal health assessments are outlined in Chapter 2: Antenatal care.


Immunisation against vaccine-preventable sexually transmitted infections, such as hepatitis B and human papilloma virus, should be enquired about and offered as appropriate to all youth (refer to Chapter 3: Child Health, ‘Immunisation’).

Screening and behavioural interventions

Consensus-based recommendations from Australia, US and UK include three interventions for young people: anticipatory guidance/counselling; screening for sexual activity and at-risk sexual behaviour; and appropriate counselling for preventing unplanned pregnancies.1,11,35–37
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 health care’.17,38 There is strong evidence that, interventions such as oneto-one, nurse-led counselling or computer-aided contraception decision-making results in fewer unplanned pregnancies. There is some evidence that one-to-one counselling with young people aged <18 years can increase contraception use.11,35–37,39

Parents or guardians should also receive health guidance regarding adolescent development and behaviour.40–42
Barrier methods of contraception, especially male condoms, are effective for both pregnancy prevention and reducing risk of some sexually transmitted infections (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.11 There is strong evidence that counselling on condom use combined with demonstration of condom use results in increased condom use and engagement with clinical services.11 Condoms are recommended as a primary prevention intervention with ongoing education to emphasise the importance of consistent and proper use.


Hormonal contraception includes the progestin-only and combined oral contraceptive pills (OCP), and longacting reversible contraception (LARC), which is defined as any method that requires administration less than once per cycle or month. Examples of hormonal LARCs available in Australia include progestogen-only injections, progestogen-only sub-dermal implants, and progestogen-only intra-uterine devices (IUDs) while copper intrauterine devices are a form of non-hormonal LARC. Unlike the oral contraceptive pill, effectiveness of LARC does not depend on daily compliance. There is some evidence that copper IUDs are more effective than hormonal methods in pregnancy prevention.43

There is insufficient evidence to compare the contraceptive efficacy and continuation usage in young people, between the various contraception options mentioned.44 There is scant but reassuring literature on the use of IUDs in adolescents.45 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 below 18 years.46 On the other hand, sub-dermal progestogen LARCS are not known to be associated with reduced bone mineral density, and are highly effective.46,47 On the basis of extrapolated evidence, all other hormonal contraception has the same safety and efficacy profile in young women as in adult women. It is recommended to provide advice on and provide access to all hormonal contraception methods.11,37

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.48 There is good evidence that dispensing contraceptives from school-based health centres increases the provision of contraception, but the outcomes in terms of contraceptive use are unknown.11

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.39 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 adolescents, there is strong evidence to support advance provision of emergency contraception as it demonstrates increased use of emergency contraception without adversely impacting on use of other contraception or increasing risky behaviour.11 In addition, experience with emergency contraception was associated with an increased probability of condom use and an increased perceived capacity to negotiate condom use.35 The recommendation is therefore to support young women’s knowledge of, and access to, emergency contraception.


There have been a few reviews of the effectiveness of primary pregnancy prevention programs in young people.
Interventions studied have been in both low-income and middle-income countries and high-income countries. They include school-based programs, community-based programs, family planning clinics, workplace programs, use of social media, mass-media programs (including social marketing) and health facility–based programs.45,49 Overall, most of these programs have a positive impact on knowledge and attitudes.

There is strong evidence that combining educational curriculum interventions with community outreach can be effective in preventing teenage pregnancy and risky sexual behaviour. There is moderate evidence that outreach programs on their own do encourage youth to attend mainstream sexual health services, but their effect on reducing unintended pregnancies is unknown.11 There is also good evidence that multi-session support and home visiting for disadvantaged, low-income pregnant women or mothers can prevent repeat pregnancies.37

There is moderate evidence that a) computer-based interventions can reduce pregnancy and increase use of emergency contraception; and b) a ‘virtual world’ intervention was effective when associated with a curriculum-based intervention about sexual risk behaviour, in increasing understanding about reproductive health.11 A clearer picture is therefore emerging of the utility of information technology–based interventions in increasing understanding and reducing risky sexual behaviour. There is also moderate evidence that generic health programs for teenage mothers could be effective in reducing repeat pregnancies.11
One systematic review of educational interventions to inform contraceptive choice – theory-based groups as compared to usual care – consistently demonstrated favourable results in terms of reduced pregnancies, choice of effective contraception and adherence to contraception. These included social cognition models (particularly social cognitive theory), motivational interviewing and the AIDS Risk Reduction Model.50 Communitybased 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.11

There is weak evidence that social marketing campaigns could have a significant effect on the use of contraception or emergency contraception.11 Abstinence programs were the least successful intervention and are not recommended.51

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


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