Each year in the United States, approximately 1 million adolescents, or 10 percent of females 15 to 19 years of age, become pregnant.¹ These pregnancies, which account for 13 percent of all births, usually are unintended and occur outside of marriage.² Since 1991, the adolescent pregnancy rate in the United States has fallen by 25 percent, from 116 to 87 per 1,000 females 15 to 19 years of age.³ This decline has been attributed to delayed initiation of sexual intercourse, increased use of contraception, and education about human immunodeficiency virus transmission and pregnancy prevention.^4,5 Despite the decline, adolescent pregnancy remains a major public health problem with lasting repercussions.

In 2001, the U.S. Surgeon General presented “The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior,”⁶ which discussed the need for a national dialogue on this topic, expanding research into sexual health, and improving health care access and social interventions to increase responsible sexual behaviors.

Impact of Teenage Pregnancy

Compared with nonpregnant adolescents, teenage mothers are less likely to graduate from high school and are more likely to score below average in language and reading skills.^7,8 These teenagers also are more likely to have low self-esteem and symptoms of depression.^9,10 Many of them have behavior and substance-abuse problems and lack the resources to fully foster the emotional development and enrichment of their children’s lives.^11–13

Children of adolescent mothers are at greater risk of preterm birth, low birth weight, child abuse, neglect, poverty, and death.^14–17 They are more likely to have behavior disorders and difficulties in school, and to engage in substance abuse.^18,19 In 1996, the poverty rate among children born to teenage mothers was 42 percent, twice that of the overall rate in children.²⁰ The infant mortality rate (i.e., deaths in infants younger than one year per 1,000 live births) is higher in children of teenage mothers than in other children.²¹

All Americans are affected by adolescent pregnancy. The Annie E. Casey Foundation²² reports that more than 75 percent of teenage mothers receive public assistance within five years of delivering their first child. The societal cost of caring for these mothers and their children, including medical expenses, food and housing support, employment training, and foster care, is estimated at $7 billion per year.²⁰

Strategies for Prevention

Many prevention programs are designed to reduce the number of adolescent pregnancies and sexually transmitted diseases (STDs) in the United States. In general, these programs aim to improve the use of contraception and to modify the high-risk behaviors associated with teenage pregnancy and STDs.

YOUTH SOCIAL DEVELOPMENT

Youth social development programs target social and psychologic skills that are necessary to avoid high-risk behaviors such as early sexual activity. These programs operate on the premise that adolescents who delay sexual activity have high educational aspirations, peers with similar norms, and parent-child relationships characterized by supervision, support, and open communication.²³

The Seattle Social Development Project²⁴ is a program designed to increase students’ social skills and attachment to school and family. Eighteen elementary schools were assigned to receive intensive training or the usual education curriculum. In the intensive training arm, teachers and parents received annual training in proactive classroom management, problem-solving skills, child behavior management, and drug use prevention in adolescents. The intervention did not include sex education.

Follow-up of 93 percent of the 349 participants at 21 years showed that students in the intervention group had their first sexual experience later than students in the control group (16.3 years versus 15.8 years; P < .05), fewer lifetime sex partners (3.6 versus 4.1; P < .05), and fewer pregnancies (38 percent versus 56 percent; P < .05). These differences were greater in black and female participants.

In the Children’s Aid Society–Carrera Program,²⁵ 600 disadvantaged New York City adolescents 13 to 15 years of age were assigned randomly to a typical after-school program or one with a comprehensive youth development curriculum. Follow-up of 79 percent of participants at three years showed that the girls in the intervention group had lower odds of being sexually active (odds ratio [OR], 0.5; P < .05) and of having been pregnant (OR, 0.3; P < .05). Participation in the program had no impact on boys’ sexual and reproductive behavior.

The Teen Outreach Program (TOP),²⁶ another social development program, focuses on volunteer activities. In one evaluation of TOP, 695 high school students from diverse backgrounds were randomized by classroom to TOP or no intervention. Program participants had lower self-reported rates of teen pregnancy, school failure, course failure, and school suspension at one year. The program’s success might be a result of mentorship as well as increasing self-esteem through volunteerism.

ABSTINENCE-ONLY PROGRAMS

Abstinence-only programs teach that abstinence is the only certain way to avoid unmarried pregnancy, STDs, and associated health problems; they may not teach about, endorse, or promote contraception use.²⁷ Such programs became increasingly common after 1996, when Congress allocated $87.5 million per year for distribution to states providing abstinence-only education.

One of the largest and most rigorous studies of abstinence-only programs evaluated the Postponing Sexual Involvement (PSI) program in 31 California counties.²⁸ PSI is a five-session program taught by trained adults or teenagers. A total of 7,340 students with varied racial backgrounds were assigned randomly to intervention or control groups and were followed for up to 17 months. There was no significant difference in pre- and post-intervention self-reported scores on the initiation of sex, frequency of sex, number of sex partners, use of condoms and other birth-control methods, or reported pregnancy rates.

Studies of other abstinence-only programs also have failed to show significant improvement in self-reported rates of intercourse or pregnancy.²⁹ However, the evidence is inconclusive because most of the published studies have major design weaknesses (e.g., small sample size, no comparison group, nonrandom assignment, high attrition rate, inadequate follow-up). Results of larger, more rigorous studies are expected. Mathematica Policy Research, Inc., and the University of Pennsylvania are conducting an independent, federally funded review of Title V Abstinence Education Programs. These reviews have found that, in 700 programs nationwide, most participants report positive feelings about their program experience. Results showing the impact on teenage pregnancy rates are expected in 2005.

COMPREHENSIVE SEX-EDUCATION PROGRAMS

Comprehensive sex-education curricula present abstinence as the most effective method of preventing pregnancy and STDs but also discuss contraception as the appropriate strategy for persons who are sexually active. A review²⁹ of 28 well-designed experimental studies found that most comprehensive sex-education programs do not adversely affect the initiation or frequency of sexual activity, the number of sex partners, or the reported use of condoms and other contraceptive methods. In fact, many programs were shown to significantly improve these outcomes.

Successful programs vary in their approach. Program characteristics that are important in reducing risky sexual behaviors by teenagers are summarized in Table 1.²⁹

SEX AND CONTRACEPTIVE COUNSELING

Health care professionals can play a key role in improving contraception use and STD prevention. Success in this regard could have a profound impact on teenage pregnancy rates: the pregnancy rate is 85 percent among young couples who are sexually active for one year without using contraception, and 15 to 30 percent of sexually active teenagers do not use contraception.³⁰

The American Academy of Family Physicians (AAFP),³¹ the American Academy of Pediatrics (AAP),³² and the American Medical Association (AMA)³³ advise physicians to provide adolescents with guidance on sexuality and sexual decision making. Physicians are encouraged to engage all young people—boys and girls—in open, nonjudgmental, and confidential discussions during regular office visits. Counseling should include complete and medically accurate information on responsible sexual behavior. These proactive conversations should begin early and continue throughout a patient’s adolescence. A model for talking to teenagers about responsible sexual behavior is summarized in Table 2.³⁴

Family members are encouraged to be actively involved in sex education efforts, because an adolescent’s values and sense of sexual responsibility are influenced by family norms and expectations. However, to maintain confidential and open discussions, the AAFP and AAP recommend that physicians offer adolescent patients the opportunity to have their examination and counseling sessions separate from their parents and guardians, while still encouraging adolescents to involve their caregivers in health care decisions.^31,32

The Society for Adolescent Medicine³⁵ defines confidentiality as “an agreement between patient and provider that information discussed during or after the encounter will not be shared with other parties without the explicit permission of the patient.” That organization, along with the AAFP, AAP, and AMA,^31–33,35 recommends informing adolescents and their parents about the requirements and limits of confidentiality, because some patients may refuse to give accurate medical information without it. Each state has different laws about confidentiality and consent for adolescent health care, and physicians should be familiar with local regulations.³⁶

The AAFP, AAP, and AMA also advise physicians to stress abstinence as the only certain way to prevent pregnancy and STDs.^31–33 However, if an adolescent chooses to become sexually active, he or she must be counseled on appropriate contraceptive options, and condom use should be encouraged regardless of whether another contraceptive method is used.³⁷ Because condom failure that leads to pregnancy generally is due to improper and inconsistent use, and not defects or breakage,³⁸ providing adolescents with confidential access to condoms and education on consistent and proper use is a priority.

Many effective contraceptive methods are available (Table 3).^39–41 Discussing common misconceptions, side effects, and other benefits of contraceptives in simple, age-appropriate terms may improve adherence to a chosen contraceptive plan.⁴² A history, pregnancy test (if indicated), and blood pressure reading are adequate to begin hormonal contraception. The pelvic examination may be deferred until a later visit.⁴³ The American Cancer Society⁴⁴ now recommends that cervical cancer screening be delayed until three years after the onset of vaginal intercourse or no later than 21 years of age. The Centers for Disease Control and Prevention⁴⁵ recommends that all sexually active women 25 years of age and younger undergo annual screening for chlamydial infection.

Once the adolescent chooses a contraceptive and STD prevention plan, the AAP recommends intermittent screening for high-risk behaviors and STDs, and frequent monitoring of the patient’s satisfaction with and ability to adhere to the plan.³³ Contraception adherence should be discussed at each visit, emphasizing the plan for missed or delayed doses (if the patient is using hormonal contraceptives), and whether modifications to the plan are needed.

In addition to encouraging appropriate contraceptive use and STD prevention, the AAP advises physicians to educate all sexually active adolescents about the availability and use of emergency contraception.³³ Counseling should emphasize that emergency contraception is intended only for emergency use, is not as effective in preventing pregnancy as regularly used hormonal methods, and does not protect against the transmission of STDs. However, emergency contraception is safe and effective, and does not act as an abortifacient.⁴⁶ Advance supply of emergency contraception is associated with increased knowledge and use, without adversely affecting the use of routine contraception.⁴⁷ Various emergency contraception options are summarized in Table 4.⁴⁶

COUNSELING MALE ADOLESCENTS

Teenage boys typically experience first intercourse at a younger age and have more sex partners than teenage girls, yet they seek care for reproductive concerns less frequently.^48,49 Most adolescent health clinics and education programs target the health of girls, with fewer interventions aimed at boys. A 1993 survey of publicly funded family planning clinics indicated that only 6 percent of patients were male.⁵⁰ Adolescent boys desire information about STDs, contraception, pregnancy, and sexual health, but as few as 32 percent of sexually active boys receive this information from their health care providers.⁵⁰ Decreasing the incidence of teenage pregnancy will require focused attention on male adolescents, including establishing avenues for routine sexual health services and targeted educational programs.

Results from the National Survey of Adolescent Males in 1995 indicated that nearly 67 percent of teenage boys used condoms during their most recent act of intercourse. Overall, however, only 69 percent of teenage males used condoms consistently.⁴⁹ Knowledge about condoms and contraceptives does not appear to encourage initial or consistent use.⁵¹ For an adolescent boy, the primary motivating factors for condom use include not only pregnancy and STD prevention, but also partner desires, his perception of his ability to use condoms (“condom use self-efficacy”), and peer perceptions about condoms.⁵²

Guidelines

Several medical organizations endorse efforts to prevent teenage pregnancy and STDs. These guidelines are summarized in Table 5 and serve as a model for family physicians’ roles in teenage pregnancy and STD prevention.^31–33,37