||Counseling To Prevent Unintended Pregnancy
Guideline From The US Preventive Services Task Force
Periodic counseling about effective contraceptive
methods is recommended for all women and men at risk for unintended pregnancy
(see Clinical Intervention
should be based on information from a careful sexual history and should take
into account the individual preferences, abilities, and risks of each patient.
Sexually active patients should also receive information on measures to prevent
sexually transmitted diseases (see Chapter
Burden of Suffering
Approximately two thirds of all American women are at risk for
unintended pregnancy (i.e., they are sexually active but do not want to become
and a substantial proportion of all pregnancies
each year in the U.S. are unintended.
In a national
survey of over 8,000 women ages 15-44,
57% of all pregnancies were unintended, including those that were unwanted (i.e., in women who did not want more children) and those that
were mistimed (i.e., in women who did not
want children at that time).
The proportion of pregnancies that are unintended is high in women of all
ages: 42% of all pregnancies in women ages 30-34 and 77% in women ages
Births resulting from unintended and
unwanted pregnancies have gradually increased since 1982. Approximately 40%
of live births to women ages 15-44 were the result of unintended pregnancies,
including 12% due to unwanted pregnancies.
Unintended Teenage Pregnancies.
An increasing number of teenagers are at risk for unintended pregnancy.
a 1993 survey, 32% of 9th grade girls, 44% of 9th grade boys, and over two
thirds of all high school seniors reported having had sexual intercourse;
over half of seniors were sexually active within the previous 3 months.
Factors associated with early sexual activity include:
lower socioeconomic status; use of tobacco, alcohol, or other drugs; and single-parent
Approximately 20% of sexually active
teenage girls (age 15-19) become pregnant each year in the U.S., and
over 80% of teen pregnancies are unintended.
account for over 1 million pregnancies and over 500,000 births a year in the
Almost 40% of teenage births in 1992 were to
mothers age 17 or younger, including 12,000 births in girls under age 15.
Although pregnancy rates among sexually active teens declined
steadily from 1972 to 1986, pregnancy and birth rates have increased for the
entire teen population, due to increasing teenage sexual activity and declining
of teenage pregnancy and teenage birth (61 births/1,000 women ages 15-19
remain substantially higher in the U.S.
than in most Western countries.
Adverse Effects of Unintended Pregnancy.
A 1995 Institute of Medicine (IOM) report on unintended pregnancy summarized
the consequences of unintended pregnancy for both the parents and the child.
The most obvious adverse consequence of unintended pregnancies
is elective abortion. Roughly half of all unintended pregnancies end in abortion,
accounting for most of the 1.5 million abortions performed annually in the
rates have declined modestly over the past 15 years in the U.S.,
they remain higher in the U.S. than in most Western countries.
Separating the effects of unplanned births from other important social
and environmental factors (e.g., maternal health, education, and income) is
difficult. Adverse social and medical consequences are most consistently
observed for teenaged childbearing, most of which is attributable to unintended
pregnancy. Teenage mothers are less likely to get or stay married, less likely
to complete high school or college, and more likely to require public assistance
and live in poverty.
Infants born to teenage mothers,
especially mothers under age 15, are more likely to suffer from low birth
weight, neonatal mortality, and sudden infant death syndrome (SIDS),
and they may be at greater risk of child abuse, neglect,
and behavioral and educational problems at later ages.
Risk factors common in young mothers (poverty, single, parenthood, poor nutrition,
and inadequate prenatal care) may be more important than young maternal age
From 1985 to 1990, the public costs
of births to teenage mothers (Aid to Families with Dependent Children, Medicaid,
etc.) were estimated to be over $120 billion.
The adverse consequences of unintended pregnancy and childbirth are
not restricted to teenagers. Women who become pregnant unexpectedly forego
the opportunity to receive preconception counseling to improve the health
of the fetus.
Pregnancies after age 40 are often
unintended and are associated with increased risks to both mother and infant.
Women with unwanted pregnancies are less likely to receive adequate prenatal
care, more likely to smoke or drink, and more likely to have low birth weight
Some studies have suggested that developmental
problems are more frequent among unwanted children,
but other environmental factors are probably important; more than 40% of children
resulting from unintended pregnancies in the U.S. are born into single-parent
Efficacy of Risk Reduction
Complete sexual abstinence
is the only certain form of contraception. Without contraception, an estimated
85% of heterosexual couples who engage in regular intercourse will conceive
within 1 year.
Available methods to prevent conception
vary considerably in their effectiveness, convenience, reversibility, side
effects, and cost, and are reviewed in detail in a number of up-to-date references.
of contraceptive methods is usually expressed in two ways: the failure rate
under "perfect use" (annual pregnancy rates among persons who use the method
correctly on every occasion) and under "typical use" (average users in retrospective
surveys or clinical trials).
Because many methods are not used consistently and correctly by the average
couple, failure rates with typical use are often considerably higher than
with perfect use. Nearly half of all unintended pregnancies occur in women
who report using some form of contraception,
inconsistent or incorrect use of contraception is the major cause of such
contraception "failures." User knowledge, motivation and ability, cooperation
of their partner, the cost, comfort, and ease of use of a particular method,
and individual concerns about side effects or safety are all important determinants
of compliance with a chosen method of contraception.
hormones include oral contraceptives (combined estrogen/progestin preparations
and progestin-only pills), long-acting progestational agents that are injected
or implanted, and postcoital preparations.
Combination oral contraceptives (OCs) are the most popular
method of reversible contraception, used by an estimated 10 million American
women. The pill is generally taken daily for 21 days, followed by either
placebo or no pills for 7 days. The failure rate is about 3% per year with
typical use and as low as 0.1% per year when used correctly and consistently.
Noncompliance remains the major cause of OC failure, especially
in unmarried women. Failure rates calculated from a 1988 survey were 7%;
rates were higher among women who were young, unmarried, or poor.
Side effects of OCs, such as breakthrough bleeding, nausea, and breast
tenderness, decline over time and have been minimized in recent years by lowering
the dose of hormones.
Epidemiologic studies demonstrated
an association between early OCs and cardiovascular disease (myocardial infarction,
stroke, and thromboembolic disorders).
was most pronounced in heavy smokers and older women, and has been attributed
to thrombotic effects of higher doses of hormones in early formulations.
Any risks associated with current
OCs seem to be minimal.
In several studies conducted after 1985, OC use was associated
with an increased risk of occlusive stroke (an extremely rare event in young
but effects on the risk of myocardial infarction have not been consistent.
For most women (with the possible
exception of older smokers), potential risks of OCs are lower than the risks
of pregnancy and childbirth.
In one U.S. study of
newer OCs, there were no cardiovascular deaths in 55,000 patient-years of
Patient satisfaction is generally higher for
OCs (94%) than most other methods.
net effect of OC use on cancer risk appears to be negligible and may be favorable
(see Chapter 64).
The lifetime risk of breast cancer is similar in OC users and nonusers, but
some studies suggest a modest increase in early breast cancer among long-term
users or those beginning OC use at a young age.
The absolute increase in risk is small, may be due to factors
other than OCs (e.g., delayed childbearing), and may not apply to current
formulations. A modest increase in cervical cancer has also been reported,
but the significance of this association is also controversial.
In contrast, OC use is associated with a 40-50% reduction in the risk
of ovarian and endometrial cancer (see Chapter
64). Additional noncontraceptive benefits of OCs include lower
incidence of menstrual disorders, benign breast disease, uterine fibroids,
and clinical pelvic inflammatory disease (PID).
Extended follow-up (12-20 years) of several large
cohorts reported no effect of prolonged OC use on overall or cause-specific
The progestin-only pill ("mini-pill")
effective than combination OCs (failure rate 0.5-4%) and is more likely
to cause irregular menses.
It is a useful alternative for women who are breast-feeding or who have contraindications
to estrogen. Injectable progestins (depot-medroxyprogesterone
acetate [DMPA], i.e., Depo-Provera) and subdermal progestin
implants (i.e., Norplant) provide long-term contraception without
the need for daily compliance. DMPA is administered as intramuscular injections
given 4 times a year and has a failure rate of only 0.3%.
Subdermal implants can be inserted and removed as an office procedure and
provide effective contraception for up to 5 years. Cumulative 5-year pregnancy
rates in large case-series were 0.5-1.2%.
Satisfaction with subdermal implants seems high among selected
but it is not as
high as with OCs. Common side effects with progestin-only contraceptives
include irregular bleeding (up to 50-70%), headache, and weight gain;
cases of stroke and pseudotumor cerebri have been reported among users of
Norplant, but no causal association has been established.
Removal complications (e.g., broken or imbedded implants) occurred in 5%
of patients in 1985-1993.
reported no significant increase in breast cancer,
and a substantial reduction in endometrial cancer,
among women using DMPA. DMPA causes modest adverse effects on serum lipids,
but the long-term effects on cardiovascular disease are not known for any
of the progestin-only contraceptives.
administration of estrogen and progestin can reduce subsequent
pregnancy if initiated within 72 hours after unprotected intercourse.
The best-evaluated regimen consists of two doses of 100
micro-g ethinyl estradiol and 1 mg levonorgestrel (i.e., two 50 micro-g combination
OC pills), given 12 hours apart. Based on reported failure rates (0.2-7.4%),
it is estimated to reduce risk of pregnancy by 75%.
Prominent side effects include irregular bleeding, nausea
(up to 50%), and vomiting.
Alternate regimens using
danocrine (Danazol) have fewer side effects but have been less well studied.
In two recent trials in Great Britain, mifepristone (RU
486) was as effective as, and better tolerated than, estrogen/progestin regimens
for postcoital contraception.
RU 486 is under study in the U.S. but not yet available.
Surveys indicate that knowledge of and use of postcoital contraception remains
low among patients and clinicians.
contraceptive methods include the male and female condom and female barriers
used with spermicide. Barrier methods have fewer side effects than hormonal
contraception, but average effectiveness is more variable due to inconsistent
or incorrect use. When used reliably, latex condoms
have a 3% failure rate, compared to 12-16% among average users.
condom has failure rates comparable to other female barriers:
5% under perfect use and 20% under typical use.
Cost ($2.50) and unfamiliar appearance may be obstacles to regular use.
Latex condoms (and presumably female condoms) also provide
protection against human immunodeficiency virus (HIV) and other sexually transmitted
diseases (STDs) (see Chapter 62).
Condoms infrequently slip or rupture, but most failure is due to inconsistent
or improper use.
Other female barriers include the diaphragm,
cervical cap, vaginal sponge, and vaginal film. Diaphragms have a failure rate of about 6% when used consistently, and 18-22%
under average conditions.
Among reliable users, failure rates appear higher (10% vs. 3%) in women having
more frequent intercourse (>=3 times per week).
The cervical cap and contraceptive vaginal
sponge are as effective as the diaphragm in nulliparous women, but less effective
in parous women (failure rates 20-36%).
can be left in for longer periods than the diaphragm (24 hours). The only
American manufacturer of sponges discontinued production in 1995, however.
Spermicides (foams, creams,
jellies) used alone are estimated to have failure rates of 6% when used consistently
and 21-25% under typical usage conditions.
Both barrier methods and spermicides can reduce the risk
of infection with gonorrhea and chlamydia, but effects on HIV transmission
are uncertain (see Chapter 62).
Intrauterine devices (IUDs) can provide
very effective contraception (0.1-0.6% failure rate) for extended periods.
Two IUDs are currently available in the U.S.: a copper
IUD (Paragard), approved for continued use for up to 8 years, and a progesterone-releasing
IUD (Progestasert), which should be replaced annually; approval of a levonorgestrel
IUD, which can be left in place for 5 years, is pending in the U.S.
Despite adverse publicity in the 1980s that led to the withdrawal
of most IUDs from the U.S. market, these newer IUDs have been used widely
in other countries and have proven to be safe and reliable.
In a study of nearly 23,000 women, the risk of PID was increased only in
the first 20 days following IUD insertion, but thereafter remained low (1.6
cases/1,000 years of use);
risk was not increased
among monogamous women using IUDs. Between 2% and 10% of women will experience
expulsion of their IUD in the first year, and up to 15% may require removal
due to pain or bleeding. For many women, especially those at low risk of
STDs, IUDs offer excellent alternatives to OCs and other methods.
Coitus interruptus (withdrawal) and periodic abstinence may be more acceptable alternatives
with religious objections to artificial contraception
and others who are unwilling or unable to use other methods. It is often
difficult to perform these methods correctly. Abstinence during fertile periods
can be based on date of last menstrual period (calendar or "rhythm" method)
or changes in temperature or cervical mucus (ovulation method). The ovulation
method is more effective than the calendar method (1-3% vs. 9% failure
rate under perfect use)
but requires abstinence for about 17 days of each cycle.
Coitus interruptus can fail if
withdrawal is not timed properly or if preejaculatory fluid contains sperm.
Due to these difficulties, failure rates of withdrawal and periodic abstinence
are 18-20% annually in actual practice.
Effectiveness may be improved by combining these methods
with other contraception during the fertile period of the menstrual cycle.
Sterilization is the most common
method of contraception in the U.S.
and has no proven
It differs from other methods in
that it is intended to provide permanent contraception. The average failure
rate is 0.1-0.2% for male sterilization (vasectomy) and 0.4% for female
sterilization (tubal ligation).
Between 1% and 2%
of vasectomies are accompanied by transient side effects (hematoma, infection,
The complication rate from tubal
ligation depends on the type of procedure (e.g., mini-laparotomy, laparoscopy,
colpotomy) but is generally less than 1%.
2 years of the procedure, up to 3% of American women reported regret over
can be restored in up to 50% of men after reversal of vasectomy, and up to
70% of women after reversal of tubal ligation.
does not protect against sexually transmitted infections, but tubal ligation
is associated with lower risk of PID and ovarian cancer.
Many adolescents and adults could potentially benefit
from counseling about how to prevent unintended pregnancy. In a 1990 survey,
12% of sexually active women ages 15-44, and 22% of sexually active
teens, reported not practicing any form of contraception.
Contraception use at first premarital intercourse remains lower than at any
other stage in life: 29% of all teens and more than half of women under age
17 report using no contraception at first intercourse.
Many more persons use contraception but fail to use it consistently or correctly.
Nearly half of all unintended pregnancies occur in women using a contraceptive
method. Among teenagers, the most common reasons given by teenagers for not
using contraception at last intercourse were "Didn't expect to have sex" and
"Just didn't think pregnancy would occur."
study of college students fitted for a diaphragm, only 57% reported using
it with each coitus.
Information on the
effectiveness of counseling by primary care clinicians in altering sexual
practices or improving the use of contraception remains limited, however.
What evidence does exist comes primarily from studies of interventions delivered
in other settings (classrooms, school clinics, family planning clinics) or
targeted to AIDS-related behaviors rather than unintended pregnancy. The
1995 IOM report identified 23 pregnancy prevention programs that had been
adequately evaluated, most of which targeted high-risk adolescents.
These programs employed a variety of interventions: community-
and school-based education about sexuality, life skills, and contraception;
individual counseling through school or hospital clinics; and provision of
contraceptive services. Most evaluations were based on change in self-reported
sexual activity and contraceptive use rather than actual rates of unintended
pregnancy. There were several major conclusions of the IOM review: only
13 of 23 programs were even somewhat effective in changing behavior, and magnitude
of effect was often small; evidence of the effectiveness of abstinence-only
programs was inconclusive; education programs that provided information on
both abstinence and contraceptive use had generally favorable effects, without
promoting early sexual activity or frequency of intercourse; and only a few
programs included measures to ensure access to contraception.
One of the most effective programs combined a school curriculum with
contraceptive services through a school-linked clinic.
Another community-based program that included contraceptive services demonstrated
early success in preventing adolescent pregnancy,
but not in later years after contraceptive services were dropped.
Evaluations of other school-based clinics suggest no clear effect on teenage
but most pregnancies occurred before students had used the clinic or discussed
Kirby et al.
reviewed the effects of 23 school programs providing sex and HIV education
(including some reviewed in the IOM report). They noted isolated positive
effects of some programs on use of contraception at first intercourse, but
less effect on contraception use among sexually experienced teens. As in
the IOM report, they found no evidence that education about sexuality or instruction
about contraception led to earlier or more frequent sexual activity among
teenagers. All effective programs went well beyond simply providing factual
information about contraception and sexuality; most sought to reinforce specific
norms about sexual behavior and to develop skills to help teens resist sexual
A variety of HIV prevention programs have employed
individual or group counseling in a clinic setting (see Chapter
62). A number of these demonstrated an increase in condom use after
counseling men, but interventions emphasized STD prevention rather than contraception.
A randomized trial of reproductive health counseling of young men age 15-18
did not increase overall use of contraception or use of condoms.
Access to family planning clinics appears to help prevent unintended
adolescent pregnancy. Teenagers who attend family planning clinics were more
likely to use oral contraceptives and less likely to engage in unprotected
adolescents living in communities
with subsidized family planning services were less likely to become pregnant
in one analysis.
Clinic attenders are self-selected,
however, and many of the effects of counseling are short-lived. In one study,
less than one half of all adolescents attending a family planning clinic were
compliant with contraception after 1 year.
to improve compliance through family counseling, telephone follow-up, or contingency
planning have met with limited success.
There are obvious limitations in generalizing from such programs to
routine office counseling by clinicians. Furthermore, little is known about
interventions to improve contraception in nonadolescent women and men.
At the same time, the potential to improve counseling practices
in the primary care setting is apparent. A minority of primary care providers
-- from 18% of pediatricians to 53% of nurse practitioners -- routinely
ask their female patients about family planning needs.
Surveys document that many adolescents and adults are misinformed about the
risks of unintended pregnancy, the benefits and risks of particular contraceptive
methods, and the proper use of contraception.
about risks of contraception (especially OCs and IUDs) are important reasons
why women delay seeking contraceptive services, use contraceptives inconsistently,
or prematurely discontinue their use.
The effectiveness of counseling
depends on the age, maturity, sex, and experience of the patient, as well
as on the level of training and counseling skills of the provider.
Selection of an appropriate method of birth control must
take into consideration the personal preferences, religious beliefs, and abilities
of the patient, and the nature of their relationship with their partner(s).
As documented in the IOM report, physician training in family planning is
highly variable and often limited.
are reluctant to prescribe contraceptives for adolescents without parental
although most states explicitly or implicitly
permit minors to consent
to contraceptive services without parental approval.
Informing parents may discourage adolescents from seeking
needed assistance and conflict with the duty to protect the well-being of
the patient and the confidentiality of the doctor-patient relationship.
Concern that a physician will inform parents is commonly
cited by adolescents as a reason for choosing family planning clinics over
private physicians to obtain contraception.
estimated 5 million teenaged women at risk for unintended pregnancy in the
U.S., however, only 1.2 million receive services at publicly funded family
Recommendations of Other Groups
recommend counseling sexually active adolescents and adults about unintended
pregnancy. The American Academy of Family Physicians,
the AMA Guidelines for Adolescent Preventive Services (GAPS),
the American Academy of Pediatrics (AAP)
, the American
College of Obstetricians and Gynecologists (ACOG),
the Society for Adolescent Medicine,
Task Force on the Periodic Health Examination,
each recommends that clinicians counsel
all adolescents about preventing unintended pregnancy (including the role
of abstinence) and provide effective contraception for all sexually active
patients. These groups also encourage physicians to protect the confidentiality
of the doctor-adolescent relationship within the confines of local legal requirements
regarding parental consent. Healthy People 2000, a U.S. Public Health Service
report of national health objectives, endorses efforts to increase sexual
abstinence among adolescents and increase the proportion of primary care providers
offering age-appropriate family planing counseling.
Updated family planning information from the World Health Organization was
released in 1995.
Unintended pregnancy remains a critical problem
in the U.S. Although the consequences of unintended pregnancy are most pronounced
in young, unmarried women, the problem affects women and men throughout the
reproductive period of their lives. Multiple factors are involved in unintended
pregnancy, including personal and societal attitudes toward sex, contraception,
and pregnancy. Postponing early sexual activity among teens and increasing
the consistent use of effective contraception continue to be elusive goals
for parents, clinicians, and educators alike. Nonetheless, a variety of evidence
indicates that a combination of patient education and access to effective
contraception can reduce unintended pregnancy. Although their ability to
influence patient sexual behavior may be limited, clinicians can offer information
about contraceptive options and prescribe effective and appropriate contraception.
The public health benefits of better contraceptive practices would be enormous:
reducing the proportion of women not using contraception by half could prevent
as many as one third of all unintended pregnancies and 500,000 abortions per
There is no ideal contraceptive
method for all patients. The choice of an appropriate method must consider
each patient's motivation and ability to use a particular method, their individual
preferences (and partner's preferences), cost and safety factors, and their
relationship with their sexual partner(s). Women bear the largest burden
from unintended pregnancy, and methods under female control (hormonal contraception,
IUDs, and female barriers) appear to be used more regularly than those requiring
male cooperation (condoms, coitus interruptus, periodic abstinence). On the
other hand, female methods (with the possible exception of the female condom)
do not offer reliable protection against transmission of HIV or other STDs,
which are important threats to many individuals. The importance of measures
to reduce the risk of STDs (abstinence, maintaining monogamous relationships,
avoiding sex with high-risk persons, and using condoms consistently) need
to be emphasized along with the importance of effective contraception. Clinicians
need to remain alert to factors that may contribute to noncompliance (anxiety,
cost, discomfort, embarrassment, etc.).
The effectiveness of counseling
depends in part on the clinician's sensitivity to the personal concerns and
privacy of the patient. These issues are especially important when addressing
issues of sexuality with adolescents, who may have conflicted feelings about
sexuality or childbearing, limited information about fertility and contraception,
and unrealistic perceptions of the risks of unprotected sex. Clinicians can
encourage abstinence as the safest choice, provide support for individuals
choosing to postpone sexual activity, and prescribe effective contraceptive
methods for young persons who continue to be at risk. The low rate of contraception
at first intercourse indicates that discussion of sexuality and contraception
should begin before adolescents become sexually active.
Periodic counseling about effective contraceptive
methods is recommended for all women and men at risk for unintended pregnancy
("B" recommendation). Counseling should be based on information from a careful
history that includes direct questions about sexual activity, current and
past use of contraception, level of concern about pregnancy, and past history
of unintended pregnancies. Counseling should take into account the individual
preferences, concerns, abilities, and risks of each patient and his or her
partner, including risk of STDs (see Chapter
62). Counseling should include a discussion of the risk associated
with the patient's current contraceptive practice and, when indicated, available
alternatives for more effective contraception. Clinicians should inform adolescent
patients that abstinence is the most effective way to prevent unintended pregnancy
and STDs, although the effectiveness of abstinence counseling has not been
should be provided for the proper use of recommended contraceptive techniques.
Hormonal contraceptives, barrier methods used with spermicides, and IUDs
should be recommended as the most effective reversible means of preventing
pregnancy in sexually active persons. Sexual abstinence, the maintenance
of a mutually faithful monogamous sexual relationship, and consistent use
of condoms should be emphasized as important measures to reduce the risk of
STDs (see Chapter 62). Clinicians
should monitor satisfaction and compliance of patients with any chosen form
and a nonjudgmental, supportive attitude are especially important when discussing
issues of sexuality with adolescents. Clinicians should involve young pubertal
patients (and their parents, where appropriate) in early, open discussion
of sexual development and effective methods to prevent unintended pregnancy
and STDs. Clinicians should explore attitudes and expectations of adolescents
and other patients who are not currently involved in a sexual relationship
to anticipate future need for contraception, and inform them how to obtain
information and contraception if they plan to begin engaging in sexual intercourse.
Preferably, adolescents should be examined without their parent(s) present.
Clinicians providing birth control for minors should take into consideration
both the confidentiality of the doctor-patient relationship as well as local
legal restrictions when deciding whether to notify parents before prescribing
contraception. The optimal frequency of counseling to prevent unintended
pregnancy is unknown and is left to clinical discretion.
The draft update of this chapter was prepared for the U.S. Preventive
Services Task Force by David Atkins, MD, MPH, with contributions from materials
prepared by William Feldman, MD, FRCPC, Anne Martell, MA, CMC, and Jennifer
L. Dingle, MBA, for the Canadian Task Force on the Periodic Health Examination.
The sexual and reproductive behavior of American women, 1982-1988.Fam Plann Perspect 1990;22:206-214.
Committee on Unintended Pregnancy, Institute
The best intentions: unintended pregnancy and the well-being
of children and families. Brown SS, Eisenberg L, eds. Washington DC: National
Academy Press, 1995.
of unintended pregnancy and contraceptive use.Am J Obstet
Gynecol 1994;170(Suppl 2):1485-1489.
Unintended pregnancy and childbearing.In: Wilcox
LS, Marks JS, eds. From data to action: CDC's public health surveillance
for women, infants, and children. Washington, DC:U.S. Department of Health
and Human Services,1994:73-82.
Centers for Disease Control and Prevention.
Youth Risk Behavior Surveillance--
United States, 1993.MMWR 1995;44(SS-1):1-56.
Alan Guttmacher Institute.
and America's teenagers.New York: Alan Guttmacher Institute, 1994.
Ventura SJ, Taffel
SM, Mosher WD, et al.
Trends in pregnancies and pregnancy rates: estimates
for the United States, 1980-92. Monthly vital statistics report; vol
43 no 11 (suppl). Hyattsville, MD: National Center for Health Statistics,1995.
Ventura SJ, Martin JA, Taffel SM,
Advance report of final natality statistics, 1992. Monthly vital
statistics report; vol 43 no 5 (suppl). Hyattsville, MD: National Center
for Health Statistics,1994.
LM, Smith JC, Ramick M.
Abortion surveillance -- United States, 1991.In:
CDC Surveillance Summaries, May 1995.MMWR
SK, Van Vort J.
Abortion services in the United States, 1991 and 1992.Fam Plann Perspect 1994;26:100-106, 112.
Induced abortion: a world
review, 1990.Fam Plann Perspect 1990;22:76-89.
Furstenberg FF Jr, Brooks-Gunn
J, Morgan SP.
Adolescent mothers and their children in later life.Fam Plann Perspect 1987;19:142-51.
National Institute of Child Health and Human Development.
of a conference. Outcomes of early childbearing: an appraisal of recent evidence.Bethesda: National Institute of Child Health and Development, May 1992.
Center for Population
Teenage pregnancy and too-early childbearing: public costs, personal
consequences. 6th ed. Washington, DC: Center for Population Options,1992.
and social competence of children unwanted at birth: a follow-up study at
the age of 16.Acta Psychiatr Scand 1988;77:181-187.
Hatcher RA, Guest F, Stewart F,
Contraceptive technology. 16th rev ed.New
York: Irvington, 1994.
Speroff L, Darney P.
A clinical guide for contraception.Baltimore: Williams & Wilkins, 1992.
Jones EF, Forrest JD.
Contraceptive failure rates based on
the 1988 NSFG.Fam Plann Perspect 1992;24:12-19.
Baird DT, Glasier AF.
contraception.N Engl J Med 1993;328:1543-1549.
Stampfer MJ, Willett WC, Colditz
GA, et al.
Past use of oral contraceptives and cardiovascular disease:
a meta-analysis in the context of the Nurses' Health Study.Am J Obstet Gynecol 1990;163:285-291.
DaVanzo J, Parnell AM, Foege WH.
Health consequences of contraceptive
use and reproductive patterns. Summary of a report from the U.S. National
Research Council.JAMA 1991;265:2692-2696.
Vessey MP, Villard-Mackintosh
I, McPherson K, et al.
Mortality among oral contraceptive users: 20 years
follow up of women in a cohort study.BMJ 1989;299:1487-1491.
Colditz GA for the Nurses' Health
Study Research Group.
Oral contraceptive use and mortality during 12 years
of follow-up: the Nurses' Health Study.Ann Intern Med 1994;120:821-826.
Thorogood M, Mann J, Vessey M.
Fatal stroke and use of oral contraceptives:
findings from a case-control study.Am J Epidemiol
PC, Croft PR, Kay CR.
Oral contraception and stroke. Evidence from the
Royal College of General Practitioners' oral contraception study.Stroke 1994;25:935-942.
Oral contraception and risk of cerebral thromboembolic
attack: results of a case-control study.BMJ
L, Palmer JR, Lesko S, et al.
Oral contraceptive use and the risk of myocardial
infarction.Am J Epidemiol 1990;131:1009-1016.
Thorogood M, Mann J, Murphy M,
Is oral contraceptive use still associated with an increased risk
of fatal myocardial infarction? Report of a case-control study.Br J Obstet Gynaecol 1991;98:1245-1253.
Kost K, Forrest JD, Harlap S.
Comparing the health
risks and benefits of contraceptive choices.Fam Plann
Porter JB, Hershel J, Walker AM.
Mortality among oral contraceptive users.Obstet Gynecol 1987;70:29-32.
Forrest JD, Fordyce RR.
attitudes and use in 1992.Fam Plann Perspect
Net effect of oral contraceptive use on the risk of cancer in women
in the United States.Obstet Gynecol 1995;85:793-801.
Malone KE, Daling JR, Weiss NS.
contraceptives in relation to breast cancer.Epidemiol
Romieu I, Berlin JA, Colditz G.
Oral contraceptives and breast cancer:
review and meta-analysis.Cancer 1990;66:2253-2263.
Harlap S, Kost K, Forrest JD,
Preventing pregnancy, protecting health: a new look at birth control
choices in the United States.New York: Alan Guttmacher
The safety and efficacy issues of progestin-only oral contraceptives--
an epidemiologic perspective.Contraception
Xiao BL, Gu
SJ, Wang SL, et al.
Norplant and the levonorgestrel IUD in Chinese family
planning programs.Ann Med 1993;25:161-163.
Su-Juan G, Ming Kun D, Ling-De
Z, et al.
A 5-year evaluation of NORPLANT contraceptive implants in China.Obstet Gynecol 1994;83:673-678.
Polaneczky M, Slap G, Forke C, et al.
of levonorgestrel implants (Norplant) for contraception in adolescent mothers.N Engl J Med 1994;331:1201-1206.
Berenson AB, Wiemann CM.
and side effects with levonorgestrel implant (Norplant) use in adolescents
18 years or younger.Pediatrics 1993;92:257-260.
Wysowski DK, Green L.
adverse events in Norplant users reported to the Food and Drug Administration's
MedWatch spontaneous reporting system.Obstet Gynecol 1995;85:538-542.
Dunson TR, Amatya RN, Krueger SL.
Complications and risk factors associated
with the removal of Norplant implants.Obstet Gynecol 1995;85:543-548.
World Health Organization.
Depot-medroxyprogesterone acetate (DMPA) and
cancer: memorandum from a WHO meeting.Bull WHO
Long-acting injectable contraception with DMPA.Am J Obstet Gynecol 1994;170:1543-1549.
Trussell J, Stewart F, Hatcher RA.
contraceptive pills: a simple proposal to reduce unintended pregnancies.Fam Plann Perspect 1992;24:269-273.
Fasoli M, Parazzini F, Cecchetti G, et al.
contraception: an overview of published studies.Contraception 1989;39:459-468. [Erratum, Contraception 1989;39:699].
Webb A, Russell J, Elstein M.
of Yuzpe regimen, danazol, and mifepristone (RU 486) in postcoital contraception.BMJ 1992;305:927-931.
Glasier A, Thong KJ, Dewar M, et al.
Mifepristone (RU 486)
compared with high-dose estrogen and progestogen for emergency postcoital
contraception.N Engl J Med 1992;327:1041-1044.
The contraception report. Warren
Township, NJ: Emron, Inc., 1994.Vol V, no. 3,p. 14.
Farr G, Gabelnick H, Sturgen K, et al.
and acceptability of the female condom.Am J Public Health 1994;84:1960-1964.
Choice of contraceptives.Med Lett Drugs Ther
and therapeutic technology assessment. Intrauterine devices.JAMA 1989;261:2127-2130.
Farley TMM, Rosenberg MJ, Rowe PJ, et al.
Intrauterine devices and pelvic
inflammatory disease: an international perspective.Lancet 1992;339:785-788.
Notzer N, Levran D, Mashiach S, et al.
Effect of religiosity on sex attitudes,
experience and contraception among university students.J Sex Marital Ther 1984;10:57-62.
Trussell J, Grummer-Strawn L.
Contraceptive failure of the
ovulation method of periodic abstinence.Fam Plann Perspect 1990;22:65-75.
World Health Organization.
A prospective multicenter trial of the ovulation
method of natural family planning. IV. The outcome of pregnancy.Fertil Steril 1984;41:593-598.
Klaus H, Goebel JM, Muraski B, et al.
and client satisfaction in six centers teaching the Billings ovulation method.Contraception 1979;19:613-629.
Grubb G, Refoser H, Layde PM, et al.
decision to have a tubal sterilization.Fertil Steril 1985;44:248-253.
Wilcox LS, Chu SY, Peterson HB, et al.
Characteristics of women who considered
or obtained tubal reanastomosis: results from a prospective study of tubal
sterilization.Obstet Gynecol 1990;75:661-665.
Phillips AJ, D'Ablaing G.
salpingitis subsequent to tubal ligation.Obstet Gynecol 1986;67:55S-58S.
Hankinson SE, Hunter DJ, Colditz GA, et al.
Tubal ligation, hysterectomy,
and risk of ovarian cancer: a prospective study.JAMA 1993;270:2813-2818.
Contraceptive use in the United States, 1982-90. Advance
data from vital and health statistics; no. 260. Hyattsville, MD: National
Center for Health Statistics,1995.
Mosher WD, McNally JW.
Contraceptive use at first pre-marital intercourse:
United States, 1965-1988.Fam Plann Perspect
Waszak C, Ziegler J.
Six school-based clinics: their reproductive health
services and impact on sexual behavior.Fam Plann Perspect 1991;23:6-16.
A comparison of satisfaction with types of diaphragms among
women in a college population.J Obstet Gynecol Neonatal
Zabin LS, Hirsch MB, Smith EA, et al.
Evaluation of a pregnancy prevention
program for urban teenagers.Fam Plann Perspect
Clearie AR, Schluchter MD.
Reducing adolescent pregnancy through school
and community-based education.JAMA 1987;257:3382-3386.
Koo HP, Dunteman GH, George G,
Reducing adolescent pregnancy through a school- and community-based
intervention: Denmark, South Carolina, revisited.Fam
Plann Perspect 1994;26:206-211, 217.
Edwards L, Steinman M, Arnold K, et al.
services in high school clinics.Fam Plann Perspect
Kirby D, Resnick
MD, Downes B, et al.
The effects of school based health clinics in St.
Paul on school-wide birthrates.Fam Plann Perspect
Kirby D, Short
L, Collins J, et al.
School-based programs to reduce sexual risk behaviors:
a review of effectiveness.Public Health Rep
R, Marcy S, Plunkett A, et al.
Reproductive health counseling for young
men: what does it do>Fam Plann Perspect 1990;22:115-121.
Forrest JD, Hermalin A, Henshaw
The impact of family planning clinic programs on adolescent pregnancy.Fam Plann Perspect 1981;13:109-116.
Moore KA, Caldwell SB.
The effect of
government policies on out-of-wedlock sex and pregnancy.Fam Plann Perspect 1977;9:164-169.
Emans SJ, Grace E, Woods E, et al.
with the use of oral contraceptives.JAMA 1987;257:3377-3381.
Herceg-Baron R, Furstenberg FF
Jr, Shea J, et al.
Supporting teenagers' use of contraceptives: a comparison
of clinic services.Fam Plann Perspect 1986;18:61-66.
Namerow PB, Weatherby N, Williams-Kaye
The effectiveness of contingency-planning counseling.Fam Plann Perspect 1989;21:115-119.
National Center for Health Statistics.
Healthy People 2000
review, 1994. Hyattsville, MD: U.S. Public Health Service,1995.(Publication
The influence of client-provider relationships on teenage women's
subsequent use of contraception.Am J Public Health
physicians and the provision of contraceptives to adolescents.Fam Plann Perspect 1984;16:83-86.
Our daughter's decisions: the conflict in state
law on abortion and other issues.New York: Alan Guttmacher
on Education in Family Life, American College of Obstetricians and Gynecologists.
management of sexual crises in the minor female. Washington, DC: American
College of Obstetricians and Gynecologists,1982.
Chamie M, Eisman S, Forrest JD, et al.
adolescents' use of family planning clinics.Fam Plann
Smith JC, Franchino B, Henneberry JF.
Surveillance of family planning
services at Title X clinics and characteristics of women receiving these services,
1991.In: CDC surveillance summaries, May 5, 1995.MMWR 1995;44(SS-2):1-21.
American Academy of Family Physicians.
Age charts for periodic health
examination. Kansas City, MO: American Academy of Family Physicians, 1994.(Reprint
American Medical Association.
for adolescent preventive services (GAPS): recommendations and rationale.Chicago: American Medical Association, 1994.
American Academy of Pediatrics.
and adolescents.Pediatrics 1990;86:134-138.
American College of Obstetricians
The adolescent obstetric-gynecologic patient.Technical Bulletin no. 145. Washington, DC: American
College of Obstetricians and Gynecologists,1990.
Society for Adolescent Medicine.
Position papers on reproductive
health care for adolescents.J Adolesc Health Care
Task Force on the Periodic Health Examination.
Canadian guide to clinical
preventive health care.Ottawa: Canada Communication Group, 1994:540-547.
U.S. Department of Health and Human Services.
Healthy People 2000: national
health promotion and disease prevention objectives. Washington, DC: Public
Health Service,1991:185-205. (Publication no. PHS-91-50212.)
World Health Organization Special Programme
of Research, Development and Research Training in Human Reproduction.
technical report -- 1994.Geneva: WHO,
Fertility and family planning in the United States: insights from the
National Survey of Family Growth.Fam Plann Perspect
Bright Futures: guidelines for health supervision of infants, children,
and adolescents. Arlington VA: National Center for Education in Maternal and
[a] The 1988 National
Survey of Family Growth (NSFG) is the source of the most widely cited statistics
on unintended pregnancies and births. Data from the 1995 NSFG are scheduled
to be released in 1996.
[b][b] Some states permit minor consent
on the basis of age (age 14 or 16) or if referred by doctor, family planning
agency or school.
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