AAP Updates Adolescent Contraception Guidance
An adolescent-centered approach to contraceptive counseling for adolescents should be informed by evidence, with attention to sexual and reproductive health equity, according to a new policy statement from the American Academy of Pediatrics (AAP).
The policy statement and an accompanying clinical report were published online in Pediatrics .
The statement updates the previous policy statement issued in 2014. One of the notable changes is the adolescent-centered approach, which is a departure from counseling approaches based entirely on efficacy. Although the authors acknowledged the complex legal support for minors to consent to contraception or receive confidential care in the United States, which varies by state, the statement recommends 'a sexual and reproductive health equity-informed and adolescent-centered approach to counseling about contraception.'
The statement also recognized that adolescent-centered contraceptive counseling goes beyond pregnancy prevention. Sexually active adolescents are at risk for sexually transmitted infections (STIs), and the authors emphasized the importance of addressing adolescents' broader sexual health needs, including discussions of healthy relationships and interpersonal violence, human papillomavirus vaccination, STI screening, and use of contraception for STI prevention.
The goal of the recommended shared decision-making approach is to center adolescents' priorities about contraception and help them identify a contraceptive method that best aligns with their 'goals, preferences, and life circumstances,' the authors wrote. The pediatrician provides method-specific information and counseling to enable the adolescent to meet those goals, they noted.
For example, adolescents for whom pregnancy prevention is the most important goal could be prescribed highly effective long-acting reversible contraception, but for those for whom the use of no hormones or devices is a priority, a clinician could recommend a barrier method supported by pediatrician education and counseling to meet this goal.
'On a practical note, adolescents' buy-in is critical to contraceptive use, and a less-effective method that is consistently and correctly used may provide better pregnancy protection than a more effective method that is discontinued,' the authors wrote.
Sexual and reproductive health is an important component of both adolescent and adult well-being, but contraceptive use among adolescents remains low, said corresponding author Mary Ott, MD, in an interview with Medscape Medical News . 'By their final year of high school, about half of adolescents have had sex, yet only about half of those adolescents report condom use and a third report contraceptive use; consequently, adolescents experience unacceptably high rates of unintended pregnancies and other negative sexual health outcomes,' said Ott, a professor and adolescent medicine specialist at Icahn School of Medicine at Mount Sinai in New York City.
The updated statement provides the pediatrician with tools to improve adolescents' access to counseling and contraception in a pediatric primary care setting, Ott said.
Statement Shows Shift in Approach
Ott told Medscape Medical News that in the updated statement, '[t]he pediatrician is encouraged to approach the adolescent from a position of curiosity and empathy, assess the adolescent's reproductive health goals and preferences, attend to developmental and contextual factors, and to use a shared decision-making approach to contraceptive counseling.' For example, if an adolescent strongly wants to avoid pregnancy, the pediatrician might start with a discussion of long-acting reversible contraceptive methods, such as an implant or an IUD, but if the adolescent would like medical benefits such as improvement in acne or in heavy, painful periods, the pediatrician might recommend a combined estrogen-progestin method, she said.
Barriers of Time and Communication
'Time is always a barrier when counseling adolescents, and the AAP has information on time-based billing,' Ott said. Additionally, not all pediatricians are well versed in all contraception methods, but the AAP's suite of reports on contraceptive methods can help, as can the companion clinical report issued in conjunction with the new policy statement, she said.
'While parents and caregivers are often considered barriers to adolescent contraceptive access, the reality is much more nuanced,' Ott noted. Parents and caregivers are often their child's first and most important sex educators, and provide grounding in family and community values, but this is not true in all cases, said Ott. Some adolescents want to involve parents or other trusted adults in contraceptive decision-making, while others may not feel safe or comfortable doing so, she said. 'As a best practice, adolescents may choose to include parents, caregivers, or other trusted adults in healthcare visits involving contraception and sexual health, but [they] should always have the option to talk one on one with their pediatrician about their sexual and reproductive health needs and preferences,' Ott said.
'The AAP supports innovative approaches to expand contraceptive access, such as through pediatric primary care, virtual visits, pharmacies, and over-the-counter access,' said Ott. 'Same-day, low- or no-cost access to contraception has been shown to decrease adolescent pregnancies,' she added.
A Clinician's Take
The recommendation to shift to adolescent-centered care over efficiency alone for contraception was surprising, given the state of reimbursement and relative value unit-driven medical practices, said Margaret Thew, DNP, FNP-BC, a nurse practitioner and specialist in adolescent medicine at the Medical College of Wisconsin, Milwaukee, in an interview.
Adolescent care overall takes more time, and shared decision-making requires extensive education of the patient, said Thew. 'Another surprise is the promotion of telehealth and pharmacy prescribing for contraception; both are absolutely available and encouraged, but provider bias and reimbursement concerns result in barriers to offering care,' she said. 'In my experience, pediatricians do not feel confident to prescribe contraception and refer to adolescent medicine or a gynecologist, which delays access,' she added.
Persistent barriers to offering contraception to adolescents include the politics within states that are driving fragmented reproductive care, Thew told Medscape Medical News .
Other barriers to offering adolescent-centered counseling include lack of time, potential provider bias, lack of understanding on the part of providers of the confidential care for adolescents available within their states, and fears of upsetting parents, Thew said.
Additional research is needed to understand more completely how the impact of potential bias, provider confidence, and barriers to access affect prescribing contraception, and the resulting impact on adolescent access to contraception, Thew noted.
However, 'the implications of providers prioritizing and respecting reproductive autonomy to adolescents will improve access and remove barriers to contraceptive care,' Thew said. 'There are both public health and societal implications with offering adolescent-centered counseling on contraception, including reducing unintended pregnancies and abortion, but also empowering women and transgender and gender diverse persons with access to contraception, leading to improved socioeconomic outcomes,' she said.
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