National Partnership for Women & Families

Monthly Women's Health Research Review

Study reviews sexual, contraceptive behaviors among adolescents seeking EC

Summary of: "Sexual and contraceptive behaviors among adolescents requesting emergency contraception," Cwiak et al., Journal of Pediatric and Adolescent Gynecology, June 8, 2016.

Despite a decline in the adolescent pregnancy rate between 2000 and 2010, 82 percent of pregnancies among women ages 15 to 19 are unintended, according to Carrie Cwiak, of the Division of Family Planning at the Department of Gynecology and Obstetrics at the Emory University School of Medicine, and colleagues. Further, the researchers noted that older teenagers, between ages 18 and 19, account for most of the decline in the adolescent pregnancy rate, meaning that "younger adolescents are still at significant risk."

Citing data showing "[t]he proportion of pregnancies that are unintended is higher in younger age groups and progressively decreases as age and contraceptive use increases," the researchers "hypothesized that the high rate of unprotected sex plays a particularly important role among adolescents, and likely more so" among younger than older adolescents. For the study, Cwiak and colleagues analyzed research on single-tablet levonorgestrel 1.5 mg emergency contraception (EC) "to evaluate the correlations between age and baseline sexual and contraceptive behaviors to better define the population of adolescents who request and use EC."

Methodology

For the analysis, the researchers examined "a multicenter, non-comparative study that simulated [over-the-counter (OTC)] conditions for EC use for adolescent females presenting to teen reproductive health clinics requesting EC." The study included women who were ages 11 to 17, had not previously participated in a study of levonorgestrel 1.5 mg EC, had requested EC for themselves for current use, understood and were literate in English, and were willing to complete follow-up procedures in line with study protocol. Study participants were asked to respond to a questionnaire that asked, "'Why did you come to the clinic today to get EC?'" The responses were sorted by reason. Reasons included: unprotected sex, "condom problems," "forgetting or otherwise incorrectly using ongoing method of contraception," or concern about a potential pregnancy for unspecified reasons.

Participants completed a baseline questionnaire that inquired about age at menarche, time since first sex (coitarche), pregnancy history, including current pregnancy status, previous contraceptive use, and previous EC use.

Findings

According to the researchers, the analysis of the OTC EC simulation study included a final sample of 343 participants. The participants were ethnically and racially diverse, and had a mean age of 15.7.

The researchers found that "the most commonly reported contraceptive methods ever used, in descending order," were: condoms, oral contraception, no method and withdrawal. When categorized by age group, the researchers found that 13- and 14-year-olds most commonly reported no contraceptive use, while the other age groups -- 15-, 16- and 17-year-olds -- most commonly reported using condoms. The researchers wrote that the percentage of teenagers who reported never having used contraception before requesting EC decreased with age, declining from 53 percent of 13- and 14-year-olds to 15 percent of 17-year-olds. They added, "For condoms, oral contraceptives, and withdrawal, ever-use of each method tended to increase with age." Overall, less than 1 percent of participants had used long-acting reversible contraception.

The researchers noted that 38 percent of participants reported first sex within the year prior to study enrollment, 49 percent reported first sex within the last one to two years before enrollment and 13 percent reported first sex more than two years before enrollment. According to the researchers, the four "most commonly reported contraceptive methods ever used were: condoms, oral contraceptives, no method, and withdrawal, regardless of years since coitarche; however, the frequency of use of those methods differed by years since coitarche." The researchers wrote that "[t]he percentage of participants who had never used contraception decreased as years since first sexual intercourse" increased, while ever-use of condoms, oral contraception and withdrawal "increased as years since first sexual intercourse increased."

The researchers also "evaluated first-time use of EC by age and reproductive characteristics." They found that 61 percent of participants reported using EC for the first time. The average age of first-time users was 15.4, while the average age of repeat users was 16. The researchers noted that while repeat users were more likely than first-time users to report previous pregnancy or abortion, "the proportion of first-time EC users who had ever given birth was similar to the repeat EC users." According to the researchers, first-time users "were more likely to report no previous contraceptive use compared with repeat EC users," while repeat users were more likely than first-time users "to report ever-use of [most contraceptive methods]."

Looking at participants' reported reasons for requesting EC, the researchers found that 50 percent of participants reported not having used contraception, making unprotected sex "the most common reason across all age groups." According to the researchers, 17 to 27 percent of 14-to-17-year-olds listed an issue with condom use as a reason for requesting EC. The researchers noted that only 2.3 percent of respondents reported missed oral contraception as a reason.

Discussion

The analysis found that "adolescents who presented requesting EC most commonly reported ever-use of contraceptive methods that rely heavily on user adherence (condoms, oral contraceptives, or withdrawal) or no method at all," the researchers wrote. According to the researchers, these findings align with national trends, as do the findings that "the youngest age group (13- and 14-year-olds) were the least likely to have ever used any contraceptive method."

The researchers added, "Although contraceptive use did increase with age in our study, the methods most commonly used remained those that require coitally-related or daily use." Similarly, they noted that while "contraceptive use overall as well as experience with a greater variety of methods increased with years since coitarche," teenagers "consistently report use of methods that rely heavily on user adherence" regardless of how long it has been since first sex.

According to the researchers, 29 percent of the study sample reported no prior use of contraception. However, they noted that 50 percent of participants cited "'no [contraceptive] method' as their reason for requesting EC." In turn, the researchers suggested, "Rather than focus on EC as a stand-alone contraceptive option, these findings support current recommendations that adolescents requesting EC also receive information on highly effective, long-term methods … that facilitate sustained use."

The researchers also noted that prior "EC use was more likely among adolescents who had previously experienced a pregnancy or used contraception," which suggests that "education about or access to EC is inadequate outside of reproductive healthcare settings (i.e. not until pregnancy- or contraceptive-related care is accessed)." They wrote, "Increasing education and decreasing barriers to EC in non-reproductive healthcare settings is key for adolescents who do not seek care in reproductive healthcare settings."

Regarding strengths of the original study, the researchers noted that it "surveyed adolescents before they spoke to any healthcare provider," which meant that answers "may more accurately represent the sexual and contraceptive behaviors of adolescents who have not yet heard educational messages from providers about protecting themselves from unintended pregnancy and sexually transmitted infections."

However, the researchers wrote that because the study involved women who were requesting EC at a clinic, "the most vulnerable population of adolescents who either have not heard of EC or do not access primary healthcare has not yet been investigated," which "limits the generalizability of [the study's] findings to adolescents who are familiar with EC and know how to access healthcare." The researchers also noted that there has been an uptick in LARC use among adolescents since the study was completed, so the trends in the study "may differ from those of contemporary adolescent populations."

The researchers concluded that that the findings "confirm a significant lack of effective contraceptive use among adolescents who request EC, especially those at a younger age." The researchers recommended "increasing educational interventions for EC in all healthcare settings that adolescents utilize, such as pediatric practices and emergency departments, [to] increase awareness of EC among all adolescents." They also noted that "the provision of EC should be used as an opportunity to provide adolescents with a bridge to highly effective, long-term contraceptive methods that would more effectively address the ongoing risk of unintended pregnancy in adolescent patients."