CTF Structured Abstract: Prevention of Unintended Pregnancy and STDs

Canadian Task Force on Preventive Health Care

Structured Abstract

Prevention of Unintended Pregnancy and Sexually Transmitted Diseases in Adolescents

Prepared by William Feldman, MD, FRCPC, Department of Pediatrics, University of Toronto, Anne Martell, MA, CMC, Martell Consulting Services Ltd., Halifax, NS, and Jennifer L. Dingle, MBA, Canadian Task Force Coordinator (1989-1994)

These recommendations were finalized by the Task Force in October 1993

Objective
Burden of Suffering
Options
Outcomes

Evidence
Values
Benefits, Harms, and Costs
Recommendations

Validation
Sponsors
Selected References

Objective

To make recommendations about the prevention of unintended pregnancy and sexually transmitted diseases (STDs) among adolescents in Canada.

Burden of Suffering

In 1989, there were 39,600 teenage pregnancies in Canada. The teenage pregnancy rate for Canada (pregnancies per 1,000 women aged 15-19) was 44.1, down from 53.4 in 1975. In 1985, there were 37 versus 95 pregnancies per 1,000 Canadian and American girls (age 15-19 years), respectively.

The Risk/Effects of Teenage Pregnancy
The most serious physical risk to the teenage parent is death from pregnancy complications. For girls under 15 years the complication rate is 60% higher than the rate for all women and 2.5 times higher than the rate for mothers 20 to 24 years old. However, the increased risk of maternal complications may be associated more with socioeconomic factors than with age. Compared to those who do not bear children early, teen mothers can expect to complete less education, to attain lower levels of work success and long-term income, and feel less satisfied with their vocational achievements. Infants born to mothers less than 15 years of age are twice as likely as other infants to weigh less than 2,500 g (5 lb, 8 oz), a factor associated with increased infant mortality. Infants born to mothers less than 17 years of age are three times more likely to die in the first 28 days of life.

Sexually Transmitted Diseases
38,074 cases of genital chlamydia, 9,451 cases of gonococcal infection and 1,196 cases of syphilis were reported in Canada in 1992. Given the prevalence of STDs in the adolescent population, the spread of HIV is particularly worrisome to health care providers. As of January 1, 1992, 22 cases of AIDS were reported in Canadians aged 15-19 years (<1% of all cases; 8 were reported in the 10-14 year age-group) and 1,092 cases (20%) were reported for those aged 20-29 years.

Options

Main options considered were physician identification of adolescents at high-risk and counselling about contraception . Contraceptive methods included oral contraceptives (OCs), intrauterine devices, barrier methods and spermicides (e.g., condom, foam, diaphragm, cream, cervical cap, contraceptive sponge), subdermal implants (e.g., progestin implant), morning-after pill and periodic abstinence.

Outcomes

Pregnancy rates, birth rates, STD infection rates; knowledge, attitudes, behaviours (e.g., acquisition or use of various contraceptive methods, initiation/frequency of sexual activity, contraceptive continuation); service utilization (e.g., clinic attendance, prenatal visits); costs and adverse effects of various contraceptive methods.

Evidence

MEDLINE was searched for the years 1988 to November 1993 using the keywords 'pregnancy, unwanted', adolescent, contraception, inject, contraceptive agents, contraceptive devices, human, contraception behaviour, and sex counselling.

Recommendations were graded as:

A Good evidence to support the recommendation that the condition be specifically considered in a PHE.

B Fair evidence to support the recommendation that the condition be specifically considered in a PHE.

C Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.

D Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

E Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

Quality of evidence was rated according to 5 levels:

I Evidence from at least 1 properly randomized controlled trial (RCT).

II-1 Evidence from well-designed controlled trials without randomization.

II-2 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.

II-3 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.

III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Values

The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from January 1993 to October 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs

Results of comparisons of time and place indicate that appropriate, compliant use of contraceptives can decrease the incidence of adolescent pregnancy. Advantages, disadvantages (e.g., effectiveness, adverse effects, protection against STDs, availability, ease of use) and costs of various contraceptive methods are presented in table format. Accidental pregnancy percentages were calculated for typical couples who initiate and continue the use of a particular method and experience a pregnancy during the first year of use. Lowest percentages were for implants (0.03%, 0.04%), injectable progestogen (0.3%, 0.4%) and highest were for spermicides (21%), periodic abstinence (20%) and the sponge in parous women (28%). Percentage for oral contraceptives was 3% and for condoms was 12%.

No studies evaluate whether physician identification and counselling leads to changes in knowledge and behaviour. Results of comparisons of time and place suggest that interventions to improve compliance with birth control are somewhat effective. An RCT involving 75 sexually active women in a clinic setting found that education programs increased knowledge of AIDS but made no difference in attitudes and condom acquisition. Other behaviours were not measured. The results of 8 effective community-based and school-based programs are summarized in a table. Two studies of school-based programs involving a non-middle class, non-college bound population suggest that adolescent birth rates can be reduced by >50% without substantial increases in abortion rates.

The advantages, disadvantages and costs associated with various contraceptive methods were presented in a table.

Recommendations

Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

There is fair evidence to include counselling about the correct use of oral contraceptives and condoms in the PHE of sexually active adolescents [B, II-3].

Validation

This report was externally peer-reviewed. The 1989 U.S. Preventive Services Task Force recommended that physicians obtain a detailed sexual history and discuss sexual development and contraceptive methods with prepubertal adolescents. Recommended contraceptive methods were complete abstinence, OCs and barrier methods (with spermicides). Patients who have multiple partners, or those who may have a STD should be instructed in the proper use of condoms. The American Ad Hoc Committee on Reproductive Health (sub-committee of Society for Adolescent Medicine) and the Committee on Adolescence of Council of Child and Adolescent Health recommend physician training for adolescent pregnancy counselling.

Selected References

Source Document

Feldman W, Martell A and Dingle JL. Prevention of unintended pregnancy and sexually transmitted diseases in adolescents. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 540-57.

Link to Full Text of this review

Link to Summary Table of Recommendations of this review

Link to Selected References list of this review

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A	Good evidence to support the recommendation that the condition be specifically considered in a PHE.
B	Fair evidence to support the recommendation that the condition be specifically considered in a PHE.
C	Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.
D	Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.
E	Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

I	Evidence from at least 1 properly randomized controlled trial (RCT).
II-1	Evidence from well-designed controlled trials without randomization.
II-2	Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.
II-3	Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.
III	Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.