Canadian Task Force on Preventive Health Care

Full Text Review

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

UpContents

UpOverview

In 1987 the Canadian Task Force on the Periodic Health Examination recommended that physicians who see adolescents should advise those who are sexually active about the correct use of appropriate contraception (B Recommendation). Review of more recent evidence has not altered this recommendation, however oral contraceptives have been identified as the method of choice for adolescents in combination with a condom to protect against sexually transmitted diseases (STDs). Evidence from school-based clinics and community-based programs aimed at the reduction of adolescent pregnancy and STDs has also been evaluated, and supports the preventability of unintended teen pregnancy.

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.

Teenage pregnancy levels are much lower in Canada than in the United States. In 1985, there were 37 pregnancies per 1,000 Canadian females aged 15-19 compared with 95 pregnancies per 1,000 females of the same age in the United States. In 1985, the fertility rate for Canadian teenagers (23 births per 1,000) was less than half that of the U.S. teenagers (52 per 1,000). The proportion of teenagers accepting abortion is comparable (38% in Canada and 44% in the U.S.) so that in 1985, the abortion rate for Canadian teenagers was 14 per 1,000, about one third of the U.S. rate (42 per 1,000).

The Risks/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.

Teen mothers can expect to complete less education than those who do not bear children early. Teen mothers also reach lower levels of work success and of long-term income, and feel less satisfied with their vocational achievements. Satisfaction with career progress is also lower for married teenagers with children compared to married teenagers without children.

Adolescent mothers who marry subsequent to their child’s birth are more likely than other adolescent couples to divorce or separate. Most teenage families with children are single-parent families.

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. 6.7% of live births in Canada during 1990 to women aged <20 years were of infants weighing <2,500 g, compared to 5.5% low birth weight babies born to mothers of all ages. Infants born to mothers less than 17 years of age are three times more likely to die in the first 28 days of life. However, cigarette smoking, poor gestational nutrition, low pre-pregnancy weight, primiparity and short stature are probably more important risk factors than maternal age.

Thus, adolescent pregnancy and childbearing may carry increased medical risk for mother and baby as well as lasting social, academic and economic disadvantages for mother, father and children. Except for academic and economic disadvantage, the evidence is weakened by lack of control for confounding variables.

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. Chapter 58 on HIV provides more extensive discussion of risk groups; there are several other related Chapters on STD prevention/screening.

Maneuver

Counselling for Contraception

All physicians who see adolescents should assess whether those who are sexually active are practising appropriate contraception. Although some physicians may be uncomfortable discussing these matters with young people, the third-person approach may be useful (e.g., "Some people your age are dating, some are having sexual intercourse. How about you?".)

Durant and colleagues<1> developed a model that can be used clinically to anticipate and recognize the multiple inter-relationships between factors that usually influence adolescent contraceptive behaviour. However, findings from empiric tests of the model indicate that among low socioeconomic black female adolescents, only a small part of the variation in frequency of intercourse or of engaging in unprotected coitus was explained. Clinical attempts to identify adolescent patients at risk of pregnancy using only one or two criteria will probably be unsuccessful. Thus, all adolescents should receive counselling.

Teenage Use of Contraception and Compliance

Of all age groups, teens are the least likely to practice contraception. As one study noted "...the most notable feature of adolescent contraceptive behaviour is inconsistency." Although adolescents are thought not to visit a physician very often, a random sample of 1,000 teenagers in Ottawa (response rate 73%) revealed that 85% had seen their physician in the preceding year but only one-third of sexually active girls had ever discussed contraception with their physicians.

To eliminate the risk of pregnancy, an adolescent should understand that the only absolute method of contraception is abstinence. When this is not the adolescent’s choice, however, appropriate contraceptive options should be offered.

Studies have shown that adolescent compliance is determined in part by the relationship established with health care providers. Accessible clinic hours, positive attitudes in the reception area, time spent waiting for the physician, care taken with the examination and assurances of confidentiality are all factors associated with adolescents’ compliance. A further consideration may be financial as many adolescents have limited financial resources. Additionally, physicians should be open to some female adolescents’ preference for a female examiner. Table 1 identifies actions a physician can take towards ensuring compliance. The effectiveness of these steps in ensuring compliance has not been systematically evaluated.

Contraceptive Options

Table 2 summarizes the available adolescent contraceptive methods with their advantages and disadvantages.<2> Table 3 provides additional information on estimates of contraceptive failure by type of contraception method over its first year of use.<3>

Oral Contraception

The oral contraceptive pill is highly effective in preventing pregnancy using reversible means. It has been reported to be the overwhelming favourite prescription method of contraception for adolescents (84% vs. 4% for IUD and 11% for diaphragm).<4> Additional advantages include its relative low cost and ease of use.

At the same time, however, clinicians are concerned that by relying solely on an oral contraceptive (OC), adolescents are leaving themselves open to STDs and particularly to HIV/AIDS. Experts recommend that adolescents who are sexually active should be advised to use condoms in combination with oral contraceptives.<5> This combination has not been evaluated.

Case-control studies have shown that OC’s reduce the risk for endometrial cancer,<6> epithelial ovarian cancer,<2,7> pelvic inflammatory disease,<8> toxic shock syndrome<9> and ectopic pregnancy.<10> The potential association between OCs and cervical neoplasia is unsettled.<2> There is also some concern regarding a possible association between breast cancer and the use of OCs. However, many of the case-control studies evaluated in meta-analysis< 11,12> were of low quality, without protection from bias or from the potentially confounding effects of duration of lactation, induced abortion, recent pregnancy or a history of diseases that are associated both with reduced use of OCs and reduced risk of breast cancer. One study<13> suggested that prognosis for breast cancer is worse for those who start oral contraceptives at an earlier age. Further evaluation is required.

While most epidemiologic studies have shown an association between oral contraceptive use and an increased risk of venous thrombosis and embolism, the risk for teenagers is very small. Finally, OCs can improve the quality of life by conferring protection against a number of common ailments that affect teenagers: primary dysmenorrhea, benign breast disease, ovarian cysts and iron deficiency anemia.

Expert opinion supports the use of OCs by teenagers as a safe method to avoid unwanted pregnancy since the overall risks of taking OCs are much less than the risks of pregnancy. Low-dose OCs have not been linked with either heart attack or stroke in contemporary U.S. studies and the evidence regarding breast cancer is contradictory. While the overall risk of thromboembolism in oral contraceptive users may be increased over that of the general population, the risk to teenagers, especially those who do not smoke, is minimal. As with all medical choices, the benefits of a treatment must be weighed against potential risks.

Benefits/Risks of Intrauterine Device (IUD)

While compliance is assured with intrauterine devices and effectiveness is comparable to that of OCs, they provide no protection from sexually transmitted diseases and the risk of adverse affects associated with IUDs appears to be higher for adolescents. Expert opinion supports their use mainly for older women in stable monogamous relationships.<14>

Barrier Methods and Spermicides

In their recent review,<15> Rosenberg and Gollub reported that observational studies show that condoms offer widely divergent degrees of protection against sexually transmitted diseases. Meta-analysis shows that for most outcomes, condoms decrease infection rates by approximately 50%. While protection seems to increase with more consistent use, condoms may not protect against organisms transmitted by external genital contact. The rate of condom use among 15-19-year old males in the United States was 58% in 1988, more than double the rate reported in 1979 (21%); 20% of sexually experienced females reported currently using condoms (47% at first intercourse), compared with 11% in 1982. Condoms are widely available but are less effective in preventing pregnancy than IUDs or OCs.

Foams, diaphragms and creams are unpopular with adolescents in North America.<2,16> Each of these options interferes with spontaneity, requires the adolescent to plan ahead, requires motivation and familiarity with technique, and is "messy". Diaphragms and cervical caps, which are assumed to be used in conjunction with spermicide, leave a portion of the vagina unprotected; observational studies indicate a reduction in sexually transmitted diseases of 50-100%.<15>

Long-Acting Contraceptives

The impact of new long-acting contraceptives such as the progestin implant (Norplantâ) on the reduction of adolescent pregnancy is currently unknown and will likely depend on the cost and availability of the method and on teens’ acceptance of these methods (including insertion discomfort and tolerance of menstrual irregularity). One observational study suggests Norplant is well accepted by adolescents.<17> Compliance is assured and effectiveness is high, but the methods again offer no protection from STDs.

Implant systems (for men) are under investigation as are vaginal rings releasing levonorgestrel and injectable hormone contraceptives. Birth control "vaccines" are also being developed, the most advanced being a vaccine inducing antibodies against human chorionic gonadotrophin (HCG).

The Morning-After Pill

Postcoital contraception (PCC) (the morning-after pill/ Ethinyl estradiol/dl-norgestrel in combination) has been shown to prevent pregnancy for most women when given after sexual intercourse. Termination of the pregnancy was not achieved for 1.1-2.0% of women treated, resulting in 15-30% of the expected number of pregnancies.<18-21> Side-effects include nausea (50%) and vomiting (20%). Women who rely on barriers, spermicide, withdrawal or periodic abstinence should be informed about the "morning-after pill".

Effectiveness of Prevention and Treatment

The Primary Care Physician

There have been no studies evaluating whether physicians identifying sexually active teenagers and counselling them on contraception will lead to more appropriate knowledge and behaviour. Most studies have evaluated interventions provided by non-physicians. However, the success of these interventions demonstrates that unintended pregnancy is preventable. There is no indication that physicians would be less successful.

A randomized controlled trial of 75 sexually active females in a clinic setting also showed that education programs increased knowledge of AIDS (p<0.001).<22> No significant differences were noted regarding attitudes or condom acquisition and other changes in behaviour were not addressed. School-based AIDS-prevention curricula have had modest effects.

Community-based Programs

A recent report documented a successful community-based program to reduce adolescent pregnancy in counties of South Carolina characterized as rural, low income and undereducated. Their public health approach involved teenagers, parents, community leaders, ministers, schools, churches, and community groups. School sex education, use of mass media and training of adult leaders in the community were all included. The estimated pregnancy rate declined 35%, compared with pre-intervention levels (95% confidence interval (CI): -14% to -57%). Comparison communities (no intervention) had 5-16% increases in the rate of teenage pregnancy (p<0.002). While the counties were comparable in terms of racial/ethnic composition, population density, income, and education, the comparison communities initially had lower estimated pregnancy rates (35-53% versus 61% in the target community).<23>

School-Based Programs

Most of the evidence regarding school-based programs (SBPs) comes from the United States. Most SBPs report a rate of use exceeding 75% of the school population once teens become aware of available services. An evaluation of the Baltimore SBPs’ attendance suggests that their accessibility rather than any new or newly packaged information about sex, family planning or other new services was responsible for high student use.<24> St. Paul, Minnesota<25> and western Massachusetts<26> studies have shown that birth rates for teenagers can be reduced by more than 50% without major reliance on abortion, in a population which is not upper middle class, not college bound, and which has traditionally been viewed as very hard to reach.

Table 4 summarizes a number of examples of effective community-based and school-based programs operating in the United States.<23-29> This is grade II-3 evidence that comprehensive school-based efforts to lower the rates of teenage pregnancy can be effective.

Sex Education in the Schools

Education programs and computer games are effective in providing at least short-term knowledge and attitudinal change in adolescents but school sex education by itself appears to have little or no effect on adolescent sexual activity or pregnancy rates. However, a study of 536 low-income minority students in Atlanta showed that those who participated in a family planning outreach program for eighth graders led by older students, were less likely (p<0.01) to report initiation of sexual activity by the end of the 9th grade (24% versus 39% of students had not had sexual intercourse).<28>

Recommendations of Others

In 1989, the U.S. Preventive Services Task Force<30> recommended that clinicians should obtain a detailed sexual history from all adolescent patients. Empathy, confidentiality and a nonjudgemental supportive attitude were stressed. It was recommended that clinicians involve young pubertal patients and, where appropriate, their parents in early, open discussion of sexual development and effective methods to prevent unintended pregnancy and sexually transmitted diseases, and that sexually abstinent adolescents be encouraged to remain abstinent. Oral contraceptives and barrier methods (with spermicide) were recommended as the most effective means of reducing risk in sexually active persons, and complete sexual abstinence as the most effective method overall. The U.S. Task Force stated that sexual abstinence and the maintenance of a mutually faithful monogamous sexual relationship should be emphasized as two important measures to reduce the risk of sexually transmitted diseases. Patients who engage in sexual activity with multiple partners or with persons who may be infected with sexually transmitted organisms should be advised to use condoms and instructed in their proper use.

The American Ad Hoc Committee on Reproductive Health (Sub-committee of the Society for Adolescent Medicine)<5> and the Committee on Adolescence of the Council on Child and Adolescent Health<31> advocate more physician training regarding pregnancy counselling for adolescents. The Council also recommends that pediatricians who do not want to counsel their teenage patients about sexual matters, refer their patients to counselling facilities experienced and sensitive to the needs of adolescents.

Conclusions and Recommendations

Given prevention program successes in community- and school-based clinics, there is fair evidence that physicians can reduce the toll of unwanted pregnancy by provision of education and contraceptive services, by involving pubertal patients and, where appropriate, their parents in early, open discussion of sexual development, prevention of sexually transmitted diseases, and prevention of unwanted pregnancy. Physicians caring for sexually active adolescents should address their contraceptive practices and where indicated, should provide a combination of services: education, counselling, contraception and follow-up (this may include repeat D (Rh) blood group antibody screening before induced abortion or other obstetric procedures, see Chapter 11). Oral contraceptives combined with condoms are the first choice for adolescents who do not wish to be sexually abstinent.

Unanswered Questions (Research Agenda)

The following have been identified as research priorities:
  1. Evaluating Canadian school-based clinics.
  2. Evaluating the effectiveness of physicians in identifying sexually active and unprotected teenagers, counselling, prescribing contraceptives, and altering their behaviour
  3. Examining the effectiveness of a more widely available "morning-after pill" program because the majority of teenagers are unprotected during their first sexual encounter.
  4. Further research into the reasons for noncompliance with oral contraception and the development of creative and effective solutions for non-compliance. Research into the effectiveness of counselling adolescents in the use of condoms in combination with oral contraceptives and with spermicide is also recommended.

Evidence

The MEDLINE search strategy undertaken for the years 1988 to November 1993 identified articles using the following key words: pregnancy, unwanted; adolescent; contraception; inject; contraceptive agents; contraceptive devices; human; contraception behaviour; and sex counselling.

This review was initiated in January 1993 and recommendations were finalized by the Task Force in October 1993.

Acknowledgements

Funding for this report was provided by Health Canada under the Government of Canada’s Brighter Futures Initiative. The Task Force also thanks Dr. Steven Woolf, MD, MPH, Science Advisor, U.S. Preventive Services Task Force, Washington, DC and Assistant Clinical Professor, Department of Family Practice, Medical College of Virginia, Richmond, VA, USA for reviewing the draft report.
 

Table 1: Steps to Encourage Compliance with Contraceptives
 
 
  1. Discuss mechanism of action of contraceptive methods.
  1. Provide close follow-up (every 8 to 12 weeks).
  1. Discuss anticipated side effects.
  1. Review instructions and the importance of compliance at each visit.
  1. Assure patient confidentiality.
  1. Provide a contact person.
  1. Explain all tests.
  1. Provide verbal rewards to patients who keep follow-up appointments and comply with instructions.
  1. Give oral and written instructions.
  1. Telephone patients who miss appointments.
  1. Give samples at initial visit.
  

Table 2: Adolescent Contraceptive Methods <2>
 
 
Non-hormonal method Advantages Disadvantages Cost1
Condom Male shares responsibility; non-prescription; demonstrated protection against sexually transmitted diseases (STDs); highly effective when used with vaginal spermicide Interferes with spontaneity and requires high degree of motivation.  12 @ $4.40-7.50; 12 @ $7-10 with spermicidal lubricant 
Diaphragm Some protection against STDs Requires prescription (Rx) and fitting; "Messy" to use; increased risk of UTI; requires motivation, consistent compliance and forethought. Physician visit; $30 and $4-5/tube of cream of jelly
Cervical cap Some protection against STDs Requires Rx and fitting; may not be able to fit; possible cervical abnormalities; associated with problems of odour, dislodgment, discomfort, difficulty inserting and removing, vaginal discharge, discomfort to partner, and bleeding. Physician visit; caps not available (US$100); $4-5/tube of cream of jelly
Contraceptive sponge Some protection against STDs; non-prescription Need access to water prior to use; may be difficult to remove. 3 @ $8
Vaginal spermicide Some protection against STDs; non-prescription Interferes with spontaneity; "Messy" to use; may need to wait for dissolution; less effective when used alone. Foam $17-20/container; $16-19/tube cream of jelly
Intrauterine device Compliance assured; highly effective Requires Rx and insertion; no protection against STDs; increased risk of pelvic infection; increased bleeding and cramping; high expulsion rate; inappropriate for use by adolescents, particularly nulligravidae. Physician visit $50 lasts 4 years
Periodic abstinence No chemicals or devices; reduces the risk of STDs Fertile interval less predictable in adolescents; no protection against STDs; requires extensive education, high motivation, self-control; requires participation of partner. Instructional visits; Thermometer and charts less than $10
Oral contraceptives Highest degree of efficacy of reversible methods; long-term safety well documented; no complicated techniques to use; formulation can be tailored to individual needs Requires Rx; compliance with schedule necessary for effectiveness; no protection against STDs. Physician visit; $18-20/mo.
Subdermal implantation (norplant) Compliance assured; high degree of efficacy Requires Rx; recently released in Canada; secondary effects may be unacceptable to adolescents; no protection against STDs. Cost from the company $450; physician/ installation charges vary (US$750); lasts 5 years
1Cost at 1 Halifax location, January 26, 1993; US prices 1991 publication <2>
 
 
 

Table 3: Lowest Expected and Typical Percentages of Accidental Pregnency in the United States During the First Year of Use of a Method <3>
 
 
Method
Lowest Expected1
Typical2
Chance
85
85
Spermicides3
3
21
Periodic Abstinence
     

    Calendar 
    Ovulation method 
    Sympto-thermal 
    Post-ovulation

9
3
2
1
20
Withdrawl
4
18
Cap4
6
18
Sponge 
    Parous women 
    Nulliparous women

9
6

28
18
Diaphragm5
6
18
Condom6
2
12
Intrauterine device (IUD) 
    Progestasert 
    Copper T 380 A

2
0.8

3 
Pill 
    Combined 
    Progestogen only

0.1
0.5

3
Injectable progestogen 
    Depot Medroxyprogesteron acetate 
    Norethisterone

0.3
0.4

0.3
0.4
Implants 
    NORPLANT (6 capsules) 
    NORPLANT (2 rods)

0.04
0.03

0.04
0.03
Female sterilization
0.2 
0.4 
Male sterilization
0.1 
0.15 
1Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the author’s best guess of the percentage during the first year if they do not stop use for any other reason.
2Among typical couples who initiate use of a method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason.
3Foams and vaginal suppositories.
4Cervical mucous (ovulation) method supplemented by calendar in the preovulatory and basal body temperature in the postovulatory phases.
5With spermicidal cream or jelly.
6Without spermicides.
 

Table 4: Examples of Effective Community-Based and School-Based Programs
 
 
Study and Program Services/Methodology Results
Edwards Laura et al 1980 <25>

St. Paul Maternal & Infant Care Project

 Operates a comprehensive clinic on the school premises. Screening, counselling and pelvic examinations are performed at school. Students requesting contraceptive services are referred to the same staff at a nearby clinic after school hours. Follow-up is performed at school.

The clinic also provides prenatal and postpartum care, gynecologic exams, contraceptive education, counselling and referral and testing for STDs.

Additional services include athletic and physical exams, weight-reduction program, well-child physical exams, immunizations and drug education and counselling.

 Over the first three years of operation, the student birth rate was reduced by 56% from 70 per 1,000 (37 births out of approximately 470 female students) in the 1972-3 school year to 35 per 1,000 (13 births among 371 female students) in 1975-6. This decline was significant (p<.01) and was a more rapid decline than that which occurred in the nation as a whole.

The percentage of mothers dropping out of school after delivery fell from 45% to less than 10%.

The young mothers continuing their education have accepted contraception and have had no repeat pregnancies.

The contraceptive continuation rate at 12 months was 86.4 per 100. By the end of the third year of the clinic, (1976) 50% of the entire student body had attended the clinic at least once and 92% of the pregnant students had obtained prenatal services.
Brann Edward A et al 1979 <26>

Family Planning Council of Western Massachusetts

 Awareness Program at a vocational high school. Teachers in the schools’ home economics department became concerned when they noted that approximately 40% of each class got pregnant before completing school. Together with the Family Planning Council they devised a special awareness program conducted twice yearly with the female students. The program consists of a film and group discussion. Led to a decline in the pregnancy rate from 40% to approximately 4%.

Over the 2.5 years the program was in place, there were only two pregnancies, one planned and carried to term and one intentionally aborted. The teachers also noted that the participants in the program were less eager to get married immediately upon graduation, a common event in the period before the program.
Kirby Douglas et al 1991<27>

Six diverse school-based clinics serving low-income populations. Five of the six serviced a predominantly black population.

 Every clinic employed at least one part-time or full-time physician. They all provided primary health care, contraceptive counselling and pregnancy tests, but they differed in the emphasis placed on reproductive health, provision of sexuality education and family planning services. Survey data collected indicated the clinics neither hastened the noset of sexual activity nor increased its frequency.

At least one school where pregnancy was a high priorityand staff issued vouchers for contraceptives, the use of condoms and pills were significantly higher than in the comparison school.

Another school clinic which focused on high-risk youth, emphasized pregnancy prevention and dispensed birth control, recorded a significantly higher use of pills than its comparison school.

Another clinic which focussed on AIDS education and prevention found condom use increased significantly over time but not pill use.
Brian Edward et al 1979 <26>

The Maryland State Department of Health and Mental Hygiene

 Program in education and human sexuality for adolescents in two rural areas of the state.

The program consisted of a combination of sex education in the schools taught by trained teachers, sensitization of county health departmental staff to the situation of teenagers, and access to contraception in distribution centres where teens were known to gather.

 In Charles, Calvert and Worcester Counties, the combined fertility rate for 15- to 19-year-olds fell from 84 births per 1,000 females in 1972 to 56 per 1,000 in 1975, a 33% drop. In the 15 to 17 year old range, the rate fell from 66 per 1,000, to 42 per 1,000, a 36% drop.
Vincent Murray L et al 1987 <23>

The School/Community Program for Sexual Risk Reduction Among Teens in the western portion of a South Carolina county

 The program consisted of the education of adults in the target community – parents, ministers, community leaders and the media. Sex education in the schools was only a small part of an overall effort to postpone the age of first coitus and to promote the consistent use of effective contraception. Central to the project was an educational program to help adults improve their skills as parents and as role models in the community. In the pre-intervention years, the intervention and comparison portions of the county had similar average rates of 60.6 and 66.8 pregnancies per 1,000 females. In 1984 and 1985 (two and three years after implementation) the estimated pregnancy rate (EPR) declined in the intervention group to a level of 25.1 pregnancies per 1,000 females. This was significantly lower (P<.01) than the average EPR in the comparison counties.
Zabin et al 1986 <24>

Baltimore

 Pregnancy prevention program implemented in 1 inner-city junior and 1 senior high school with a predominantly black, low-income population. 2 schools serve as the control. Program provided students with sexuality and contraceptive education, individual and group counselling and medical and contraceptive services over a period of 3 years. Decreases in pregnancy rate were reported in contrast to city-wide rate increases. Changes in sexual and contraceptive knowledge occurred; age at first intercourse was delayed (median 7 months); the percentage of students going to the clinic or doctor before first intercourse increased from 50 to 71% as did attendance during the first months of sexual activity; junior high boys used the clinic as freely as girls their same age. The authors conclude that access to free high-quality services was probably crucial to success.
Howard & McCabe 1990 <28>

Atlanta

 Family-planning outreach program for eighth graders in a local school system. The program is led by older teenagers and focusses on helping students resist peer and social pressures to initiate sexual activity. By the end of the eighth grade, students who had not participated in the program were as much as five times more likely to have begun having sex than were those who had had the program.
Orton & Rosenblatt 1986 <29>

Ontario

 Combination program of school sexuality education and clinic contraception services. A decline in teen births (-13%) plus the decline in the younger teen population (-10%) resulted in a 22% decline in the annual number of pregnancies to younger teens by 1981 – almost a thousand less than in 1976.

 Full Citation

Link to Structured Abstract of this review

Link to Summary Table of this review

Link to Selected References list of this review

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