How Can We Use the Emergency Department to Prevent Unintended Teen Pregnancies?
Despite a significant decrease in adolescent pregnancies in the U.S. over the last decade – due in large part to increased use of effective contraception – our country continues to have one of the highest rates of unintended teen pregnancies among industrialized nations. One of the underlying causes of this trend is that many teens miss the opportunity to receive sexual and reproductive health counseling when they forgo routine health care visits because they are generally healthy.
In fact, a recent study reported that fewer than 35 percent of 16- to 18-year-old females attended a well child visit in the preceding year – and many adolescents utilize the emergency department (ED) as their primary source of care. Adolescents account for almost 19 million ED visits in the U.S. annually, for reasons ranging from minor illness and injury to concern for sexually transmitted infection and pregnancy-related complications to severe trauma. Several studies have found that the rate of unprotected sexual activity, and therefore the risk of pregnancy, is higher among adolescents seeking care in the ED when compared to the general population. Therefore, we believe the ED is well-positioned as a site to offer contraceptive counseling and initiation for this population.
Unfortunately, ED providers face a number of challenges to effectively delivering this type of care. First, ED providers have considerable time constraints in their busy environment, in which they are also tending to other patients who need immediate attention. Second, ED providers may not feel comfortable addressing the sexual health needs of adolescents or may not feel that is within their scope of practice. And finally they face significant systems-level barriers – EDs generally don’t have the confidentiality protections that are afforded for services funded under the federal Title X Family Planning program, and the adolescents that they care for may not have the ability to independently consent for contraceptive services based on the state they live in. As pediatric emergency medicine specialists, we see firsthand how these issues impede our ability to provide appropriate, evidence-based care for our adolescents.
Consider the case of Ashley*, a 16-year-old girl who came to the ED complaining of a twisted ankle. She is otherwise healthy and hadn’t seen her pediatrician in over a year. While in the ED, when asked about her general health, she volunteered that she was nervous about becoming pregnant because she was having frequent unprotected sexual intercourse with her boyfriend. Fortunately, she was open with her mother about her situation, and we were able to bring her into the conversation and come up with a plan together. We provided Ashley with emergency contraception (“the morning-after pill”) in the ED because she had had unprotected sex with her boyfriend 24 hours earlier and, after counseling, a physician provided her with a prescription for oral contraceptive pills and instructions to follow-up with a family planning clinic within the next two weeks. Had she not been willing to share her story with her mother, which is the case for many teens, we would have had great difficulty providing her with these potentially life-altering interventions in a confidential manner. For this reason, researchers and advocates are working to create better systems and improve policies to allow for easier access to confidential care in all health care settings.
Recent research by us and others has found that adolescents and parents are interested in sexual and reproductive health care in the ED setting – they are willing to talk to providers about these issues, even when not related to their chief complaint. However, efforts to facilitate follow-up reproductive care, such as providing text message reminders or assistance with scheduling an appointment and reminder phone calls have had mixed results, and we still don’t know the best way to support all teens. It is likely that a one-size-fits all approach isn’t best; some adolescents may desire immediate counseling and contraception initiation, while some may benefit from an explanation of services in the community with a clear plan for accessing those in the near future. We are working to better understand these issues, with a plan to provide contraceptive counseling in the ED followed by in-depth interviews with teens.
Given that tens of thousands of at-risk adolescents seek care in the ED every year, we need to create innovative strategies and interventions that take advantage of this non-traditional setting while, at the same time, advocating – during Global Teen Health Week and beyond – for all teens to have access to the contraceptive care they need when they need it. By eliminating barriers to teens receiving contraception and related counseling in the ED, we could have a significant impact on reducing the rate of unintended pregnancies in this country and providing more teens with opportunities to transition into healthy, productive adults.
*This case is a composite of many, and does not present identifying information of any single patient.
Melissa Miller, MD, is an associate professor of Pediatrics at Children’s Mercy Hospital in Kansas City, Mo., and an attending in pediatric emergency medicine. She has a research focus/expertise on adolescent reproductive health care and brief behavioral interventions in the emergency department setting.