US adolescent pregnancy rates: declining, but more progress is needed: editorial review

Abstract

Adolescent pregnancy rates in the USA are among the highest in the Western industrialized world; these rates are at least double the rates in Canada and Western Europe, and many times higher than the rates in the Netherlands and Japan – the two countries having the lowest such rates [1]. Widespread support exists in the USA for the concept that pregnancy during adolescence is not optimal. Adolescent pregnancies affect individual adolescents, their families, their children and us as a society. Thus, a focus on decreasing adolescent pregnancy rates is appropriate. Recently reported data from the CDC's 2002 National Survey of Family Growth indicate that progress is being made [2]. Adolescent pregnancy rates in the USA have declined markedly since the 1950s (see Fig. 1). The declines beginning in the 1960s were undoubtedly due to the availability of new contraceptive technologies, most notably oral contraceptive pills. Recent changes in contraceptive behaviors have resulted in further declines in adolescent pregnancy since recent benchmark high levels of the 1990s; an estimated 34% of teens, however, will still experience a pregnancy by age 20 [3•]. Those changes in contraceptive behaviors have included the greater use of long-lasting methods of contraception that require less active compliance, such as the injectable progestin depot medroxyprogesterone acetate; increasing rates of dual-use of both a hormonal method of contraception and condoms; and increasing use of contraception at the time of first intercourse [4]. Other changes in sexual behaviors such as delayed initiation of sexual intercourse have also contributed to declining rates of adolescent pregnancies; controversy, however, exists over estimating and measuring the extent to which contraception and increasing abstinence each contributes to the decline. It has been estimated that changes in contraceptive behaviors account for 50–75% of the decline [5,6]. An approach to adolescents that promotes the postponement of sexual activity until an individual adolescent is developmentally capable of participating in a mature, healthy, mutually respectful relationship while also encouraging responsible sexual behavior that incorporates effective contraception is a goal that clinicians, parents, teachers and other responsible adults can support. Widespread support for sexuality education has been documented among US adults [7]. Suggested explanations for the difference in adolescent pregnancy rates between the USA and other developed countries include: (a) better sexuality education in these other developed countries; (b) better reproductive health services with easier access to care; and (c) better use of birth control, including oral contraceptives in particular [2]. National organizations, including the American Medical Association (AMA) and the American Academy of Pediatrics (AAP), have established preventive services guidelines for adolescents that include the routine and confidential assessment of sexual activities and need for contraception. Adolescents typically wait a year or more after initiating intercourse to seek medical contraceptive advice, so such a pro-active approach by primary clinicians is critical [8]. The AMA developed the Guidelines for Adolescent Preventive Services [9], and the American College of Obstetricians and Gynecologists developed a ‘tool kit’ for physicians to facilitate preventive guidance and services designed to routinely screen for sexual activity and to counsel about the potential risks of unintended pregnancy and sexually transmitted diseases (STDs) [10]. While discussion about the evidence for the effectiveness of current screening recommendations and the provision of preventive guidance exists, detecting adolescents at risk is essential for the provision of medical contraception and for providing preventive guidance aimed at minimizing the risks of unintended pregnancies and STDs.