In a move sure to provoke controversy among some, the American Academy of Pediatrics has come out in favor of strengthening the role of pediatricians in helping to reduce adolescent pregnancy in the United States. The group recommends that pediatricians provide birth control and now, emergency contraception (EC) counseling, to all adolescents, males and females, and to families of disabled adolescents as part of routine preventive care.

The Academy wants pediatricians to take a more active role in prescribing the medication.

The reasons for the newly-released updated Policy Statement on Emergency Contraception are straightforward. The birth rate among girls aged 15 to 19 in the U.S. remains a very high 34.3 per 1000 and 80% of these are unintended and result from contraceptive failure or non-use. In addition, 10% of sexually active teens may be victims of sexual assault or date rape.

Why Adolescents Need Access to Emergency Contraception

Emergency contraception can prevent pregnancy in cases of sexual assault, unprotected intercourse, condom breakage or slippage, and missed or late doses of hormonal contraceptives, including the pill, patch, ring, or injection. The AAP wants to be sure that pediatricians let girls and their parents know that EC is available to help in these types of circumstances.

Emergency contraception, contraception designed for prevention of pregnancy after intercourse, is most effective within the first 24 hours, but can reduce the risk of pregnancy up to 120 hours after unprotected intercourse. At present, females 17 years or older and males 18 years or older can obtain emergency contraception without a prescription, but in most states adolescents younger than 17 years are required to have a prescription. Studies have shown that adolescents are more likely to use emergency contraception if it has been prescribed in advance of need, rather having to obtain it after failed or not used contraception. The Academy wants pediatricians to take a more active role in prescribing the medication.

The Varieties, Risks, and Benefits of EC

There are several emergency contraception regimens available. The most popular, Plan B, Plan B One Step and Next Choice contain levonorgestrel that acts hormonally to prevent pregnancy, but do not interrupt pregnancies that are already established and do not cause birth defects in already growing fetuses. This is the preferred emergency contraception for teenagers because there are fewer adverse effects and a physical exam and pregnancy test are not required prior to administration. The rate of nausea and vomiting is lowest of the available options.

Levonorgestrel acts hormonally to prevent pregnancy, but does not interrupt pregnancies that are already established and does not cause birth defects in already growing fetuses.

A recently approved product, ulipristal acetate, is very effective but has the disadvantage that it may cause miscarriage if the user is already in the first trimester of a pregnancy. Therefore, a pregnancy test must be taken prior to starting this treatment.

There are other possibilities including physician-prescribed, short-term increased doses of standard contraceptive pills. Although less effective than the Plan B products, this strategy can be helpful when there is limited access to emergency contraceptive products. No form of emergency contraception prevents sexually transmitted diseases, and none is recommended for use as ongoing birth control.

The Academy of Pediatrics' Recommendations

The AAP statement stresses that the most effective methods for preventing adolescent pregnancy are effective contraceptive use with dual methods (condoms plus hormonal contraception/IUE) or abstinence. However, they note that teens are at high risk for contraceptive failure or non-use and emergency contraception is a critical element in preventing unwanted pregnancy.

No emergency contraception prevents sexually transmitted diseases, and none are recommended for use as ongoing birth control.

Given the number of unintended teen pregnancies, the AAP wants pediatricians to provide prescriptions for emergency contraception when requested by adolescents who have had unprotected intercourse and are in immediate need. They also recommend that pediatricians provide prescriptions for teenagers in advance, before they have unprotected intercourse, so that they will be available for future emergencies, eliminating the need to access a medical provider during the critical time period immediately after unprotected sex or failed birth control. They recommend levonorgestrel-containing products as first-line EC drugs because they have fewer side effects and there is no need for a pregnancy test prior to use.

Physicians' Duty Is to Offer Counseling, Despite Beliefs

Some physicians may have conflicting feelings or religious concerns about teenage sexual behavior and the use of contraception. But this should not prevent a pediatrician from offering their patients information on EC. In fact, pediatricians are prohibited from refusing to provide information or treatment on the basis of conscience according to the Academy of Pediatrics committee on bioethics. They are obligated to tell their patients about the "relevant, legally available treatment options to which they themselves object and to refer patients to other physicians for education and provision of these services." The newly-published Emergency Contraception statement cites this policy and underscores that the “failure to inform/educate about availability and access to emergency contraception services violates this duty to their adolescent and young adult patient.”

Emergency contraception is a legally available treatment. It is a method for preventing unwanted pregnancy as a result of unprotected intercourse or failed birth control. It is not a method of routine contraception, and it is not a method of inducing an abortion. It does not prevent sexually transmitted diseases. It is an important strategy to reduce unwanted teen pregnancy. For these reasons, the AAP hopes pediatricians will provide emergency contraception both immediately and in advance of need to their patients and advocate for reduction of the barriers to non-prescription access to emergency contraception regardless of the patients’ ages or insurance coverage.