EXECUTIVE SUMMARY

New research shows more supportive counseling in reproductive health is needed for adolescents, especially after sexual initiation, and in support of adherence or tolerance of side effects.

  • Access to different types of birth control has increased in the past decade, but not as much progress has been made in supporting decision-making or counseling with respect to neurodevelopmental functioning.
  • Clinicians need to take adolescents’ cognitive and emotional skill sets into consideration.
  • Clinicians and researchers need to change their counseling techniques to be used by a wider range of healthcare providers, such as pediatricians and primary care providers, and to use methods like electronic toolkits.

The type of contraceptive method women choose and their patterns of contraceptive use can have a big effect on their risk of unintended pregnancy, new research shows.1

It is important for healthcare professionals caring for adolescents to be part of a support system to empower adolescents with their reproductive health choices — regardless of race or gender.2

“In my practice, we’ve spent a lot of the last decade increasing access to different types of birth control, which is needed,” says Andrea Elena Bonny, MD, section chief of adolescent medicine and principal investigator at the Center for Clinical and Translational Research at Nationwide Children’s Hospital. She also is an associate professor of pediatrics at The Ohio State University.

“I think we’ve done a lot less of considering what we say and how we say it,” she adds. “We’ve been really focused on information-giving and imparting information rather than supporting decision-making.”

Counseling adolescents is different because young people are in a unique development period in which they have relatively weaker executive functioning and a higher reward system, Bonny says.

Investigators of a recent study on contraceptive counseling, which Bonny references in her editorial on this topic, suggested clinicians look at intermediate outcomes that address neurodevelopmental functioning in the counseling they provide.

“We should be looking at whether our counseling ability affects skills like emotional regulation and stress modulation, rather than looking at the outcome of whether the adolescents used a birth control method,” Bonny says. “If we begin to look at these mediating outcomes, we might find new opportunities for counseling.”

For instance, researchers and clinicians should consider adolescents’ cognitive and emotional skill sets. Are they prepared to make a good decision?

“Instead of looking at what decision they made, what if we start looking at those skill sets and how our counseling can impact the strength of those skill sets?” Bonny asks. “For example, an adolescent might be more impulsive with decision-making, rather than slowing down.”

Clinicians could engage in motivational interviewing, a technique often used with adolescents with substance use issues. “We can help them look at the pros and cons of whatever decision they’re making,” Bonny explains. “Adolescents may want to make a quick decision, but we may counsel so they are slower in their decision-making.” If adolescents make a decision more slowly, they could better understand side effects that might occur from the contraceptive they selected.

Bonny also references the contraceptive counseling study’s four critical and unique time frames in the contraceptive care continuum:

Counseling before sexual activity. “The literature has really focused on counseling before you become sexually active. That’s our comprehensive sex education programs, which are widely variable,” Bonny says.

Not all sex education is of high quality in terms of evidence-based information. But several randomized trials focused on sex education programs and the various types of education provided prior to sexual initiation.

Counseling after someone has initiated sexual activity. Research shows that reducing unintended pregnancies in young, sexually active women requires clinicians supporting these women to use their chosen method correctly and consistently.1

Contraceptive counseling for sexually active young women also should include guidance on how to switch contraceptives to avoid usage gaps that place them at risk for pregnancy. This means providers should identify and address patients’ individual contextual factors in their lives.

Counseling to support adherence or tolerance of side effects. One study of 10,000 women in St. Louis found that young women were 1.4 times more likely to stop contraception in the first 12 months of use when compared to older adult women.1,3

Reproductive health providers should counsel their patients about the side effects of using methods such as the pill, patch, vaginal ring, and shot, which are methods that require daily, weekly, monthly, or quarterly dosing. When young women experience difficulty adhering to their dosing regimens because of side effects or other reasons, it results in method failures.1

More research is needed to learn about what type of counseling can help support adherence or transition to a new method if an adolescent is dissatisfied with their current method, Bonny says.

Counseling in the postpartum period. “There has been a lot of work done in the postpartum area,” Bonny says. “People are much more open to the idea of counseling an adolescent once they’ve had a baby.”

Reproductive health clinicians can use a variety of counseling techniques in working with adolescents, including motivational interviewing, decision-support tools, and reproductive life planning frameworks such as PATH (Parenthood preferences/pregnancy attitude, Timing of desired pregnancy, and How important is pregnancy prevention currently).

Consistent, quality contraceptive counseling has been elusive, but clinicians are getting better at it, Bonny says. Research that identifies best practices in contraceptive counseling and that is targeted for various providers, including pediatricians, primary providers, OB/GYNs, and other reproductive health providers, is needed.

“Counseling science needs to improve,” Bonny says. “If you want a very busy primary care provider to be able to do this in the context of their clinical practice — along with everything else they’re doing — we need something that is comprehensive and easy to do.”

Clinicians also could benefit from using electronic toolkits. “I think it would be helpful to have easy-to-use tools that can be utilized at different windows of counseling, for any range of sexual activity,” she adds. “These types of tools could focus on where patients are in the contraceptive continuum, and also give [providers] a sense of where their patients are neurocognitively in terms of skill sets.”

Incorporating science-based tactics and toolkits could help increase access and decrease barriers to contraceptive use.

“Helping these providers feel confident in doing this is important so that women have equal access to these reproductive health options,” Bonny says.

REFERENCES

  1. Hoopes AJ, Timko CA, Akers AY. What’s known and what’s next: Contraceptive counseling and support for adolescents and young adult women. J Pediatr Adolesc Gynecol 2021;34:484-490.
  2. Bonny AE. Contraceptive counseling for adolescents: Current evidence and road map for the future. J Pediatr Adolesc Gynecol 2021;24:435-436.
  3. Rosenstock JR, Peipert JF, Madden T, et al. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol 2012;120:1298-1305.