Receipt of Reproductive Health Services Among Sexually Experienced Persons Aged 15–19 Years — National Survey of Family Growth, United States, 2006–2010

Crystal P. Tyler, PhD

Lee Warner, PhD

Lorrie Gavin, PhD

Wanda Barfield, MD

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC

Corresponding author: Lee Warner, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-5989; E-mail: dlw7@cdc.gov.

Introduction

The prevention of pregnancy, childbirth, and sexually transmitted diseases (STDs) among teenagers has garnered recent attention both from public health and clinical organizations. In 2011, the U.S. birth rate among teenagers reached a historic low of 31.3 births per 1,000 females aged 15–19 years and has decreased 49% percent from 1991 to 2011 (1). Despite recent decreases, U.S. birth rates among teenagers remain higher than those in other industrialized countries. For example, in 2009, the U.S. teenage birth rate was approximately 1.5 times the birth rate in the United Kingdom, nearly 3 times the birth rate in Canada, and nearly 8 times the birth rate of Denmark. Approximately 20% of births to teenagers aged 15–19 years are repeat births, and significant disparities by race and ethnicity persist (1–3).

In 2011, nearly 20 million new cases of STDs were diagnosed in the United States, with numerous cases occurring among persons aged 15–19 years (4,5). STDs such as chlamydia and gonorrhea are associated with increased risk of adverse outcomes including tubal infertility, ectopic pregnancy, and chronic pelvic pain.

Access to clinical reproductive health services can improve health and reduce costs by covering pregnancy prevention and STD testing, treatment, and counseling. Improving the reproductive health of teenagers is a public health priority. For example, one Healthy People 2020 objective (objective FP-7) is to increase by 10% the proportion of all sexually active persons who received reproductive health services in the past 12 months (6). Rules promulgated pursuant to the Patient Protection and Affordable Care Act of 2010 (as amended by the Health Care and Education Reconciliation Act of 2010 and referred to collectively as the Affordable Care Act [ACA]) require that women's health services supported by the Health Resources and Services Administration (HRSA) be provided by private insurers without copayment, including contraception as prescribed for women (including teenagers) with reproductive capacity (7). In addition, the National Prevention Strategy highlights providing teenagers with effective, medically accurate, developmentally appropriate, evidence-based sexual education and enhancing the early detection of human immunodeficiency virus (HIV) infection, STDs, and viral hepatitis and improving linkages to clinical care (8). The National Quality Forum (NQF) endorsed two related performance measures: 1) the percentage of sexually active women aged 16–24 years who had at least one test for chlamydia in a year (NQF #0033) and 2) the percentage of teenagers with documentation of assessment or counseling for risky behavior (i.e., sexual activity and alcohol, tobacco or other substance use) by the age of 18 years (NQF #1507) (9,10).

The U.S. Preventive Services Task Force (USPSTF) recommends that all sexually active females aged ≤24 years receive annual screening for chlamydia. This is a USPSTF Grade A recommendation, which means that USPSTF strongly recommends the service because the certainty is high that the benefits substantially outweigh the potential harms. The same screening is recommended for gonorrhea. This is a USPSTF Grade B recommendation, which means that USPSTF recommends the service because the certainty is moderate that the benefits substantially outweigh the potential harms. USPSTF recommends that adolescents aged ≥15 years, as well as younger teenagers who are at increased risk, also should be screened for HIV infection (USPSTF Grade A recommendation). USPSTF also recommends that all sexually active adolescents be provided high-intensity behavioral counseling* for sexual risk reduction (USPSTF Grade B recommendation) (11). The Bright Futures guidelines, developed by the American Academy of Pediatrics (AAP) and supported by HRSA, encourage streamlining medical care and consider clinical encounters for acute care, health maintenance visits, or sports physicals to be opportunities to teach adolescents about healthy sexuality. This approach aligns with the Medical Home Model of the National Initiative for Children's Healthcare Quality (12,13). Bright Futures guidelines recommend that adolescents, regardless of sexual experience, should receive health guidance annually on the advantages of delaying sexual activity and information on STDs and contraception, including emergency contraception (12). In addition, numerous professional organizations recommend reproductive health visits during early adolescence, which might include screening for sexual experience, screening for STDs, medically accurate reproductive health counseling, and provision of contraception when appropriate (12,14). The public health community plays a critical role in promotion of adolescent reproductive health by encouraging health-care providers to adhere to evidence-based recommendations from professional organizations and USPSTF and by monitoring progress toward achieving the Healthy People 2020 goals. Increasing the proportion of adolescents, particularly those who are sexually experienced (i.e., have ever had penile-vaginal intercourse) who visit a health-care provider for reproductive health services is essential to promote adolescent health.

The reports in this supplement provide the public and stakeholders responsible for infant, child, and adolescent health (including public health practitioners, parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations) with easily understood and transparent information about the use of selected clinical preventive services that can improve the health of infants, children, and adolescents. The topic in this report is one of 11 topics selected on the basis of existing evidence-based clinical practice recommendations or guidelines for the preventive services and availability of data system(s) for monitoring (15). This report analyzes 2006–2010 data from the National Survey of Family Growth (NSFG) to estimate the proportion of sexually experienced persons aged 15–19 years who received reproductive services during the 12 months before the interview. Researchers, policy makers, and health-care providers can use these data to track improvements in receipt of these services.

Methods

To estimate the proportion of sexually experienced persons aged 15–19 years who received reproductive health services during the 12 months before the interview, CDC analyzed 2006–2010 data from NSFG. NSFG is a nationally representative, in-person household survey conducted by CDC that uses a stratified, multistage probability sample of females and males aged 15–44 years. A maximum of 1,389 males and 1,053 females aged 15–19 years were included as part of this analysis; the number included in each analysis varied. Survey topics include sexual activity and receipt of health services from a medical provider (16). Selected reproductive health services are based on recommendations from national organizations and Healthy People 2020 (6,12). For females, these included contraceptive services (i.e., provision of a method or prescription, a checkup, counseling, or pregnancy test), gynecologic services (i.e., pelvic exam or Papanicolaou [Pap] smear), or STD counseling, testing, or treatment. For males, reproductive health services included advice about male and female contraception, a testicular exam, or advice about STDs, HIV, or acquired immunodeficiency syndrome (AIDS).

Respondents were considered sexually experienced if they indicated they had ever had penile-vaginal intercourse. (Adolescents who had a history of only oral sex, only anal sex, or both were not included). Female respondents were classified as receiving reproductive health services if they indicated they had received selected contraceptive, gynecologic services, or STD services from a health-care provider in the past 12 months. Male respondents were classified as receiving reproductive health services if they indicated receipt of advice about male and female contraception; a testicular exam to check for congenital abnormalities, lumps, or other abnormalities such as an undescended testicle; or advice about STDs, HIV, or AIDS.

Receipt of reproductive health services was stratified by sociodemographic characteristics: insurance coverage in the past 12 months (private, Medicaid, other public, or none); age (15–17 or 18–19 years); race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, or other); and maternal education (less than high school, high school equivalent, or college or greater). Receipt of reproductive health services also was stratified by sexual risk behaviors: number of sexual partners in the past 12 months (none, one, two, or three or more); age at first sex (≤15 years, 16–17 years, or 18–19 years); and whether females had a previous pregnancy or males had fathered a previous pregnancy. Finally, receipt of formal sex education before age 18 years was stratified by reproductive health topics (how to say no to sex, methods of birth control, STDs, and any of these three topics) and whether the adolescent had ever spoken to a parent or guardian about a reproductive health topic (how to say no to sex, methods of birth control, STDs, and any of these three topics). Differences in proportions between subgroups were assessed using a two tailed t-test. Comparisons mentioned in the text are statistically significant at the p<0.05 level unless otherwise stated. All analyses were conducted using statistical software to account for the complex sample design of NSFG.

Results

During 2006–2010, 76.5% of sexually experienced females aged 15–19 years (95% CI = 73.0%–80.1%) and 43.9% (CI = 40.6%–47.2%) of all females aged 15–19 years, regardless of sexual experience, reported receiving a reproductive health service from a health-care provider in the past 12 months (Figure). Approximately 70% of sexually experienced females received any contraceptive service (method or prescription, counseling, checkup, or test), 57.1% (CI = 53.4%–60.9%) received any gynecologic service (Pap smear or pelvic examination), and 31.2% (CI = 27.5%–34.9%) received STD counseling, testing, or treatment. The most commonly received services were a Pap smear (53.7% [CI = 50.2%–57.2%]) and a contraceptive method or prescription (53.6% [CI = 49.4%–57.9%]). Similarly, 62.5% (CI = 56.9%–68.2%) of sexually experienced males aged 15–19 years and 58.2% (CI = 55.1%–61.3%) of all males aged 15–19 years, regardless of sexual experience, received a reproductive health service from a health-care provider in the past 12 months (Figure). The majority (55.5% [CI = 50.2%–60.8%]) of sexually experienced males received a testicular exam to screen for testicular cancer, whereas 22.8% (CI = 17.4%–28.2%) received advice about male or female contraception, and 26.1% (CI = 19.6%–35.6%) received advice about HIV or other STDs.

The percentage of sexually experienced females aged 15–19 years who received reproductive health services is shown by select characteristics (Table 1). Sexually experienced females with insurance coverage in the past 12 months, regardless of the type of coverage, reported a significantly higher prevalence of receiving any reproductive health service than did those without insurance coverage (private, 77.3%; Medicaid, 78.6%; other public, 82.4%; and no insurance, 60.9%). Receipt of any reproductive health service and of any contraceptive service differed significantly by age, with females aged 18–19 years reporting a higher prevalence of receiving both reproductive health services and contraceptive services (81.0% and 74.0%, respectively) than younger teenagers aged 15–17 years (68.2% and 63.0%, respectively) (Table 1). Compared with females with no sexual partners during the past 12 months, females with one or more sexual partners reported a higher prevalence of receiving any reproductive health service (zero partners, 48.7%; one partner, 79.8%; two partners, 76.3%; and three or more partners: 79.1%). Females who stated they had never been pregnant (91.7%) reported a higher prevalence of receiving any reproductive health service than those who stated they had ever been pregnant (71.2%). Those who had received formal sex education on methods of birth control reported a higher prevalence of receiving any reproductive health service (79.1%) and any contraceptive service (72.9%) than those who had not (67.3% and 60.3%, respectively). Females who had spoken with a parent or guardian about any reproductive health topic (including how to say no to sex, methods of birth control, and STDs) had a higher prevalence of receiving any reproductive health service and any contraceptive service (79.0% and 73.5%, respectively) compared with those who had not (66.6% and 56.9%, respectively).

The percentage of sexually experienced males aged 15–19 years who received reproductive health services is shown by select characteristics (Table 2). Among sexually experienced males, having insurance coverage in the past 12 months, regardless of the type of coverage, was associated with a higher prevalence of receiving any reproductive health service than those without insurance coverage (private, 61.7%; Medicaid, 69.1%; other public, 65.4%; and no insurance, 43.4%) (Table 2). Males who had fathered a previous pregnancy reported a higher prevalence of both receiving advice about male or female contraception (34.3%) and any STD service (39.2%) than did males who reported never having fathered a pregnancy (20.9% and 24.0%, respectively). Males who had received formal sex education on how to say no to sex reported a higher prevalence of receiving any reproductive health service (65.1%) than did males who had not (52.9%). Those who had received formal sex education on methods of birth control or on STDs were as likely to have received reproductive health services as those who had not received formal sex education. Compared with sexually experienced males who had not spoken with their parent or guardian about a reproductive health topic (i.e., how to say no to sex, methods of birth control, or STDs), those who had spoken with a parent or guardian about a reproductive health topic had a higher prevalence of having received any reproductive health service (66.3% versus 53.8%), advice about male or female contraception (27.2% versus 12.5%), any STD service (29.2% versus 18.9%), and a testicular examination (59.6% versus 45.9%).

Discussion

The majority of sexually experienced persons aged 15–19 years received a reproductive health service from a health-care provider in the 12 months before the interview. Those with insurance coverage (regardless of type), who received formal sex education, and who spoke with a parent or guardian about any reproductive or sexual health topic had the highest prevalence of receiving reproductive health services. However, many did not receive needed reproductive health services. During the 12 months before the interview, approximately 30% of sexually experienced females aged 15–19 years did not receive contraceptive services, nearly 70% of sexually experienced females aged 15–19 years did not receive recommended STD services, and 74% of sexually experienced males aged 15–19 years did not receive STD services. Persons aged 15–19 years without insurance coverage, younger females aged 15–17 years, and persons aged 15–19 years with a previous pregnancy also had a lower prevalence of receiving reproductive health services.

Ongoing changes in the U.S. health-care system offer opportunities to improve the use of clinical preventive services among infants, children, and adolescents. ACA expands insurance coverage, consumer protections, and access to care and places a greater emphasis on prevention (17). As of September 23, 2010, ACA § 1001 requires nongrandfathered private health plans to cover, with no cost-sharing, a collection of four types of clinical preventive services, including 1) recommended services of USPSTF graded A (strongly recommended) or B (recommended) (18); 2) vaccinations recommended by the Advisory Committee on Immunization Practices (19); 3) services adopted for infants, children, and adolescents under the Bright Futures guidelines supported by HRSA and AAP (12) and those developed by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children (20); and 4) women's preventive services as provided in comprehensive guidelines supported by HRSA (21). Therefore, pursuant to guidelines supported by HRSA, new private health plans must provide coverage without cost-sharing for contraceptive methods and sterilization procedures approved by the Food and Drug Administration and patient education and counseling for all women with reproductive capacity (7). Most state Medicaid/Children's Health Insurance Program programs cover various forms of pregnancy prevention and reproductive health services for teenagers as part of their family planning services.

The Health Insurance Marketplace (or Health Insurance Exchange) began providing access to private health insurance for small employers and to persons and families interested in exploring their options for coverage, with policies taking effect as early as January 2014.† Federal tax credits are available on a sliding scale to assist those living at 100%–400% of the federal poverty level who purchase health insurance through the Marketplace (ACA § 1401). Insurance plans sold on the Marketplace must cover the four types of recommended clinical preventive services without cost-sharing, including contraceptive methods and sterilization procedures approved by the Food and Drug Administration and patient education and counseling for all women with reproductive capacity.

Pregnancy prevention and reproductive health services for teenagers also are mentioned in several places in ACA. The law provides states the option to provide family planning services to eligible pregnant and nonpregnant women (ACA § 2303) and provides grants to implement innovative strategies that educate teenagers on both abstinence and contraception to prevent pregnancy and STDs (ACA § 2953). The law also establishes a Pregnancy Assistance Fund to establish or maintain services for pregnant and parenting teens and women (ACA § 10212).

Contraception has been shown to be highly effective at preventing unintended pregnancy (especially long-acting reversible contraceptive methods such as intrauterine devices and implants) and is very cost-effective, with >$4 saved for every $1 invested (22,23,25,27). USPSTF has made evidence-based recommendations to provide the following reproductive health services to teenage clients: screening for STDs such as chlamydia, gonorrhea, and HIV infection (16) and counseling for sexual behavior that place teens at high risk for STDs and pregnancy (11). On the other hand, because of recent changes to USPSTF recommendations, health-care providers might need to stop providing some reproductive health services to adolescents. USPSTF specifically recommends against the provision of services that many teenagers reported receiving. For example, testicular examinations for adolescent and adult males are not recommended (USPSTF Grade D recommendation) because the potential harms of routine screening outweigh the benefits; however, 56% of males in the sample in this report indicated that they received a testicular examination. Pap smears are no longer recommended for women aged <21 years, and pelvic examinations are only recommended when an indication exists (e.g., pelvic pain or a suspected STD) or at the initiation of an intrauterine device or a diaphragm (24,25). Unnecessary procedures such as pelvic examinations are barriers to use of services by adolescents; removing these barriers to care could improve receipt of vital reproductive health services (26).

Professional organizations recommend that female teenagers start reproductive health visits that include screening for sexual activity, medically accurate sexual health and reproductive health counseling, and contraceptive access for those who are sexually active in early adolescence. Given that female teenagers can only obtain hormonal contraception and intrauterine devices from a health-care provider, regular reproductive health visits for teenagers can facilitate access to contraception and a subsequent decrease in pregnancies among teenagers (12,27).

Another important aspect of reproductive health visits involving adolescents is confidentiality. Because many insurance providers send an explanation of benefits that specifies each clinical service received, teenagers might be reluctant to use their health insurance (obtained through their parents) to ensure that their reproductive health services are kept confidential (19,28–32). Although many adolescents reported speaking to their parents about their sexual and reproductive health, adolescents who request confidential services should be able to receive them.

This report shows that lack of insurance coverage is a considerable barrier to use of clinical preventive services. Measures to increase health-care access through expanded health insurance are likely to increase the use of reproductive health services among adolescents. Giving adolescents the skills to make informed decisions about reproductive health and that encourage parent-child communication might also be helpful. Health-care providers need to be more aware of recent recommendations regarding appropriate reproductive services for adolescents. Efforts to increase use of reproductive health services should target youths who are least likely to receive recommended services (e.g., younger adolescents and those without parental support).

CDC, in collaboration with the U.S. Department of Health and Human Services' Office of Adolescent Health and several state and local community-based organizations, is using evidence-based strategies to reduce rates of teen pregnancy and birth in communities with the highest rates, with a focus on African American and Hispanic persons aged 15–19 years. One component of this 5-year project focuses on increasing access among teenagers to contraceptive and reproductive health-care services by establishing linkages between community-based organizations and health-care providers and by ensuring that clinicians provide teen-friendly, culturally competent reproductive health-care services (32). CDC also is partnering with AAP to develop training for providers on how to screen and counsel adolescents on sexual activity and contraceptive use.

Key stakeholders (e.g., schools, community-based organizations, and faith-based organizations) can improve the use of reproductive health services by providing evidence-based reproductive health education, supporting parents' efforts to speak with their children about reproductive health (including pregnancy prevention) as recommended by CDC's Community Guide for Preventive Services, and connecting adolescents to health-care providers for reproductive health services. Key professional medical associations recommend that health-care providers provide teenagers with access to an array of contraceptive methods and medically accurate reproductive health counseling (33–35). Topics could include the safety of contraception and the importance of consistent and correct use of contraception, particularly condoms because of the added protection from STDs, including HIV infection. Finally, health-care providers should be aware that all contraceptive methods, including long-acting reversible contraception (i.e., intrauterine devices and implants) have not been documented to cause long-term adverse effects when used by teenagers and are recommended for use by various professional organizations (27,36).

Births among teenagers cost an estimated $10.9 billion each year in health-care and child welfare expenditures, increased incarceration rates among children of teenage parents, and lost tax revenue from lower income and future potential earnings among the children of teenage parents during their own adult lifetimes (37). Furthermore, a 2004 report estimates that the total cost of STD cases among persons aged 15–24 years was approximately $6.4 billion (38). Ensuring access to clinical reproductive health services can save billions of dollars and allow for funds to be spent on other public health issues.

Limitations

The findings in this report are subject to at least two limitations. First, because data on the receipt of reproductive health services are self-reported and were not verified by clinical record assessment, the actual services received might have been underestimated. Second, because of social response bias, teenagers might underestimate or overestimate their receipt of reproductive health services. The data are derived from adolescents' self-report of previous sexual intercourse, and certain respondents might not have wanted to admit to a history of sexual activity. In addition, adolescents who reported engaging in oral or anal sex but not sexual intercourse were not included; however, oral and anal sex can cause STDs, which also might have resulted in an underestimate.

Conclusion

Many adolescents are not receiving recommended preventive reproductive health services. Recent changes in health care related to reducing or eliminating copayments might increase the number of adolescents who receive these essential preventive services, including contraception and STD services. Simply making services available is unlikely to be sufficient to increase use. Teenagers should be educated, parents should be engaged, and health-care providers should be given the necessary skills to support increased use of reproductive health services by adolescents. Because this report provides baseline estimates of receipt of reproductive health services by sociodemographic and sexual risk behaviors of adolescents, the data can be used to monitor improvements in the receipt of clinical reproductive health services by adolescents over time to ensure achievement of national health goals and improvements in the reproductive health of adolescents.

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