Washington, DC—In new guidance out today, the American College of Obstetricians and Gynecologists (ACOG) underscored the importance of beginning the conversation between provider and patient about contraception during adolescence. Contraception plays a vital role in women’s health care, from preventing pregnancy to management of chronic conditions. Most women will use contraception off and on for over 30 years.
By the 12th grade, more than half of young women report having had sex. In an effort to provide anticipatory guidance, discussions about contraception, sexually transmitted disease prevention, and other sexual health issues should begin before a girl has become sexually active, ideally during the first reproductive health visit between ages 13-15. However, regardless of a patient’s age or previous sexual activity, contraceptive counseling should be a routine part of every visit.
“Contraception should be a conversation with patients as early as appropriate,” said Committee Opinion author, Karen Gerancher, M.D. “When we’re able to reach patients before they become sexually active, or early on in their sexually active life, we empower them to take control of their reproductive health, and prevent sexually transmitted infections and unintended pregnancies that could permanently impact the future they’ve envisioned for themselves.”
Conversations should be comprehensive, addressing patients’ reproductive health history, contraceptive needs, expectations and concerns.
ACOG recommends ob-gyns begin with a discussion of the most effective forms of contraception, including long-acting reversible contraceptives (LARC). However, patient preference should take priority; women and girls have the right to make their own decisions about whether and when to start and stop any contraceptive method. All discussions should include the effectiveness, advantages and disadvantages of each method.
It’s also important doctors are aware of and sensitive to barriers to accessing certain methods and patient preferences, and adjust their counseling as necessary. Ob-gyns should also be careful to note that methods like the pill or LARC do not prevent the transmission of STIs, and so a dual method use, condoms to prevent STIs in combination with a more effective contraceptive, is ideal.
Young patients may not be as effective in verbalizing concerns, and are often more susceptible to embarrassment, intimidation, and coercion from peers, parents and even their physicians. Through open-ended dialogue ob-gyns can enable adolescent patients to make informed decisions about contraception guided by individual priorities and preferences.
“It’s our job to be a trusted resource for young patients,” said Gerancher. “By establishing that trust early on, patients are more likely to ask routine but important questions about their reproductive health and turn to us in confidence when they’re concerned about their health.”
Adolescents may prefer to keep conversations about contraception within the confidences of the patient-provider relationship. When feasible, this should be respected, but it’s also important that ob-gyns are familiar with their state’s statutes on the rights of minors to consent to health care services.
Following an initial reproductive health visit, ob-gyns should continue to check in with adolescent patients about their contraceptive choices at subsequent visits, assessing for adherence to and satisfaction with chosen methods.
More information is available in Committee Opinion #710, ‘Counseling Adolescents About Contraception.'
Other recommendations issued in the August Obstetrics & Gynecology
Committee Opinion #709, "Commercial Enterprises in Medical Practice"
Monetary reimbursement of physicians in exchange for medical advice and treatment is well established and accepted in medical practice. However, financial pressures and the pervasiveness of entrepreneurial values have led some physicians to widen the scope of activities for which they seek reimbursement. Some of these commercial activities are ethically problematic in the clinical setting. Obstetrician–gynecologists should strive to ensure that commercial enterprises in medical practice do not compromise the patient-focused mission of clinical care. In this Committee Opinion, the American College of Obstetricians and Gynecologists' Committee on Ethics differentiates between commercial activities judged to be generally ethically appropriate for obstetrician–gynecologists and those that are not.
Committee Opinion #711, “Opioid Use and Opioid Use Disorder in Pregnancy”
Opioid use in pregnancy has escalated dramatically in recent years, paralleling the epidemic observed in the general population. To combat the opioid epidemic, all health care providers need to take an active role. Pregnancy provides an important opportunity to identify and treat women with substance use disorders. Substance use disorders affect women across all racial and ethnic groups and all socioeconomic groups, and affect women in rural, urban, and suburban populations. Therefore, it is essential that screening be universal. Screening for substance use should be a part of comprehensive obstetric care and should be done at the first prenatal visit in partnership with the pregnant woman. Patients who use opioids during pregnancy represent a diverse group, and it is important to recognize and differentiate between opioid use in the context of medical care, opioid misuse, and untreated opioid use disorder. Multidisciplinary long-term follow-up should include medical, developmental, and social support. Infants born to women who used opioids during pregnancy should be monitored for neonatal abstinence syndrome by a pediatric care provider. Early universal screening, brief intervention (such as engaging a patient in a short conversation, providing feedback and advice), and referral for treatment of pregnant women with opioid use and opioid use disorder improve maternal and infant outcomes. In general, a coordinated multidisciplinary approach without criminal sanctions has the best chance of helping infants and families.
Committee Opinion #712, "Intrapartum Management of Intraamniotic Infection"
Intraamniotic infection, also known as chorioamnionitis, is an infection with resultant inflammation of any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua. Intraamniotic infection is a common condition noted among preterm and term parturients. However, most cases of intraamniotic infection detected and managed by obstetrician–gynecologists or other obstetric care providers will be noted among term patients in labor. Intraamniotic infection can be associated with acute neonatal morbidity, including neonatal pneumonia, meningitis, sepsis, and death. Maternal morbidity from intraamniotic infection also can be significant, and may include dysfunctional labor requiring increased intervention, postpartum uterine atony with hemorrhage, endometritis, peritonitis, sepsis, adult respiratory distress syndrome and, rarely, death. Recognition of intrapartum intraamniotic infection and implementation of treatment recommendations are essential steps that effectively can minimize morbidity and mortality for women and newborns. Timely maternal management together with notification of the neonatal health care providers will facilitate appropriate evaluation and empiric antibiotic treatment when indicated. Intraamniotic infection alone is rarely, if ever, an indication for cesarean delivery.
Committee Opinion #713, "Antenatal Corticosteroid Therapy for Fetal Maturation"
Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family's decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation who are at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.
Practice Bulletin #181, "Prevention of Rh D Alloimmunization"
Advances in the prevention and treatment of Rh D alloimmunization have been one of the great success stories of modern obstetrics. There is wide variation in prevalence rates of Rh D-negative individuals between regions, for example from 5% in India to 15% in North America (1). However, high birth rates in low prevalence areas means Rh hemolytic disease of the newborn is still an important cause of morbidity and mortality in countries without prophylaxis programs (1). In such countries, 14% of affected fetuses are stillborn and one half of live born infants suffer neonatal death or brain injury (1). The routine use of Rh D immune globulin is responsible for the reduced rate of red cell alloimmunization in more economically developed countries. First introduced in the 1970s, the postpartum administration of Rh D immune globulin reduced the rate of alloimmunization in at-risk pregnancies from approximately 13–16% to approximately 0.5–1.8% (2, 3). The risk was further reduced to 0.14–0.2% with the addition of routine antepartum administration (2, 3). Despite considerable proof of efficacy, there are still a large number of cases of Rh D alloimmunization because of failure to follow established protocols. In addition, there are new data to help guide management, especially with regard to weak D phenotype women. The purpose of this document is to provide evidence-based guidance for the management of patients at risk of Rh D alloimmunization.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org