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Contraception Editorial July 2008

The Lost Years: The Challenge of Delivering Reproductive
Health Care to Young Adults

By: Linda Dominguez and Wayne Shields

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Young adults — loosely defined as people in their late teens to mid-20s — are a fluid group in an exploratory phase of their lives, with their own language and style of communicating. These “20-somethings” are continuously experimenting, testing new concepts and acculturating in ways that mesh with their developing identities. These individuals are more mobile than children or older adults, many are newly independent and less rooted in their communities than other age groups, and they do not have as many societal or familial support systems as adolescents.

Complicating matters, there is a paucity of medical literature about contraceptive use and misuse in young adults. While the body of research on teens, contraception and pregnancy is fairly robust, more investigation is sorely needed to better understand barriers to care for these 20-something adults. As members of the reproductive health care team, our challenge is to make it as easy as possible for this elusive population to receive the reproductive care they need.

1. Life stage and risk perception impact reproductive care 

Pressures that can impact the lives and judgment of young adults include new status as independent adults, the distraction of establishing a career or completing an education, frequent address changes, lifestyle changes and experimentation, and alcohol and drug use. There are also significant systems barriers to their reproductive health care. Examples specific to the United States include reductions of publicly funded (Title X) services for contraceptive care, frequent and confusing formulary changes from one generic pill to another, and loss of low-cost oral contraceptive pill (OCP) pricing.1

Although unintended pregnancy rates have begun to decline in adolescents, they have consistently risen in the 20-something group in the United States. The Guttmacher Institute reported in 2006 that unintended pregnancy rates among women ages 18–24 years were twice that of other age groups, with more than one unintended pregnancy for every 10 women. This trend continues among women ages 25–29 years.2

Young adults in developed countries are especially out of touch with their short- and long-term health care needs and the impact of risky behaviors, especially when it comes to reproductive health. For example, a 2006 study from the Journal of Sex Research reports that despite participation in sexual risk activities — including highly inconsistent condom use during intercourse — young adult participants uniformly reported highly safe pregnancy and sexually transmitted disease (STD) prevention practices and little to no risk.3 In one study of undergraduate students in the United States, those who said they intended to have children someday were particularly disconnected from issues related to sexuality, pregnancy and child-rearing. This group was especially unaware of expenses associated with parenthood, consistently estimating far lower than parents or those unsure of having children.4 In an Australian study of sexually active young adults, 40% said they did not use a condom to protect against pregnancy and sexually transmitted infections all or most of the time.5 According to data collected for the latest National Survey of Family Growth, conducted by the US National Center for Health Statistics, males and females aged 20–24 years have the highest percentage risk of any age group for HIV acquisition based on risky sexual behavior, drug use or STD treatment criteria.6 Another US study from 2002 reports that nearly 20% of teens 15 to 19 years say that they did not use contraception at their last episode of intercourse and less than half use a highly effective method with a failure rate of less than 10%.7 Authors of a 2007 review article from the Australian Family Physician journal report that young people aged 12–25 years are sexually active at a younger age and have more sexual partners compared to previous generations.8 Clearly, there are risk perception, systems and lifestyle barriers to effective care for young adults.

2. The challenge for health care providers 

Unfortunately, young adults seem to be inconsistent advocates for their own health care. As members of the health care team, we must clearly understand and address barriers to effective reproductive care that are particular to this group. Some challenges to delivering effective reproductive care to young adults include:

  • Limited focus on contraception and family planning in some health care systems
  • Limited access to health care information: community health, college health, state-supported health care
  • Lack of understanding among young adults about how health care systems work
  • More mobile, newly independent, less “rooted” population
  • Less than ideal training and mentoring for health care providers on contraceptive methods and counseling techniques
  • Lack of effective sex education in schools
  • Patient dissatisfaction with their health care providers' availability, attitude and approach9
  • Knowledge gaps among members of the health care team about contraception and reproductive health10

There are a number of ways to work within your own health care system to make it as easy as possible for this elusive young adult patient to receive reproductive and contraceptive care.

2.1. Advocate for improved communication between members of the health care team 

We need to involve the entire health care team in consistently addressing the needs of young adults: clinicians, medical assistants, pharmacists, front office staff, telephone triage and anyone else who potentially has contact with 20-something patients.11 Work to ensure that all members of your health care team are saying the same thing to young adult patients and that there is an effective process in place for internal communication between team members.

2.2. Work to introduce “gateways” to care in your own practice 

There is a very real chance that young adult women might get pregnant before they are able to navigate through the many inherently complex health care systems in most countries. Many of these young adults are new to the workforce and are likely to be employed in entry level positions with few health benefits such as sick leave. When possible, work within your practice to develop systems that can reduce barriers to good reproductive health care for young adults: institute early and late appointment hours; if you do not already, institute Saturday appointments; incorporate quick start contraception protocols;12 stock as much of the various contraceptives methods as you can to help ensure consistency of care and avoid confusing situations like generic OCP switching; streamline insurance and payment processes as much as possible; and provide easy on-site and on-line access to contraceptive counseling.

2.3. Focus on unintended sex, not just unintended pregnancy 

As members of the reproductive health care team, we have an understandable tendency to focus on unintended pregnancy as an end point. We have a good chance to positively impact young adult reproductive health care if we can educate our patients about unintended sex, the precursor to unintended pregnancy. Ensure that reproductive health and contraceptive counseling includes sexuality education and strategies for preventing unintended sex.

2.4. Involve family, partners and friends in their reproductive health care 

The more you can involve family members, partners and close associates of your young adult patients in their reproductive care, the greater the chances of success. In a prime illustration of this principle, data analysis of 3828 young women who participated in the National Education Longitudinal Study indicates that parental involvement increases the odds that young adult women will use contraception.13

2.5. Develop a reproductive life plan with your young adult patients 

A reproductive life plan includes health, education, career and family goals, and is a blueprint to help your 20-something patients reach and accomplish important milestones in their lives. Work with your young adult patients to determine (1) whether or not they intend to have children, (2) what actions they will take to prevent pregnancy until they are ready, (3) what contraceptive strategies and method will best match their needs and help them to reach their goals and (4) what strategies can be developed to involve partners in the choice and use of her contraceptive method.

2.6. Advocate for continuing reproductive health education for the entire health care team 

Your young adult patients can benefit from working with an informed health care team. One recent study concluded that “young physicians have a contraceptive knowledge base that is inconsistent across primary care specialties. Improvement in this area might improve the unintended pregnancy rate in the United States”.10 Certainly, all members of the health care team can benefit from continuing reproductive health education — and so can your 20-something patients.

Young adults are in the most dynamic period of their lives. This vulnerable population needs and deserves a skillful, direct and individualized approach to their health care. The health care team's challenge is to design systems and clinical approaches that respond to the needs of young adults and move beyond barriers to their care. Despite health systems challenges, access issues, high-risk patient behaviors and the need for more health care provider training, all members of the health care team have an obligation to bring high-quality, effective reproductive health care to the young adults who can benefit most. The consequences of unintended sex and unintended pregnancy are too great.

Linda Dominguez
Southwest Women's Health
Albuquerque, NM

Wayne Shields
Association of Reproductive Health Professionals
Washington, DC


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Used with permission from Elsevier, Inc.