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Melanie Cole, MS (Host): Welcome to UAB Med Cast. I'm Melanie Cole. joining me today to discuss teen pregnancy prevention is Dr. Amy Boone. She's an assistant professor and a specialist in pediatric and adolescent gynecology at UAB Medicine. Dr. Boone. Thank you so much for joining us. What a great topic we're discussing today. Let's start with the problem of teen pregnancy in Alabama and around the country. Tell us a little bit about the prevalence and what you've been seeing in the trends.

Dr. Amy Boone: Thank you so much for having me Melanie to talk about this important topic. So teen pregnancy is a big problem. I think we're all aware of that in 2013, one in five. 15 year olds and two thirds of 18 year olds reported that they had ever had sex. So that translates to nearly three in 10 teen girls in the United States will get pregnant at least once before they turn 20 years old. Luckily this number has declined pretty considerably from its peak. It peaked in about 1990. There are certainly some racial and ethnic as well as geographic disparities to the rate of teen pregnancy. So Hispanic and non-Hispanic black teens, their birth rate of is about two times higher then that for non-Hispanic white teens.

And teen pregnancy rates are generally highest in the south and in the Southwest United States, half of these teen mothers don't graduate from high school and then another by-product of teenage sexual activity is of course, sexually transmitted infections. So about nine and a half million adolescent and young adults. And for that classification, we're talking about 15 to 24 year olds. They're diagnosed with STDs every year in Alabama, specifically that translates to in the year twenty, twenty nine hundred and seventy seven patients under the age of 18 were diagnosed with a sexually transmitted infection.

Melanie Cole, MS (Host): Wow. This is a pretty widespread issue. And I mean, there's a lot that goes into this Dr. Boone. Certainly there is now a political climate involved. There is families involved. There are so much involved now. Can you tell us any prevention strategies that have been shown to work?

Dr. Amy Boone: Luckily there's one, it's the comprehensive sex education. So this is supported by many, almost all of the medical professional organizations. So we're talking about the AMA, AAP, ACOG and all of the other ,professional organizations pretty adamantly support this. So this is talking about programs that include information about both contraception and abstinence, and that's been shown to help young people delay their sexual debut. There's also a pretty robust data. Supports that abstinence only education programs, they're pretty scientifically and ethically problematic. They systematically ignore or stigmatize many young people and they just simply don't work.

The other thing that we know works is greater acceptance of adolescent sexuality. Sexuality is a component of the human experience, and adolescents are not immune to that. And then the last thing is provision of free or subsidized contraceptives specifically will help reduce the problem of teenage pregnancy.

Melanie Cole, MS (Host): So back in the day, Dr. Boone, you know, we had sex education in our classes. Fifth grade sixth grade something, plus there were magazines, you just snuck around. Kids are much more worldly today. There's this global knowledge base and experience that they have. Where are they receiving their sex education in general? And where would you prefer that they be getting this type of education?

Dr. Amy Boone: So one of the newer phenomenons that we're all as parents and providers trying to navigate is digital media. 73% of adolescence. 13 to 17 own a smartphone. So they're carrying around a small computer with an access to a tremendous amount of information, whether that's accurate or inaccurate. Most of the time, the most alluring sites are not providing the most medically sound advice to these kids. So only about half of adolescents received formal instruction about contraception before they first had sex, about four and 10 of them got instruction about where to get birth control. So that's only about 40% school policies vary widely across the country.

Specifically in Alabama public schools, we have a policy that says sex education must stress that abstinence from sexual intercourse is the only completely effective protected. And that's protection against unwanted pregnancies, STDs and AIDs. So, as we talked about before, abstinence only education has proven to be ineffective. However, that is still the policy and our state. So over 70% of young people, 15 to 19 reported having talked with a parent about at least one of six sexual education topics, and those topics are how to say no to sex? What are the methods of birth control?

What are STDs? Where do you get birth control? How do you prevent HIV and how do you use a condom? So it's a pretty high number. There was a big study that was done looking at visits from 2009 to 2012. And they showed that sexual health conversations with patients. So in a clinical setting, patients ages 12 to 17, those conversations lasted an average of 36 seconds. It's not a lot of time to talk about all of the things and to openly answer all of the questions. So luckily we talked a lot about social media. A lot of providers and sexual health advocates are jumping on the bandwagon and they're creating content that is evidence-based and also palatable to a teenage audience to spread accurate information around sexual health.

Melanie Cole, MS (Host): Wow, this is such a great and so important topic. Now you're speaking to providers around the country. But when you are working as the expert that you are with adolescents and young adults, how are you dealing with this in your practice and with their families? Because I know there's a point where I know my 19 year old daughter where I didn't get to go into the gynecologist office with her and I had to stay back out of, you know, out in the office.

So, how do you help the families to have these conversations and how would you like other providers to start these conversations as well? Because as we said before, they've got this whole internet computer right at their fingertips. So they are seeing things that maybe their parents want discussed in a different manner. So how do you bring all this together for them?

Dr. Amy Boone: Yeah, absolutely. So like you said, we give our adolescents and young adults time by themselves in our office. So we do have a law in Alabama regarding confidentiality and miners, 14 years and older can consent for reproductive health services. So we openly communicate that with the patient and her parent or guardian and stress, the importance of that confidentiality. We talk with the patient about ways that, that confidentiality may be unintentionally breached by using the patient portal, whether their parent has access to that or not. How do they want us to communicate the results, whether that's pregnancy test or sexually transmitted infection testing.

So we get there cell phone number specifically to make sure we're not calling the wrong person. And then the use of title 10 clinics, that can definitely help avoid the explanation of benefits. So whenever you receive contraceptive services, many people receive a EOB that explains what wasdone, and that can be an unintentional breach of that confidentiality. Of course, w e encourage the patients to communicate with their parents openly there's other data that suggests that outcomes are better. Teen pregnancy rate in sexually transmitted infection rates are lower when there's an open line of communication, but we don't require it.

Not all parents are open and ready to receive that information or have those kinds of conversations. So the other important thing is just to avoid any assumptions regarding sexual orientation. We're certainly in a time of change as far as gender and sexual identity goes. This is No different to our adolescent population. The question I would say to avoid is the traditional one that we were all taught. Are you sexually active? So that means very different things to different people. So it's better to be direct and open with your line of questioning. And your overall goal is to find out if the patient's sex life is fulfilling, autonomous and contributing positively to their overall health.

One strategy that I'd like to share with other providers is to focus on the five-piece. These conversations can be a little bit uncomfortable. So if you have a guideline, like the five P's that can really help. So the first P is partners. You want to know the number and gender of the partners that can help you assess the risk. A risk is also assessed with the practices. So the next P and that's knowing what tests to order and what sites you need to obtain the from. The third P is protection from sexually transmitted infections. So talking about condom use, talking about prep, which is pre-exposure prophylaxis for HIV.

The next P is past history of STRs. Most people say no to that question, but many of them have not been tested. So you have to ask, have you ever actually been tested? Has your partner been tested? And then the last one is prevention of unintended pregnancy.

Melanie Cole, MS (Host): Very comprehensive Dr. Boone. And as we're talking about contraception and contraceptive options that are available for teenagers, again, our teens are hearing. Around the country and through social media, that these things that they're being looked at and changed. And there's all this talk. What do you tell teenagers about contraception? The importance of preventing sexually transmitted infections and unwanted teen pregnancies and all of these things, the importance of contraception and what types do you recommend?

Dr. Amy Boone: There's lots of varying questions about contraception and you're right. A lot of that stems from social media and what they hear from friends at school. So medically, many of them are concerned about things like weight gain or changes in their complexion. Many people are worried that contraceptive use for a long time will impact fertility in some way, shape or form. Many parents are concerned that contraception access as a license to have sex and data, very vehemently opposes that notion that has not panned out in any of the studies and the. And other non-medical concerns, teenagers are worried about lack of access. They're worried about lack of access either from the clinic or from restrictions, from political policies that are coming down the pipeline.

They're worried about confidential care, costs of services. There are ways get contraception online and it's legal in labama. One of the barriers is you have to have a digital form of payment to order that. So some co some form of credit card or debit card to place that. And then there's also a pervasive belief that they can't get pregnant. So they don't know that they really need it or that they've had sex several times and haven't gotten pregnant yet. So they're doing okay. And then the last thing is one thing we work on a lot is partner negotiation skills. So how do you have a conversation with your partner asking them to use contraception, to keep you both safe?

Melanie Cole, MS (Host): Yeah, that's really a great point that you just made. And this is such a comprehensive issue. It really is. It's similar in that way to the obesity epidemic. There are so many parameters and so many factors that influence what we see going on in the country today. As we wrap up, what would you like the key takeaway to be about the importance of communication, these discussions, knowledge based discussions, medically based discussions with teenagers and their families for other providers?

Dr. Amy Boone: So one of the important things is there is no restriction on any method of contraception based on age alone. There are lots of great. This is out there for providers who want to learn more about how to safely provide contraception. In 2016, the CDC updated their medical eligibility criteria for contraceptive use. There's a phone app that allows you to stratify risk based on medical conditions history which is really helpful. And then the dual method is the best for everyone, adolescent specifically. So condoms for STI protection combined with a more effective contraception. And the good news is contraceptive use is on the rise with a rapid uptake in LARC use among 15 to 19 year olds in the past five to 10 years.

The Title 10. Federal family planning program clinics exist. There are three within 20 miles of UAB and then 147 of them within 150 miles. So there are resources out there. And then the last thing is emergency contraception is also another widely available thing. So that can provide protection from pregnancy as many as as many as 120 hours after unprotected intercourse. And so the biggest takeaway is, you don't have to prescribe this to everybody. If you don't feel comfortable, but just know who to reach out to. We're always willing to give advice over the phone or to get somebody in to have these complicated conversations.

Melanie Cole, MS (Host): Well, you certainly are. And so knowledgeable. Thank you for such an informative podcast today. And a physician can refer a patient to UAB Medicine by calling The MIST line. At 1-800-UAB-MIST or by visiting our website at UAB medicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole.