Of the 6.7 million pregnancies in the US each year 48% are unplanned. Disturbingly,  about half occur in women who were using contraception at the time of conception. That statistic haunts me. As health care providers we must take that to heart and change the way we think about birth control counseling. Is there more that we can do to help prevent unplanned pregnancy in those who are actively using birth control?

When we break down the statistics and focus on young people the numbers are even more striking.  Shows like TeenMom and 16 and Pregnant draw media attention to teen pregnancy. Ironically, young women ages 15-19, are the most likely group to have used birth control the last time they had sex. The problem is this age group typically chooses methods with higher failure rates such as cycle timing, condoms, withdrawal method and birth control pills. The result is unsurprising — unplanned pregnancies.

Young patients often ask me, “what is the best birth control?” My answer is always the same – “The one that YOU will use.” There is no “right” answer. Effective contraceptive counseling involves not only providing information and options,  but also matching the right method to the right person.

Research shows that pregnancies occur less often when one chooses a contraception option that requires the least amount of effort. This is not a surprise.  Condoms work great unless you never take them out of your pocket. Birth control pills also are effective but not if you forget to swallow them. Despite the many contraception options available many patients are unaware of the choices. Linguistically speaking the phrase “birth control” is synonymous with oral contraceptives for many people. Birth control refers to many more methods than just birth control pills. Health care providers should never assume patients know all of the alternatives. Pregnancy can be prevented with a variety of nondaily options that are safe and easy to use.

When discussing  contraception with young patients, start with methods that require the LEAST amount of effort and then work backwards to the methods that require the Most effort. Direct patients to the options that have the best track record. Keep in mind that efficacy has a direct correlation with compliance. The more effort the birth control method demands from the patient the less effective it will be long term.

At Macarthur Ob/Gyn we always start with Mirena IUD, Paragard IUD and Nexplanon. We discuss the risks, benefits and potential side effects. These methods involve one visit for insertion and one for removal providing coverage for 5 years, 10 years and 3 years respectively. These methods have the highest efficacy rates and excellent continuation rates. They have excellent safety profiles, few side effects and few medical contraindications. Despite that, nationwide less than 10% of adolescents are using these methods collectively referred to as LARCS (Long Acting Reversible Contraception.) We focus on LARCS because they have the highest success rate at preventing unplanned pregnancy. We spend time addressing fears, misconceptions and myths. We make sure our patients are aware of these options. We use technology in the office via an on screen waiting room power point presentation highlighting the birth control options. We use social media platforms to educate our patients on their birth control choices. As a result a much higher percent of our young patients are choosing LARCs as their preferred method of contraception.

While the patient should ultimately choose the best for her, the health provider should be guiding her to the methods that can best meet her goal of preventing pregnancy. By increasing the use of LARCs we can dramatically impact the number of young women struggling with unplanned pregnancy while using contraception.

Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee Opinion No. 539. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:983–8.

There are certain situations in my life where I feel really stupid. One is when CNBC’s Squawk Box senior economics reporter Steve Liesman discusses the bond market. While I recognize the words he uses as English grammar,  I find almost every word to be incomprehensible gibberish. Recently, he informed me that “given the Feds propensity towards quantitative easing in Q4 the 10 year yield could hit 3%.” I think that has something to do with money, and I have a suspicion that it might be important.

Another situation in which I am humbled and forced to recognize my own ignorance is when I get my oil changed. I know nothing about cars. It’s just not my thing. About half way through the visit the mechanic comes out with this round thing in his hand. He tells me it’s an air filter. He also tells me based on my past record at the Jiffy Lube that I am due to have it replaced. I realize that I do not know the current recommendations for air filter maintenance on a Jeep. While examining the filter with the mechanic I am unable to determine if the level of grime meets the criteria for replacement. Being totally honest, I am not even sure it is really an air filter or even a car part.

I am ok with this. I don’t have to know these things. We all have our areas of expertise, and there is nothing wrong with having to rely on others to get through life. Before spending the money though, I Googled  the current recommendations for air filters. This was easily accessible material. It verified that based on my past history I was due for a replacement in the near future. This research helped guide my decision making. There was no misconception that I knew more than the mechanic. I used the information to ask better questions and to navigate through an area in my life in which I am uncomfortable. Ultimately, I made the decision based less on my research, but rather in my trust and confidence in the advice of the mechanic.

For patients, a doctor visit can feel like I did at Jiffy Lube. A patient is placed in a situation where there is a profound knowledge gap. As a doctor who believes in the power of online patient engagement, I am torn.  I want my patients to educate themselves online. I want my patients to read, to learn and to educate themselves online. But I have seen patients fall into the trap of the Dunning–Kruger effect — believing they know and understand more than they actually do. The Dunning-Kruger effect demonstrates that people overestimate their ability and knowledge when exposed to a subject. This can be dangerous when dealing with health information.

Health information is widely available online. In a simple Google search one can find a plethora of information on virtually any health topic. The problem is that health information is unsorted and often unvalidated, and thus hard to interpret in order to take action. Information can be very helpful in some cases. But in other cases it can be anxiety producing at best and at worst flat out wrong.

Researching health information is very important, but we must recognize our own limitations. Understanding health information is hard. Science is complicated. Scientific studies often contradict each other. Health questions often just beg more questions, not always definitive answers. For every topic we Google and read about there is likely a PhD who makes a living researching that one question every day. While studying on our own we must also value and respect health professionals’ years of studying, expertise and experience.

My advice to patients is to continue to use the Internet as a supplemental tool to augment the provider-patient relationship not as a wedge to hinder it. Use the Internet to improve your baseline knowledge, to ask better questions, to create a higher level conversation and to better understand the recommendations.

Recognize the content you read may just be the tip of the iceberg and acknowledge your limitations. Ultimately, use your research to help determine your level of trust and confidence in your healthcare provider.

When I look in the eyes of a pregnant teenage patient, I see my wife. My wife was a teen mother. She was a teen mother who beat the odds. She is NOT a statistic. She is an example of the tremendous potential that lies before each and every teen facing the challenges of teen pregnancy. Pregnancy did not stop her from succeeding. My wife tells the story of riding her bicycle to her doctor’s appointments. She raised her child, graduated high school and worked her way through college and nursing school. Her determination created a successful life for herself and Jaclyn, her daughter. This is what I see when I see young pregnant patients — potential and opportunity. I know that as a doctor I can make a difference that not only helps them but also the lives of their children. For this reason, I dedicate my time and energy working with teens in the office and educating Irving ISD teens about teen pregnancy.

In 2003 I joined  MacArthur OB/GYN, a medical practice in Irving, Texas. I began seeing a large volume of young teenagers in my practice and was surprised at the prevalence of sexually transmitted disease, teen pregnancy and an overall lack of knowledge regarding sexual health. I reached out to the local school nurses and offered myself as a resource. Over time this relationship evolved. Navigating through a politically charged issue like teen pregnancy was a challenge, but after gaining the support of Irving ISD administration I began giving lectures and presentations on Teen Pregnancy and STD prevention. I have spoken to countless Irving ISD students over the past 10 years providing information about sexual choices, personal responsibility, sexually transmitted diseases and pregnancy prevention.

I work closely with the Teenage Pregnant and Parenting students program, TAPPS, a district wide program that meets the needs of pregnant and parenting students. While the national high school graduation rate for teen parents hovers around 40%, the graduation rate for our TAPPS students is over 90%. By creating a partnership between the TAPPS program and MacArthur OB/GYN  we extend the reach of the program beyond the four walls of the classroom. The physicians at MacArthur OB/GYN not only care for the pregnancy, but also work with the student to make sure they are enrolled in the TAPPS program. We enroll them in the YWCA Nurse Family partnership which provides mentorship, prenatal and parenting education. We schedule visits around the school day. We empower the students to be ready to parent and aggressively educate on contraception to avoid a second teen pregnancy. We have demonstrated that identifying the pregnant students and meeting their specific needs can change lives. We see successful pregnancies and help the students achieve success in the classroom. The payoff for these efforts will be seen for generations to come.

In addition, I have served on the Irving ISD Health Advisory council since 2004. We evaluate and recommend programs on sexual health to be adopted by the district. Teens rate sexual health information as the number one issue they want to learn about in health class. Through our efforts we have implemented evidence based, effective and factual information on sexual health district wide.

In my school presentations I give fact based information from a health perspective. The students understand the type of diseases, the methods of transmission and how to avoid them. We also discuss the impact of teen pregnancy. Beyond the health information, I relay a message of individual responsibility. I empower the students to understand that they have choices. Teen pregnancy and STDs are not inevitable but rather a decision that they have control over.

During the presentation I always ask the students to write me a letter in 10 years telling the story of their life. I paint a realistic picture of what most of their stories will be. Statistically speaking the outcomes are not pretty. The sad truth is most of the young students in the office will not have an inspirational story to tell. I challenge these young people to be different. I challenge them to overcome the statistics and to tell me a story like my wife’s — one where they lifted themselves up, overcame the obstacles and created a wonderful, successful life for themselves and their child. At the end of an office visit a few years ago a patient of mine said “I have 4 more years.” I was not sure exactly what she meant. She clarified that six years before  she was sitting in a high school auditorium listening to me speaking at Union Bower High school. She was telling me in 4 more years she will write me a letter telling me how she has graduated college and nursing school. You could see and feel the pride and determination as she told me this. Knowing that my words stuck in her head motivating her to succeed caused me to tear up on the spot. Students like this reinforce to me the importance of having health care providers meet the special need of these young patients. Community leaders must continue to work with the school district to impact the lives of young people. I am not naive. I know that teen pregnancy will continue to be a challenge in Irving, Texas and across the world. But I also know that a health care provider can touch lives. Each day we can serve as one stepping stone helping a young patient along the pathway to a successful life. The physicians at MacArthur OB/GYN are committed to playing our part. Together we can make a difference.