Diane H. Schetky, M.D.

Controversy erupted last fall over the decision of the Portland, Maine School Committee to make prescriptions for birth control available to students at King Middle School through the school’s health center. The decision was spurred by Amanda Rowe, R.N., coordinator of Portland School nurses. Rowe, a tireless advocate for children’s health and sex education, also happens to be married to the Maine Attorney General. She believes it is preferable to make birth control available to students who do not heed abstinence counseling than to have them become pregnant. The decision to make birth control available to students, whose ages range from 11-15, at King Middle School was endorsed by the Family Living Advisory Board composed of school administrators, health professionals, and parents. Those children receiving contraception prescriptions would have to have approval from their parents or guardian to visit the clinic, but not necessarily for birth control pills.

Television commentators responded to the decision to provide contraception to some middle school students saying it created a conflict of interest for the Attorney General. Republicans began trying to recall school board members. The district attorney for Cumberland County responded, noting that Maine Law prohibits sex with a person under age 14, regardless of the age of the other person involved. Consensual sexual relations between adolescents are permissible as long as both are 14 or older and their age difference does not exceed 5 years. Health care providers are mandated to report all known or suspected cases of sex with minors 13 years of age and under because this constitutes a crime.

Portland’s six school-based health centers apparently have no policy in place on reporting, and staff was unaware of any duty to report sexually activity of children ages 13 and under. Critics note that were such a policy enacted, it could have a chilling effect on students seeking health care.

Maine law allows health care professionals to provide a variety of health related services, including contraception, testing for pregnancy, treatment of sexually transmitted diseases (STDs), substance abuse, and psychiatric treatment, to minors without parental consent in situations where getting parental consent might be an obstacle to care. The law further gives health professionals the discretion to notify parents in situations where failure to do so might compromise treatment or jeopardize the minor’s health.

Nationwide, teen childbearing declined steadily since the early 1990s. The decline was attributed to fewer teens becoming pregnant and to the use of abortion. By 2002, the abortion rate had dropped 50 percent from its peak in 1988, and much of this was attributed to fewer teens becoming pregnant. Marked declines in teen pregnancies occurred among black and white teenagers, but the decline was less pronounced among Hispanic teens.

Teenage birthrates were the highest in Nevada, Michigan, Texas, Arizona, and New Mexico, whereas the lowest rates were found in Vermont, North Dakota, Maine, and Massachusetts. According to Santelli et al. (2007), 86 percent of the decline in the teen pregnancy rate was due to improved use of contraceptives, whereas 14 percent was attributed to teens, mostly in the 15-17 age group, delaying having sex. By 1995, 13 percent of teens were using long-acting contraceptive methods, which may also have contributed to the declining birthrate. The authors note that these findings raise questions about the value of federal funding of abstinence programs. Despite the promotion of abstinence pledging, 88 percent of pledged teens have had sexual relations prior to marriage. In addition, participants in abstinence programs were found to be less knowledgeable about STDs, as these programs prohibit dispensing information about STDs and condoms.

A report issued by the Centers for Disease Control and Prevention in December 2007 noted that pregnancy rates among teenagers ages 15-14 rose 3 percent in 2006 and that the rates rose 4 percent among those 18-19. The report speculated that this increase, the first since 1991, was due to lessened concern about sexually transmitted diseases and subsequent decrease in use of condoms. In addition, the failure of abstinence programs is cited and studies suggesting they might actually increase pregnancy rates.

Despite the low teenage birthrate in the U.S., the rate is twice as high as that in Canada, and four times the rates in France and Sweden. The teens in countries with lower teen birth rates have ready access to sexual education and contraceptive services, and are more likely to use highly effective contraceptive methods, mainly the pill. In addition, the expectation in these countries is that young people complete their education, become independent, and be in committed relationships prior to child bearing. In contrast, there is more tolerance of out-of-wedlock pregnancies in teens in the U.S. where few pregnant teens marry prior to giving birth. Currently, 35 percent of all U.S. school districts have policies that restrict sexual education to the teaching of abstinence. Among schools in the south, 55 percent have such policies. Coincidentally, their rates of teen pregnancy are significantly higher than the national average. A recent nationwide poll of parents showed that 67 percent of them approved of schools providing birth control to teenagers, but 37 percent of this group thought there should be parental consent. Nationwide, less than 5 percent of high schools and only 1 percent of middle schools make condoms available to students. In response to all of the controversy, Portland, Maine school officials considered a plan that would allow parents to forbid schools to provide their children with prescription contraceptives; however, it was withdrawn for lack of support.

The increased use of effective contraceptives by teens has clearly decreased pregnancy in this age group whereas the success of abstinence policies is highly questionable. The question arises as to whether offering contraception to middle school children is perceived as condoning sex at an early age. Presumably, some of these children are already sexually active and one must weigh the consequences of unplanned pregnancy on their future lives and educations. Raising the topic of contraception within the confines of school health clinics allows children an opportunity to discuss their concerns with a neutral, well informed person, and for nurses to offer them sex education, guidance, and choices.

Some students who seek help may be products of abusive homes or homes where they are afraid to get the information they need. Yet, one must be concerned about infringing upon family values and the extent to which parents should control the health care choices faced by their adolescent children. Some studies suggest that by age 14 children are as competent as adults to make healthcare decisions. However, data is lacking on the long-term effects of starting oral contraceptives or Norplant implants at age or 11 or 12, which makes it difficult for anyone to give informed consent. A final issue concerns the ability of school-based health care providers to gather enough objective information to decide whether or not parents should be contacted if most of their information about the student’s home life comes primarily from the student.

Age of consent and reporting laws on underage sexual activity vary greatly from state to state. It behooves physicians to become aware of when they might have a duty to report. There is also a need to educate teens on laws relating to their sexual activities. Physicians may be able to help parents become more comfortable with discussing sex with their children or referring them to appropriate Websites.

References
Fram A. Poll: Birth control from schools OK. Bangor Daily News, (Nov 2, 2007)

Guttmacher Institute (Updated 2006). U.S. Teenage Pregnancy Statistics National and Stated Trends and Trends by Race and Ethnicity

Guttmacher Institute, (Feb 2002). Report on public policy: Teen pregnancy: Trends and lessons learned, 5(1)

Harris, G. Teenage birth rate rises for first time since ‘91. (Retrieved 12/7/07). www.nytimes.com/2007/12/06/washinton/06birth.html

Santelini J, et al. (Retrieved 11/1/07). Pregnancy rates decline as result of improved contraception. ScienceDaily. www.Sciencedaily.com/relase/20061/12/06120118053.htm

Dr. Schetky is retired from clinical practice, but continues to teach at Maine Medical Center in Portland in the Division of Child and Adolescent Psychiatry.