Contraception Use and Pregnancy Risk Among Adolescents in Pediatric EDs (2024)

Key Points

Question Among adolescents seeking emergency department (ED) care, what is the prevalence of contraceptive use and pregnancy risk, and what proportion of those eligible receive emergency contraception (EC)?

Findings In this cross-sectional study of 1063 individuals seen at 6 pediatric EDs, 28.9% of sexually active female adolescents reported no contraception use, yielding a pregnancy risk index of 7.89 expected pregnancies per 100 adolescents annually. Although 10.2% of participants were eligible for EC, only 5.6% of those eligible received it.

Meaning In this study, adolescents seeking ED care were at high risk for pregnancy and there is an opportunity to expand pregnancy prevention services in the ED setting.


Importance Unintended pregnancy is a major health risk for adolescents in the US, and adolescents face many barriers to obtaining effective and reliable contraception.

Objective To measure and describe the use of contraception, pregnancy risk index (PRI), and emergency contraception (EC) prescriptions among female adolescents accessing the emergency department (ED) for care.

Design, Setting, and Participants This cross-sectional study is a planned secondary analysis of a multicenter trial from April 2021 through April 2022 that used a tablet-based, content-validated, confidential sexual health survey at 6 urban, pediatric tertiary care EDs affiliated with the Pediatric Emergency Care Applied Research Network. Participants were individuals aged 15 to 21 years presenting to the ED who completed the confidential sexual health survey and indicated female sex assigned at birth and prior penile-vagin*l sexual intercourse. Data analysis was performed from January 2023 to February 2024.

Main Outcomes and Measures The primary outcomes were the type and proportion of contraception use, the PRI, and provision of EC. Separate multivariable logistic regression models were performed to identify sociodemographic factors associated with these outcomes.

Results A total of 1063 participants (median [IQR] age, 17.5 [16.5-18.3] years) were included in this analysis; 219 (20.8%) identified as Hispanic, 464 (44.1%) identified as non-Hispanic Black, 308 (29.3%) identified as non-Hispanic White, and 61 (5.8%) identified as other races and ethnicities. In total, 756 participants (71.1%) reported contraception use during their last sexual encounter. Long-acting reversible contraception use (LARC) was the least used (164 participants [15.4%]), and 307 (28.9%) reported no contraception use. Sociodemographic factors associated with overall contraception use, and LARC use specifically, included insurance and race and ethnicity. The overall PRI was 7.89, or an expected 8 pregnancies per 100 female individuals per year. Although 108 participants (10.2%) were eligible for EC, EC was ordered for only 6 (5.6%) of those eligible.

Conclusions and Relevance In this cross-sectional study of sexually active adolescents presenting to the ED, the majority of participants reported using at least 1 form of contraception; however, LARCs were the least used option, and 28.9% of participants reported no contraceptive use. The unintended pregnancy risk was almost 8% in the study population. Few patients eligible for EC received it. These data suggest a high need and potential opportunity for provision of contraception services in the ED setting.


Unintended pregnancy is a major public health problem that affects thousands of adolescents in the US each year. Despite a general decline in US teen pregnancy rates over the last several decades, they remain the highest among developed countries.1 In 2019, the pregnancy rate among female adolescents aged 15 to 19 years was 29.4 per 1000 individuals.2 Furthermore, the vast majority (70.8%) of these pregnancies were unintended.2 In one study3 conducted in an urban pediatric emergency department (ED), most female adolescents aged 15 to 19 years reported they wanted to avoid pregnancy, yet one-third were either pregnant or at high risk of becoming pregnant in the next year. This indicates a substantial unmet need for effective and reliable contraception among teenagers.

There are many barriers to contraception access for adolescents. Policies on minors’ ability to consent for contraceptive care vary from state to state.4 Even in states where adolescents can legally access services, other barriers such as cost and lack of transportation, education, and confidentiality remain.5 Many adolescents do not have an established primary care home and, therefore, use the ED as their primary source of health care.6 Multiple studies3,7 have demonstrated suboptimal contraceptive use and high rates of unintended pregnancy risk in the adolescent ED population.

Thus, we conducted this secondary analysis of a multicenter study to measure and describe the use of contraception and pregnancy risk among adolescents accessing the ED for care. We also sought to identify provision of emergency contraception (EC) to adolescents who were eligible for it on the basis of their sexual behaviors and contraception use.


Study Design

This cross-sectional study is a secondary analysis of a multicenter trial that used tablet-based, patient-entered data to trigger electronic health record–embedded clinical decision support for broad-scale sexually transmitted infection screening at 6 urban, pediatric tertiary care EDs across the Pediatric Emergency Care Applied Research Network from April 1, 2021, through April 30, 2022. This study was approved by each institution’s institutional review board through a single institutional review board mechanism with a waiver of parental consent for participation. All study participants provided informed consent via a tablet computer before participation. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional studies.

Study Population

The study used a content-validated computerized sexual health survey (cSHS).8 The survey was provided in English. Patients were eligible to complete the survey if they were aged 15 to 21 years and had no cognitive or developmental delay, critical illness, or altered mental status that would prohibit them from completing the cSHS. Patients were included in this secondary analysis if they identified sex assigned at birth as female, indicated they had engaged in penile-vagin*l sex, and answered the contraception use question on the cSHS. Race and ethnicity options were defined and identified by the electronic health record (Hispanic or Latino, non-Hispanic Black, non-Hispanic White, and other, which includes American Indian or Alaska Native, Asian or Pacific Islander, and any other race or ethnicity not otherwise specified).


The primary outcomes included use and type of contraception during the last sexual encounter. These data were then used to calculate the pregnancy risk index (PRI), a validated measure that summarizes pregnancy risk among all adolescents (including those identified as non–sexually active).9 A secondary outcome was prescription of EC during the ED visit for those who were eligible.

Statistical Analysis

We used descriptive statistics to summarize patient characteristics, contraception use and type, and EC provision using frequencies and percentages. Because participants could indicate multiple contraception methods, we also identified highest-ranking contraception use as determined by lowest failure rate, with failure rate defined as the percentage of participants experiencing pregnancy in the first year of use. The ranking of contraception methods from lowest to highest failure rate is as follows: contraceptive implant (0.1%), intrauterine device (IUD) (0.6%), injectable (4.0%), combined hormonal methods (pill, patch, and vagin*l ring) (7.0%), and male condom (13.0%).10

We performed multivariable logistic regression to identify sociodemographic factors associated with any contraception use. Because long-acting reversible contraception (LARC) is considered the most effective form of contraception and is recommended by the American Academy of Pediatrics as the first-line contraceptive choice for adolescents,10 we developed a separate multivariable model to identify factors associated with LARC use. LARC use was defined as the use of an IUD or implant. Covariables included in the models were age, race and ethnicity, insurance status, timing of most recent sexual encounter, and number of sexual partners in the previous 3 months. Race and ethnicity were included as covariables in the multivariable models because they are social constructs that serve as markers of structural racism and its impact on access to quality health care. The initial analysis also included a comparison between abortion-protected and abortion-not-protected sites, as defined by the Center for Reproductive Rights; however, owing to the rapidly changing landscape of abortion laws, this was not included in the final analysis.11

PRI was calculated by site and overall. The PRI summarizes the risk of pregnancy among all adolescents. A PRI of 5, for example, equates to 5 expected pregnancies per 100 female adolescents per year. The PRI is calculated as the product of 2 components: the percentage of the population currently sexually active and the contraception risk index (CRI). To calculate the PRI, we first calculated the CRI, a validated composite measure using contraceptive use data combined with contraceptive failure rates.9,12 This represents pregnancy risk for the sexually active proportion of that population by summing the product of each method’s specific failure rate and the proportion of those who are sexually active using that method at their most recent sexual intercourse. In these calculations, the nonuse of contraception is included with a specific risk of pregnancy. If a patient indicated multiple methods, then the method with the lowest contraceptive failure rate was used for the calculation. The CRI is multiplied by the percentage of the population that is currently sexually active to determine the PRI. For our analysis, we considered the percentage of the population that is currently sexually active based on the percentage of female adolescents in our sample who were eligible for this analysis of all female adolescents in the sample. We also evaluated EC ordering for eligible participants. Participants were considered eligible if they reported most recent sexual intercourse less than 5 days ago and highest-ranking form of contraception reported as no method or withdrawal.

Adjusted odds ratios (aORs) and 95% CIs were calculated, with significance defined as a 95% CI that did not include the reference value of 1. Analyses were performed using SAS statistical software version 9.4 (SAS Institute). Data analysis was performed from January 2023 to February 2024.


A total of 5136 adolescents completed the cSHS between April 1, 2021, and April 30, 2022; 3138 (61.1%) identified as female sex at birth, of whom 1171 (37.3%) reported engaging in penile-vagin*l sexual intercourse. Of these patients, 1063 (90.8%) completed the survey item related to contraception use and compose the study population for this secondary analysis. These patients had a median (IQR) age of 17.5 (16.5-18.3) years and identified as Hispanic (219 patients [20.8%]), non-Hispanic Black (464 patients [44.1%]), non-Hispanic White (308 patients [29.3%]), and other races and ethnicities (61 patients [5.8%]). The majority (693 patients [65.2%]) had government insurance at the time of visit (Table 1).

Contraception Use

Among the study cohort, 756 participants (71.1%) reported some form of contraception use in their most recent sexual encounter, 265 (24.9%) reported use of multiple concurrent methods, and 307 (28.9%) reported no contraception use. When sorted by highest-ranking method, 312 (29.4%) used a short-acting hormonal method (injectable, patch, pill, or vagin*l ring), 260 (24.5%) used male condoms, 164 (15.4%) used LARC (implant or IUD), 82 (7.7%) used withdrawal, and 50 (4.7%) used EC, whereas 195 (18.3%) used no method (Table 2). Thus, of the 756 participants who were using contraception, 494 (65.3%) reported using a highly effective method, defined as any hormonal method or IUD.

Multivariable models showed significant differences in contraception use by several different patient characteristics (Table 3). The following aORs were based on preventive contraception use and do not include EC or withdrawal. With regard to race and ethnicity, participants identifying as non-Hispanic White (aOR, 2.14; 95% CI, 1.44-3.20), Hispanic (aOR, 1.90; 95% CI, 1.31-2.78), and other race and ethnicity (aOR, 2.25; 95% CI, 1.17-4.64) had higher odds of contraception use than non-Hispanic Black participants. Participants with commercial insurance (aOR, 2.58; 95% CI, 1.78-3.80) were more likely to use contraception than those with government insurance. Participants reporting their last sexual intercourse between 5 days and 1 month ago (aOR, 1.68; 95% CI, 1.17-2.41) and those between 1 month and 1 year ago (aOR, 1.61; 95% CI, 1.08-2.40) had higher odds of contraception use than those with more recent (within the past 5 days) sexual encounters. The number of sexual partners in the last 3 months was not significantly associated with the odds of contraception use.


A total of 164 participants (15.4%) reported LARC use. Multivariable models of the association of patient characteristics with LARC are shown in Table 4. Similar to differences in general contraceptive by race and ethnicity, study participants who identified as non-Hispanic White (aOR, 2.81; 95% CI, 1.77-4.50), Hispanic (aOR, 1.87; 95% CI, 1.14-3.06), and other races and ethnicities (aOR, 2.36; 95% CI, 1.11-4.46) had higher odds of LARC use than non-Hispanic Black participants. Regarding timing of most recent sexual encounter, participants reporting their most recent sexual intercourse between 1 month and 1 year ago had lower odds of LARC use than those with last sexual encounter within last 5 days (aOR, 0.47; 95% CI, 0.28-0.77).

Pregnancy Risk Index

Calculation of the PRI was based on all adolescents assigned female sex at birth who completed the cSHS during the same study period, regardless of reported sexual activity. Of these 3138 patients, 3030 (96.6%) completed the survey item related to contraception use and were included in the PRI calculation. The overall PRI for the study population was 7.89, or an expected 8 pregnancies per 100 female adolescents per year. The PRIs calculated for each site were as follows: site A, 8.41; site B, 8.31; site C, 6.47; site D, 8.41; site E, 7.05; and site F, 7.83.

EC Administration

A total of 108 study participants (10.2%) were considered potentially eligible for EC (based on report of most recent sexual intercourse <5 days ago and highest-ranking form of contraception reported as no method or withdrawal). Among this group, EC was ordered for 6 total participants, or 5.6%. There were no significant differences between withdrawal and reporting no method on provision of EC.


This cross-sectional study demonstrates that, although most (71.1%) sexually active adolescents presenting to the ED were using at least 1 form of contraception, 28.9% reported no contraceptive use in their most recent sexual encounter. The recent Youth Behavior Surveillance System survey and the National Survey of Family Growth reported national rates of female adolescents not using contraception in their most recent sexual encounters as 13.8% and 9.8%, respectively.13,14 A previous multicenter ED study15 had similar findings, reporting that 15.8% of female adolescent patients had sex without contraception in the prior year. Our findings differ from this existing literature and suggest that the rate of contraception use among adolescents in the ED is lower than that of the general adolescent population.

Among study participants who were using contraception, 65.3% reported using a highly effective method, defined as any hormonal method or IUD.16 However, LARCs—the most effective option—were the least utilized option among participants at 15.4%. In addition, fewer than one-half (42.7%) of all participants reported male condom use, which has implications for both pregnancy and sexually transmitted infection risk.

Both insurance status and race and ethnicity were found to be significantly associated with overall contraception and, specifically, LARC use. Adolescents with government insurance had significantly lower odds of any contraception use, specifically LARC use, compared with those with commercial insurance. Health insurance status is an important determinant of access to care; therefore, these results indicate that adolescents with government insurance may not have adequate access to contraceptive services.17 Non-Hispanic Black adolescents were also less likely to report overall contraception and LARC use compared with non-Hispanic White patients. Individuals who are non-Hispanic Black disproportionately face barriers to health care access due to structural racism.18 These findings are concerning in light of racial disparities in unintended pregnancy in the US, with higher rates among non-Hispanic Black and Hispanic youth compared with non-Hispanic White youth.18 Thus, expanding ED care to also include sexual health provision may help improve contraception access to marginalized populations.

The overall PRI for our study was 7.89, which translates to an annual pregnancy risk of 7.89% for the study population. The indices of all 6 study sites were higher than the national PRI of 5.0, but lower than a 2017 single-site study conducted among a similar population, which demonstrated a PRI of 9.6.3 This indicates a potential downward trend in pregnancy risk among adolescents in the ED, but still higher than the general adolescent population.

Although 10.2% of study participants were potentially eligible to receive EC according to their survey responses, the combined rate of administration among all study sites was remarkably low, with just 5.6% of those eligible receiving EC. Practitioners were not notified about patient survey answers; therefore, determination of EC eligibility was made on the basis of independent sexual history obtained by the practitioner. These results indicated an area for improvement regarding confidential assessment of contraception use and pregnancy risk among patients presenting to pediatric EDs. Previous studies indicate that decreased knowledge, concern for lack of follow-up, time constraints, and lack clinical resources are factors associated with nonprescription of EC by ED practitioners.19 After the recent US Supreme Court decision in Dobbs vs Jackson Women’s Health Organization (2022), efforts to remove such barriers and improve access to EC for adolescents in the ED will be essential in helping this marginalized patient population maintain a degree of reproductive autonomy.


There are some potential limitations of this study that warrant mentioning. The survey was provided only in English, in accordance with on prior data across the participating study sites. Study participants completed a self-reported survey, which may have been subject to social desirability bias. However, attempts to minimize such bias were made through administration of a confidential, tablet-based questionnaire. Although the literature suggests that the majority of adolescent pregnancies are unintended, our survey did not specifically assess participants’ pregnancy intentions, which may have impacted their contraceptive choices.2 Furthermore, the survey was administered exclusively across pediatric EDs affiliated with large tertiary care children’s hospitals, which may not be generalizable to general EDs.


In conclusion, expanding contraceptive services, including EC, in pediatric EDs may improve access to care and decrease the risk of unintended pregnancy for adolescents. Future studies should focus on strategies to improve EC administration in the ED and explore provision of additional contraception care in the ED.

Back to top

Article Information

Accepted for Publication: April 19, 2024.

Published: June 28, 2024. doi:10.1001/jamanetworkopen.2024.18213

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Canter H et al. JAMA Network Open.

Corresponding Author: Monika K. Goyal MD, MSCE, Department of Pediatrics, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC 20010 (

Author Contributions: Dr Casper had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Canter, Reed, Casper, Schmidt, Elsholz, Augustine, Goyal.

Acquisition, analysis, or interpretation of data: Canter, Reed, Palmer, Casper, Stukus, Schmidt, Pickett, Mollen, Cruz, Augustine, Goyal.

Drafting of the manuscript: Canter, Elsholz.

Critical review of the manuscript for important intellectual content: Canter, Reed, Palmer, Casper, Stukus, Schmidt, Pickett, Mollen, Cruz, Augustine, Goyal.

Statistical analysis: Canter, Palmer, Casper.

Obtained funding: Reed, Goyal.

Administrative, technical, or material support: Canter, Schmidt, Elsholz, Augustine.

Supervision: Reed, Schmidt, Pickett, Augustine, Goyal.

Conflict of Interest Disclosures: Dr Reed reported owning stock in Thermo Fisher Scientific, Danaher Corporation, Intuitive Surgical, Stryker, United Health Group, Becton Dickinson Stock, and CVS Caremark outside the submitted work. Dr Casper reported receiving grants from the National Institutes of Health (NIH), National Institute of Child Health and Human Development (NICHD), and the Health Resources and Services Administration (HRSA) during the conduct of the study. Dr Stukus reported receiving grants from the NIH during the conduct of the study. Dr Cruz reported receiving royalties from UpToDate outside the submitted work. No other disclosures were reported.

Funding/Support: This project was supported by the Eunice Kennedy Shriver NICHD (grant R01HD094213 to Drs Reed and Goyal). It was also supported in part by the Pediatric Emergency Care Applied Research Network (PECARN). PECARN is supported by the HRSA of the US Department of Health and Human Services (HHS), in the Maternal and Child Health Bureau, under the Emergency Medical Services for Children (EMSC) program through the following cooperative agreements: EMSC Data Center (EDC), University of Utah (grant UJ5MC30824); GLACiER, Nationwide Children’s Hospital (grant U03MC28844); HOMERUN, Cincinnati Children’s Hospital Medical Center (grant U03MC22684); PEMNEWS, Columbia University Medical Center (grant U03MC00007); PRIME, University of California at Davis Medical Center (grant U03MC00001); CHaMP node, State University of New York at Buffalo (grant U03MC33154); STELAR, Seattle Children’s Hospital (grant U03MC33156); and SPARC node, Emory University School of Medicine (grant U03MC49671).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsem*nts be inferred by HRSA, HHS, or the US government.

Data Sharing Statement: See the Supplement.



Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med. 2016;374(9):843-852. doi:10.1056/NEJMsa1506575PubMedGoogle ScholarCrossref


National Center for Health Statistics. Rossen LM, Hamilton BE, Abma JC, et al. Updated methodology to estimate overall and unintended pregnancy rates in the United States: data evaluation and methods research. Vital and Health Statistics, series 2, number 201. April 2023. Accessed May 16, 2024.


Solomon M, Badolato GM, Chernick LS, Trent ME, Chamberlain JM, Goyal MK. Examining the role of the pediatric emergency department in reducing unintended adolescent pregnancy. J Pediatr. 2017;189:196-200. doi:10.1016/j.jpeds.2017.06.053PubMedGoogle ScholarCrossref


Sharko M, Jameson R, Ancker JS, Krams L, Webber EC, Rosenbloom ST. State-by-state variability in adolescent privacy laws. Pediatrics. 2022;149(6):e2021053458. doi:10.1542/peds.2021-053458PubMedGoogle ScholarCrossref


[No authors listed.] Committee opinion no. 615: access to contraception. Obstet Gynecol. 2015;125(1):250-255. doi:10.1097/01.AOG.0000459866.14114.33PubMedGoogle ScholarCrossref


Goyal MK, Richardson T, Masonbrink A, et al. Reliance on acute care settings for health care utilization: a comparison of adolescents with younger children. Pediatr Emerg Care. 2021;37(12):e1128-e1132. doi:10.1097/PEC.0000000000001924PubMedGoogle ScholarCrossref


Chernick L, Kharbanda EO, Santelli J, Dayan P. Identifying adolescent females at high risk of pregnancy in a pediatric emergency department. J Adolesc Health. 2012;51(2):171-178. doi:10.1016/j.jadohealth.2011.11.023PubMedGoogle ScholarCrossref


Goyal MK, Shea JA, Hayes KL, et al. Development of a sexual health screening tool for adolescent emergency department patients. Acad Emerg Med. 2016;23(7):809-815. doi:10.1111/acem.12994PubMedGoogle ScholarCrossref


Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health. 2007;97(1):150-156. doi:10.2105/AJPH.2006.089169PubMedGoogle ScholarCrossref


Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1244-e1256. doi:10.1542/peds.2014-2299PubMedGoogle ScholarCrossref


Center for Reproductive Rights. After Roe fell: abortion laws by state. January 18, 2022. Accessed April 18, 2024.


Waddell EN, Orr MG, Sackoff J, Santelli JS. Pregnancy risk among black, white, and Hispanic teen girls in New York City public schools. J Urban Health. 2010;87(3):426-439. doi:10.1007/s11524-010-9454-4PubMedGoogle ScholarCrossref


Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2019. August 21, 2020. Accessed May 16, 2024.


Amba JC, Martinez GM. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2015-2019. National Health Statistics Reports; no 196. National Center for Health Statistics. December 14, 2023. Accessed May 16, 2024.


Chernick LS, Chun TH, Richards R, et al; Pediatric Emergency Care Applied Research Network (PECARN). Sex without contraceptives in a multicenter study of adolescent emergency department patients. Acad Emerg Med. 2020;27(4):283-290. doi:10.1111/acem.13867PubMedGoogle ScholarCrossref


Daniels K, Mosher WD. Contraceptive methods women have ever used: United States, 1982-2010. Natl Health Stat Report. 2013;(62):1-15.PubMedGoogle Scholar


National Center for Health Statistics. Health insurance and access to care: NCHS fact sheet. February 2017. Accessed April 2023.


Martin JA, Hamilton BE, Osterman M. Births in the United States, 2020. NCHS Data Brief. 2021;(418):1-8.PubMedGoogle Scholar


Goyal M, Zhao H, Mollen C. Exploring emergency contraception knowledge, prescription practices, and barriers to prescription for adolescents in the emergency department. Pediatrics. 2009;123(3):765-770. doi:10.1542/peds.2008-0193PubMedGoogle ScholarCrossref

Contraception Use and Pregnancy Risk Among Adolescents in Pediatric EDs (2024)
Top Articles
Latest Posts
Article information

Author: Sen. Ignacio Ratke

Last Updated:

Views: 5933

Rating: 4.6 / 5 (56 voted)

Reviews: 95% of readers found this page helpful

Author information

Name: Sen. Ignacio Ratke

Birthday: 1999-05-27

Address: Apt. 171 8116 Bailey Via, Roberthaven, GA 58289

Phone: +2585395768220

Job: Lead Liaison

Hobby: Lockpicking, LARPing, Lego building, Lapidary, Macrame, Book restoration, Bodybuilding

Introduction: My name is Sen. Ignacio Ratke, I am a adventurous, zealous, outstanding, agreeable, precious, excited, gifted person who loves writing and wants to share my knowledge and understanding with you.