What is the primary preventive intervention for a newly married woman in her 20s who is not using contraception and wants to avoid an unplanned pregnancy?

Primary Prevention: Contraceptive Education

The primary prevention for this woman is to educate her about contraceptive methods (Option B). 1

Rationale for This Recommendation

Primary prevention in this context means preventing the unintended pregnancy from occurring in the first place. The CDC explicitly recommends that at every health care visit, clinicians should discuss family planning needs with patients of reproductive age and provide requested services as appropriate. 1 Since this woman is actively concerned about unplanned pregnancy and not using contraception, contraceptive education directly addresses her immediate need.

Why Not the Other Options?

• Folic acid (Option A) is important for preconception care and preventing neural tube defects, but it is a secondary prevention measure that reduces complications if pregnancy occurs—it does not prevent the pregnancy itself. 2 While folic acid should be recommended to all women of reproductive age, it does not address her primary concern of avoiding pregnancy.

• School-based sex education (Option C) is a population-level public health intervention, not an individual clinical intervention for this specific patient who is already married and seeking care. This represents upstream prevention but does not meet her immediate clinical need.

Evidence-Based Approach to Contraceptive Counseling

The CDC recommends a systematic five-step approach to contraceptive counseling: 1

Step 1: Tiered Counseling Approach

Present the most effective methods first, particularly long-acting reversible contraception (LARC) such as intrauterine devices and implants, before discussing less effective methods. 1 This tiered approach is supported by evidence showing:

• When financial barriers are removed, approximately two-thirds of clients choose LARC methods 1
• LARC methods have failure rates of less than 1% per year (0.05% for implants, 0.2% for hormonal IUDs) 1, 3
• LARC continuation rates at 1 year are 78-84%, compared to 41-67% for other methods 1, 3

Step 2: Discuss Full Range of Methods

Providers must counsel about all contraceptive methods that can be used safely by the patient, even if not available on-site and regardless of nulliparity status. 1 The evidence shows that approximately half of the 6.6 million pregnancies annually in the United States are unintended, with rates highest among young women. 1 Women who use contraception consistently and correctly account for only 5% of unintended pregnancies. 1

Step 3: Address Effectiveness Data

Present clear effectiveness data: 1

• Most effective (>99%): Implants (0.05% failure), IUDs (0.2-0.8% failure)
• Highly effective (91-99%): Injectable contraceptives (6% typical use failure), pills/patch/ring (9% typical use failure)
• Moderately effective (71-88%): Condoms (18% male, 21% female typical use failure)
• Least effective: Fertility awareness methods (24% failure), spermicides (28% failure)

Step 4: Remove Medical Barriers

Physical assessment is usually limited to blood pressure evaluation before starting hormonal contraceptives. 1 Pelvic examination is only required before IUD placement, not for initiating other methods. This removes unnecessary barriers to contraceptive access. 1

Step 5: Ensure Understanding

Use the teach-back method—have the patient restate the most important messages in her own words to confirm understanding. 1 This technique has been shown to improve compliance with treatment plans and health outcomes. 1

Critical Clinical Considerations

Immediate Start Protocol

If it is reasonably certain the patient is not pregnant, any contraceptive may be started immediately. 1 When hormonal contraceptives are selected, prescribe one year's supply to reduce barriers to use. 1

Dual Method Counseling

While hormonal contraceptives and IUDs are highly effective at preventing pregnancy, they do not protect against sexually transmitted infections. 1 Counsel about condom use for STI prevention regardless of primary contraceptive method chosen. 1

Common Pitfall to Avoid

Do not assume that being newly married means she will want pregnancy soon. Her stated concern is avoiding unplanned pregnancy, so respect her reproductive autonomy and provide comprehensive contraceptive education without bias. 1