Long-acting reversible contraceptive use among teens prevents unintended pregnancy: a look at the evidence

Keywords::

• long-acting reversible contraception
• teenagers
• unintended pregnancy

Teen pregnancy remains a stubborn public health problem. Of the approximately 750,000 teen pregnancies that occur annually among adolescents aged 15–19 in the USA, 82% are unintended [1]. Although the US has experienced a recent decline in teen pregnancy due to increased use of hormonal contraception, the rates remain higher than most developed nations [2]. Teens who experience unintended pregnancy and unplanned births are likely to experience serious negative education, economic, health and social consequences [3].

Nearly half of the unintended pregnancies are due to incorrect or inconsistent use of a contraceptive method; 50% reflect the nonuse of contraception, and only 5% is due to method failure [4]. Although failure rates with perfect use can be very low, contraceptive methods that require a woman to remember to take medications, return to a clinic for an injection or secure refills result in typical-use failure rates that are much higher. For example, failure rates for the commonly used oral contraceptive pill (OCP) and depomedroxy progesterone acetate injection increase from 1% when used perfectly to 6–9% in real-world use [5]. Younger women experience even greater difficulty with correct and consistent use; a recent study of women aged 20 and younger who used the contraceptive pill, patch or ring reported failure rates twice that of women aged 21 and older using these same methods [6].

Long-acting reversible contraception (LARC) is far less user dependent, and thereby closes the gap between real-world use and perfect-use effectiveness. LARC include the IUDs (the copper T380A, the 14 µg/day levonorgestrel intrauterine system and the 20 µg/day levonorgestrel intrauterine system) and a 68 mg etonogestrel single-rod implant. All of these methods are reversible, proven to be extremely safe and are over 99% effective at preventing pregnancy [7]. Because LARC methods are user independent, real-world failure rates are less than 1%; meaning real world and perfect use failure rates are nearly identical. In fact, LARC is over 20-times more effective at preventing unintended pregnancy (HR_adj: 21.8; 95% CI: 13.7–34.9) than the contraceptive pill, patch and ring [6]. User-dependent methods (OCP, contraceptive patch, vaginal ring) are less effective in teen users as compared with older users because they require frequent attention. The effectiveness of LARC however does not vary by age; women less than 21 experience the same high level of effectiveness compared with women 21 and older.

Unfortunately, most teens do not use LARC despite being the most effective reversible contraceptive methods available. LARC use among teens 15–19 years of age in the USA has tripled from nearly nonexistent (0.3%) in 2002 to 4.5% in 2009, predominately among those aged 18–19 years [8]. One barrier to greater use is that many providers incorrectly believe that LARC is an inappropriate contraceptive method for teens [9]. However, the misconceptions and myths surrounding LARC use in teens are changing. In fact, the American College of Obstetricians and Gynecologists now recommends LARC as first-line contraceptive methods for all women, including teens and nulliparous women [10]. The US CDC Medical Eligibility Criteria for contraceptive use provides evidence-based recommendations on the safety of contraceptive use and assigns one of four categories based on the level of risk for specific characteristics and conditions [11]. LARC methods have few contraindications, and in most situations the advantages of their use by teens outweigh the risks [12]. In fact, IUDs are rated Category 2 (i.e., a condition for which the advantages of using the method generally outweigh the theoretical or proven risk) for young women 20 years and younger; and the implant is classified as a Category 1 (i.e., a condition for which there is no restriction for the use of the contraceptive method) regardless of age.

Many providers are concerned that IUD use among teens increases the risk of pelvic inflammatory disease and subsequent infertility. Although the risk of pelvic inflammatory disease is elevated within the 20 days following insertion, the absolute risk of pelvic infection in teens is small and should not deter providers from considering IUDs as excellent contraceptive options for teens [13]. According to evidence-based guidelines, it is acceptable to complete sexually transmitted infection (STI) screening and place the IUD on the same visit, including for teenage patients [10]. If the test is positive, appropriate treatment should be administered. If at the time of IUD insertion there is active or suspected infection, the IUD should not be placed and the teen should be treated before IUD insertion [11]. If infection with chlamydia or gonorrhea occurs subsequent to IUD insertion, the IUD does not need to be removed; rather treatment of the STI with appropriate antibiotic therapy while the IUD is in place is usually sufficient. Adolescents who use LARC should be properly counseled to inform them that LARC does not prevent STI transmission and therefore they should practice dual-method contraception; that is, use of the LARC for pregnancy prevention and condom use for STI prevention [14]. This recommendation holds for the other non-LARC methods as well. Finally, teens experience variable levels of discomfort with IUD insertion. Unfortunately, the use of NSAIDs, paracervical injections of local anesthetic and intracervical lidocaine gel have not demonstrated improved discomfort with insertion [15,16]. Despite the potential for discomfort at the time of insertion, teen IUD users report high satisfaction and continuation rates [17].

Given the high level of effectiveness and endorsement of LARC as a first-line contraceptive options for teens, how do we increase their use to lower unintended pregnancy rates? A practical approach can be found in the Contraceptive CHOICE Project. The study enrolled 9256 women aged 14–45 years in St Louis (MO, USA) and provided free contraception for 2–3 years [18]. The objective of the study was to promote the use of LARC to reduce unintended pregnancy in the region. Participants underwent a standardized contraceptive counseling session provided by trained nonclinician staff. The contraceptive methods were presented in order of effectiveness, from most to least, and counselors briefly discussed the advantages, disadvantages, hormone profile and common side effects for each reversible method available through the project. The study participant then chose her desired contraceptive method and this was followed by telephone surveys every 6 months for the duration of follow-up to measure method satisfaction, continuation, sexual behavior and pregnancy. The study enrolled 1404 teens who overwhelming (69%) chose LARC; 35% selected an IUD and 34% selected the implant [17]. Rates of use at 12 months were significantly higher among teens who chose a LARC method (80%) compared with the teens who chose a non-LARC method (44%) [17].

Findings from the CHOICE Project and other studies examining LARC use in teens suggest there are three key barriers to greater LARC uptake: education, access and cost. The majority of teens do not know about LARC methods, with provider misconceptions compounding this lack of awareness. A tier-based counseling approach, based on method effectiveness, organizes the decision-making process around the attribute of effectiveness rather than what the participant has used in the past, or which methods her friends use.

We have observed multiple structural barriers and provider biases that limit access to LARC for teens. They include lack of methods stocked at the clinic when the teen makes her contraceptive decision, multiple clinic visits to rule out pregnancy or STI rather than same-day insertion, shortage of trained and proficient providers in LARC insertion and management and scarcity of providers and clinic staff who are proponents of LARC for teens [19]. A good place to start breaking down the barriers includes creation of teen-friendly clinics that include evening clinic hours and walk-in availability, practicing evidence-based care which means initiation of hormonal contraception without a pelvic exam (except for an IUD insertion), providing contraceptive education by peer educators, staff training on how to better communicate with and meet the needs of teens and protocols for ensuring confidentiality and building trust [19].

Finally, the cost of LARC can be a significant barrier for many teens as the up-front cost of methods is often unaffordable despite their long duration of protection. Up-front cost is not only a barrier for women, but also for providers, resulting in the inability of many clinics and provider offices to stock an adequate supply of methods [19]. Some clinics and offices have identified strategies to manage inventory and billing in a cost-effective manner, but only when the demand is adequate. When LARC use among teens is low, it decreases the availability of methods in clinics and further reduces the possibility of use.

The CHOICE Project successfully removed all three barriers. As a result teens overwhelmingly choose the most effective methods and experienced high rates of continuation at 1 year. Because of high LARC uptake and continuation we observed an 80% reduction in births among teens in the cohort compared to national statistics [20]. To effectively reduce teen pregnancy, we need to create the demand for LARC among our teens. Teens need greater education and access to affordable LARC.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.