Long-acting contraceptives for teens

Last week, the American Academy of Pediatrics published a "Contraceptives for Adolescents" policy statement that advises pediatricians to consider long-acting reversible contraception (LARC) methods as first-line contraceptive choices for adolescents. LARC methods include contraceptive implants that can be inserted into the upper arm (which can remain in place for three years) and intrauterine devices (with different versions approved for three or five years).

Unlike condoms or birth-control pills, which require repeated correct use, LARCs only need to be administered once. They have failure rates of less than 1%, compared to 9% for combined oral contraceptive pills and 18% for condoms -- and those two may be higher among adolescents than in the adult population that's most often used in contraception studies. (These are all figures for "typical use" as opposed to "perfect use," because in practice some of us forget to always have a condom or take a pill every day at the same time.) "The most effective methods rely the least on individual adherence," the statement explains.

The AAP statement covers LARCs in a broader context, and gives advice on adolescent confidentiality and parental involvement; sexual history-taking; and counseling about both abstinence and contraception. On that last topic, the statement advises:

Abstinence is 100% effective in preventing pregnancy and STIs and is an important part of contraceptive counseling. Adolescents should be encouraged to delay sexual onset until they are ready. However, existing data suggest that, over time, perfect adherence to abstinence is low (ie, many adolescents planning on abstinence do not remain abstinent). Therefore, pediatricians should not rely on abstinence counseling alone but should additionally provide access to comprehensive sexual health information to all adolescents.

Additional sections summarize the range of contraceptive options for adolescents, provide considerations for special populations, and stress the importance of frequent follow-up to maximize adherence.

Then come 14 recommendations, which include educating patients about all contraceptive methods that are safe and appropriate for them; encouraging consisent and correct use of condoms with every act of sexual intercourse; knowing about laws on minor consent and confidentiality and how best to meet patients' needs while following them; allowing sufficient visit time for discussing contraception with adolescent patients; and being aware of subsidized insurance programs and clinics that provide confidential and free/low-cost reproductive health services. The specific recommendations on LARCs are:

2. Pediatricians should be able to educate adolescent patients about LARC methods, including the progestin implant and IUDs. Given the efficacy, safety, and ease of use, LARC methods should be considered first-line contraceptive choices for adolescents. Some pediatricians may choose to acquire the skills to provide these methods to adolescents. Those who do not should identify health care providers in their communities to whom patients can be referred.

5. Pediatricians should be aware that it is appropriate to prescribe contraceptives or refer for IUD placement without first conducting a pelvic examination. Screenings for STIs, especially chlamydia, can be performed without a pelvic examination and should not be delayed.

Following these recommendations will let pediatricians help their adolescent patients choose the best contraception methods for their needs and avoid unintended pregnancies. Research suggests that teens will choose LARC methods when barriers to their use are reduced or eliminated. Vox's Sarah Kliff recently interviewed Gina Secura, who until her recent retirement directed the CHOICE Project at the Washington University in St. Louis School of Medicine. Between 2007 and 2013, that project gave nearly 10,000 women no-cost birth control. When they had free access to a wide range of contraceptive options and knowledgeable providers to help them make informed decisions, the majority of participants preferred LARCs. The New England Journal of Medicine has just published CHOICE Project results on adolescents; of 1404 teenagers enrolled in the study, 72% chose a LARC.

The Affordable Care Act requires that insurers make all FDA-approved forms of contraception available without cost-sharing to all women with reproductive capacity, so cost should no longer be an impediment to LARCs for many women. (Plans don't have to offer cost-sharing-free coverage of every single contraceptive available, as long as they're covering one of each type of contraceptive -- e.g., a woman might still have to pay a co-pay for her current birth-control pill, as long as there's another brand she could take that doesn't require a co-pay.) As Secura told Kliff in their interview, though, cost is not the only issue to be addressed:

... what we found was that it's not simply cost that is the barrier to birth control. There are all these other barriers that aren't so simple and obvious. If the clinic manager doesn't want to insert an IUD that day for example, and wants you to come back, that's a road block. There's nothing like somebody making a decision and acting on it right then. So unless clinics can afford to stock these more expensive methods, we're going to have women and hopefully teens saying, "I heard about this and I would like it," and if it's not available that's going to a problem. How do we get those existing providers trained, comfortable, and confident?

These kinds of barriers, and the need to overcome them, were also the subject of a recent commentary by Carol S. Weisman and Cynthia H. Chuang of the Penn State College of Medicine in the journal Women's Health Issues (disclosure: I'm the journal's managing editor). In "Making the Most of the Affordable Care Act's Contraceptive Coverage Mandate for Privately-Insured Women," Weisman and Chuang note that women may be uncertain about what their plans cover or unaware of various methods' attributes, while their primary-care providers may not be trained to provide LARCs.

To address these challenges, Weisman and Chuang recommend clear communication with the public and private-plan enrollees about what the ACA requires and what individual plans cover; training of primary-care providers on LARCs, and seamless referral arrangements from primary-care providers who can't offer these methods to providers who can; and the "design, assessment, and dissemination of woman-centered information and decision tools to help women make optimal contraceptive choices in the context of their own life circumstances and preferences."

The AAP's new policy statement is in line with these recommendations -- it advises pediatricians to be ready to discuss all the available contraceptive options with their adolescent patients, and either acquire the skills to provide LARCs or be ready to refer patients to colleagues who can. With knowledgeable providers helping young women choose and access the best forms of contraception for their needs, we can avert more unintended pregnancies.