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Why aren’t more teens using the most effective form of birth control?

Lila Baker

Among sexually active women of childbearing age, teens are the most likely to have an unintended pregnancy. So why are teenagers the least likely age group to use the most effective form of contraception?

Long Acting Reversible Contraception methods or “LARC” methods, which include intra-uterine devices and subdermal implants, have a failure rate of less than 1 percent, partially because they are user independent; once they are inserted by a health care provider they require little to no maintenance and are effective for three to 10 years, depending on the type. LARCs have also been professionally endorsed by the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP). However, among Minnesota teens ages 15-19 who seek contraception, only about 8.8 percent receive LARCs.

It’s no surprise that teens have been shown to have more difficulty adhering to contraceptive methods that require daily compliance (like the pill) or that require use with each instance of intercourse (like condoms). So, you might be surprised to find out that condoms and oral contraceptives are the preferred methods for sexually active teens who use contraceptives. This is concerning given that within the first year of typical use, the pill has a 9 percent failure rate and condoms have an 18 percent failure rate.

A serious problem

As the public cost of Minnesota teen childbearing (in 2010) totaled $146 million, teenage underutilization of the most effective form of birth control is a serious problem. Unintended pregnancy is a fundamental public health problem, particularly for the adolescent population, in which approximately 75 percent of pregnancies are unintended. Despite the recent national and state declines in teen pregnancy, 2,386 teenage mothers gave birth in Minnesota in 2015, which equates to 13.7 births per 1,000 women. Teen pregnancy and childbearing bring substantial social and economic costs through immediate and prolonged impacts on teenage parents and their children.

There are several reasons Minnesota teens do not use LARCs at a higher rate. Teenagers encounter many barriers when seeking birth control, including challenges in obtaining sexual health services confidentially, given their often dependent insurance status. Navigating the complex health system can be difficult for teenagers. This challenge is exacerbated by misguided concerns held by many teenagers and providers regarding the suitability of LARCs for teens. Additionally, as the high cost of LARC implementation causes concern for many providers, economic forces contribute to the problem, too. LARCs remain expensive for providers to stock, and insurance reimbursement policies are often inadequate and inconsistent.

Finally, there is a lack of consistent provider training on LARC counseling and implementation, particularly for pediatricians. This lack of provider training is especially troubling, as more uniform training and understanding of LARC use and implementation could lay a foundation for professional action in eliminating the multitude of other barriers for teen LARC access. The recent endorsements of teen LARC use by the ACOG and the AAP in 2012 and 2014, respectively, coheres the best clinical practices of obstetrician-gynecologists and pediatricians, two of the specialties that provide LARCs to teenagers. With this recent professional consensus, now is the time to ensure that current and future medical providers are properly educated on LARCs.

The Delaware CAN example

A public/private partnership between the Minnesota Department of Health and a reproductive health-care-oriented nonprofit such as Upstream USA, as demonstrated by Delaware CAN (Contraceptive Access Now), is a potential solution that would help Minnesota increase provider training while controlling costs. Delaware CAN has successfully initiated LARC training for all publicly funded health centers and larger private medical providers in the state. The joint effort has attracted millions of dollars from philanthropic sources, which funds the program along with state money reallocated by Delaware’s public health department.

Increasing teen use of LARCs and lowering the unintended pregnancy rate will require a multifaceted approach that brings together the efforts of the state government, the community, and health providers. A state-driven provider training initiative has the potential to greatly improve the health outcomes of Minnesota teens. I urge Minnesota legislators to promote the creation of a statewide provider training initiative for LARCs.

Lila Baker works as a reproductive health care counselor and is a graduate student at the University of Minnesota School of Public Health.

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Comments (6)

  1. Submitted by Barbara Skoglund on 12/21/2017 - 11:58 am.

    Have you heard of MFPP?

    Minnesota already offers affordable access to long acting contraception for teens and low income people. Long acting contraception is still mandated by employer plans and health insurance policies available on MNsure. Though MFPP teens and low income people can access contraception without parental or spousal involvement.

    The Minnesota Family Planning Programs offers instant eligibility (called presumptive eligibility) when you visit an MFPP provider and meet the eligibility requirements. You must complete a paper application form for ongoing eligibility.

    To get coverage, you:
    •Must be a Minnesota resident
    •Must be a U.S. citizen or qualified noncitizen
    •Cannot be pregnant
    •Cannot be enrolled in Medical Assistance
    •Must meet the income limit of 200 percent of the federal poverty level. The income limit and whose income is counted depend on who lives with you. If you are under the age of 21 and live with your parents or spouse, you do not have to give us information about their income.

    Visit the MFPP website for information about how to apply and a list of certified MFPP providers (142 across the state) who can instantly determine your eligibility.

    https://mn.gov/dhs/people-we-serve/adults/health-care/health-care-programs/programs-and-services/family-planning.jsp

    • Submitted by Lila Baker on 12/22/2017 - 05:18 pm.

      MFPP

      I’m very aware of MFPP and have informed dozens if not hundreds of women about the Minnesota Family Planning Program through my job as a reproductive healthcare counselor and birth control educator. I myself received contraceptives through MFPP from age s18-23. It is an excellent program, especially given the presumptive eligibility that is allowed.

      To meet the criteria for an opinion piece for Minnpost, I was allowed around 700 words and the focus of my publication is provider training and how the lack of adolescent health providers trained in LARC implementation is a contributing factor to the low rates of LARC use by teens. I sincerely appreciate your comment, especially because I’ve personally advocated for MFPP utilization for many years, but confidentiality and cost were not my focus with this piece. MFPP is an excellent resource, but most teens don’t know about it and are unlikely to use it. I absolutely want to see this change but, again, that was not the focus of my article.

      The link below is for an article that explains (in more detail) the challenges teens face in attempting to navigate a fragmented system that is confusing for most adults, let alone teens.

      http://minnesota.cbslocal.com/2015/08/03/why-dont-more-minnesota-teens-use-iuds/

      Many teens don’t know how to take advantage of government programs that remove barriers such as parental consent and cost. There is a fundamental lack of insurance/health care coverage literacy, especially among teens. Of course this is something I’d like to see change, but it won’t be easy. Increased provider training on LARC implementation and access is one platform that could allow teens to become better educated on contraceptives and the best way to obtain their preferred method.

  2. Submitted by Ray Schoch on 12/21/2017 - 02:26 pm.

    Just two illustrations

    It’s been some time, now, since I provided any meaningful counseling or even a sympathetic ear to a teen regarding their sexual activity, but from my years of teaching and being a faculty advisor, at least two scenarios come to mind right away upon reading the headline, and they remain after reading the article.

    Scenario #1 involves parents. Perhaps Minnesota parents are far more permissive and/or open-minded than I’ve supposed, but my hunch, based on my experience dealing with high school kids quite a few years ago in another state, is that many a teen (both male and female, but especially female) isn’t all that keen on announcing to mom and dad the equivalent of: “Hey. I’m sexually active now.” In a variety of ways, lots of parents make it known that they either don’t want to know, or would prefer that their offspring remain chaste until… um… let’s say… age 40 or so. In other words, no matter what their brains are telling them, emotionally, they really don’t want their teen children to be sexually active at all, despite evidence all around them that that may be, or even IS, the case. Professional therapists in the audience will correct me, I hope, but years ago, when I was listening to this sort of thing with some frequency and regularity, it sounded to me like a sort of separation issue, wherein sexual activity, for the teen, announced a degree of genuine independence, if not maturity, while for the parent, it was evidence of that same independence, and that their child was no longer a child, which is difficult emotional territory for many parents.

    Scenario #2 involves the teens themselves, in a specific context. Use of long-term contraception is an admission of planning, or at the very least, anticipation. Many teens, at least many of the ones I talked to years ago about this, did not want to acknowledge that they planned to get frisky with their boyfriend or girlfriend next weekend—or after school today. To them, it seemed much more romantic — a term I heard used often — to be “swept away” in the moment, or, phrased differently, to be spontaneous (“If it happens, it happens.), rather than measured or methodical. LARC is nothing if not an attempt to be methodical about sexual activity and its potential consequences.

    Thus, not only are many parents going to be less-than-enthused about their underage (or even “over 18”) son or daughter asking them for help in securing LARC contraception, often the teens themselves prefer the pill (admission enough, many think, that they’re sexually active), or the condom. The latter, of course, in the absence of some other method, pretty much announces a **lack** of planning, or giving spontaneity priority over safety or thought about consequences.

    For many thousands of years, devoting little or no thought to safety or consequence has been characteristic of adolescence.

  3. Submitted by Pat Berg on 12/22/2017 - 08:22 am.

    FDA approvals

    Ray makes some excellent points about the psychological aspects of this. But on a more pragmatic level, do you, Lila, or anyone else know if there are any issues with FDA approvals for intra-uterine device or subdermal implant use in this sub-adult age cohort? I’m thinking about the possibility of complications that could maybe arise with changing physiology and the way drugs work in an adolescent body (subdermal implants) or simply the continuing physical growth of a young person perhaps offering ongoing fitting issues (for the IUD).

    • Submitted by Lila Baker on 12/22/2017 - 05:02 pm.

      Professional/Evidence-Based Recommendations

      Yes, LARCs are absolutely the gold standard of birth control. This is why I mention the professional endorsement of teen LARC use by ACOG and the American Academy of Pediatrics. See the link below:

      https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Adolescents-and-Long-Acting-Reversible-Contraception

      Doctors with less recent training may be hesitant to encourage LARC use for teens but this is because of misconceptions, many of which are based on the archaic/dangerous early IUDs such as the Dalkon Shield. LARCs are absolutely appropriate for teens.

      I’ve worked as a birth control educator for over seven years. LARCs are not only the most effective contraceptive method, but they also are progesterone only (besides the copper IUD/Paraguard which doesn’t utilize hormones at all and is ideal for women who cannot tolerate hormonal methods) and release very low levels of hormones. If anything, in terms of the adolescent development you’re concerned about, they are safer than options like oral contraceptives which utilize estrogen and much higher levels of hormones.

      Please consider that this publication is well researched and well-sourced. I’m not merely throwing out my beliefs as “fact”.

  4. Submitted by Greg Kapphahn on 12/22/2017 - 09:05 am.

    The Underlying Issue

    on this story,…

    and the final story regarding the youngster who sent a sexually explicit photograph of herself to her boyfriend in Brian Lambert’s “The Glean” this morning (12/22/17),…

    and the issue of sexual harassment in general,…

    can be illustrated by showing people pictures of an attractive young-looking person of each gender,…

    and asking their impression of that person just from the picture.

    Then tell them that each young person is sexually active,…

    and ask their impressions of those youngsters taking that new information into account.

    If you’re really feeling adventurous, include that they’re sexually active with their own gender.

    Even imagining such an exercise probably brought up markedly different responses in you, the reader.

    The reality is, of course, that a young person who’s become sexually active is nothing more nor less than that,…

    EXACTLY the same person as before.

    But in our society, especially among conservatives,…

    the advent of sexual activity renders youngsters inevitably and forever soiled and diminished.

    There’s no forgiveness and no going back, especially for girls who have “lost their virginity,”…

    though in many circles, a boy who has lost HIS virginity is admired and celebrated,…

    unless he’s lost it in relating to another boy.

    Therein lies our society’s inability to deal in reasonable, thoughtful, logical ways with the behaviors our youngsters’ developmental hormones, quite naturally, cause them,…

    and caused all of US (except for those abnormal people with unnaturally low hormonal levels, or unnaturally late hormonal development) to pursue.

    Rather than help our youngsters deal with their hormones and attractions in reasonable ways,…

    we mask the whole issue in secrecy and rigidly maintain the dysfunctionally-structured mine field which guarantees that, even for the best, brightest kids,…

    with the most wonderful parents,…

    some of their lives will be blown up in adolescence by that mine field.

    According to the Bible, the “sin” of Adam and Eve was disobedience,…

    and EVERYONE: The serpent, Eve AND ADAM, received consequences for their disobedience.

    Sex had NOTHING to do with it.

    If there is such a thing as “original sin” it wasn’t sex at all,…

    it had nothing to do with sex,…

    it was disobedience,…

    but that’s way too invisible, and way too universally applicable for conservatives to use it,…

    to manipulate everyone else into doing what THEY want them to do.

    Even for conservatives, SEX (or the opposition to it) sells.

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