Initiating Contraceptive Provision with Teens

By Anita Brakman, MS
Senior Director of Education, Research & Training
Physicians for Reproductive Health
New York City

Taylor Rose Ellsworth, MPH
Manager, Education, Research and Training
Physicians for Reproductive Health
New York City

Melanie Gold, DO, DABMA, MQT, FAAP, FACOP
Medical Director
School-Based Health Centers
New York-Presbyterian Hospital
Columbia University Medical Center
New York City

Sexuality is a natural and important part of human growth for young people and a developmental milestone. Statistics from the 2013 Youth Risk Behavior Surveillance System (YRBSS) show that 47% of students report they ever have had sex, yet only 19% of those teens reported using birth control pills, and 5% reported using the contraceptive shot, contraceptive vaginal ring, or a long-acting reversible contraceptive (LARC) method (implant or intrauterine device [IUD]), at last sex.¹ Initiating conversations about sex is a key part of medical interviewing and should be part of routine assessment for adolescent well-being.²

A major component of sexual history-taking is contraceptive counseling. Adolescents should be interviewed about contraception in a developmentally appropriate manner and with confidentiality pre-established. Providers should assess contraception practices in the face of disproportionally high national rates of teen pregnancy and births. Although this rate is the lowest level in almost four decades, the main contributing factors are delayed onset of intercourse and a dramatic shift in teen contraceptive use to better practice and more effective methods.³

Pediatric hospitals are increasingly providing care to adolescents, including 80% of those with chronic conditions, which makes pediatricians uniquely positioned to serve as a critical point of care in a young person’s life.⁴ In March 2016, Pediatrics released an article addressing low rates of contraceptive counseling among pediatric specialists for patients on teratogenic medications.⁵ Stancil et al conducted a retrospective chart review of 1,694 female adolescents (aged 14 to 25; mean age 15.9), which revealed that those who were prescribed teratogenic medications receive infrequent and inadequate contraceptive counseling, referral, and/or prescribing of contraception (collectively called contraceptive provision). Contraceptive provision was documented for 28.6% of the visits. Equally disappointing is the low percentage (11%) of contraception prescriptions that were recorded during patient visits.

Similarly, a 2016 New York State (NYS) study showed that while most (>90%) of NYS pediatricians counsel female adolescents about contraception, with two-thirds counseling about LARCs, only 5% insert LARCs.⁶ This online survey of 2,957 NYS members of the American Academy of Pediatrics (AAP) also found that those who had read the 2014 AAP policy statement endorsing IUDs and implants as first-line contraception were significantly more likely to have high levels of knowledge regarding the suitability of LARCS for adolescents in addition to reporting higher rates of counseling compared to those who had not read the policy.

The AAP states that, “pediatricians should be familiar with counseling, insertion, and/or referral for LARCs” and “should be able to educate patients about LARC methods” given the efficacy, safety, and ease of use.⁷ The Centers for Disease Control and Prevention’s Selected Practice Recommendations state that IUDs and implants can be inserted anytime without technical difficulty, including postpartum. “For contraceptive methods other than IUDs, the benefits of starting to use a contraceptive method likely exceed any risk … .”⁸ These guidelines may help lessen pediatricians’ discomfort with LARC counseling and referral.

When starting contraceptive counseling, affirm confidentiality, establish rapport, ask permission, and use open-ended questions. It often is helpful to first ask questions such as “Have you ever been in a sexual relationship? Tell me about it.” This can be followed with, “When would you like to become pregnant, if that is part of your future life plan?” Finally, you can ask, “What kinds of birth control have you used in the past? Tell me about your experiences.” Also providers can ask, “What are your menstrual periods like now?”

Providers can access training for implant insertion and removal through Merck at the following site: http://bit.ly/214L2Wb. If you are unable to perform IUD insertions at your practice, you can find an adolescent-friendly referral through the Association of Reproductive Health Professionals LARC locator, which is at http://bit.ly/1SUNmKQ.

The Affordable Care Act is enhancing access to contraception by lowering privately insured women’s out-of-pocket costs for 18 methods.⁹ For your uninsured patients, payment plans are available for the ParaGard IUD through Teva Women’s Health at http://bit.ly/23GPXTV. Many family planning clinics offer free or low-cost IUDs. Address barriers, such as staffing and inadequate time, by using written questionnaires in waiting areas and training residents in LARC insertion.

Pediatricians should routinely offer contraceptive provision to their adolescent patients. Forgoing routine assessment of contraceptive need is not only a missed opportunity, but it is a health provider’s responsibility to ensure overall well-being and reduced morbidity/mortality for adolescents with medically complex conditions and to improve all adolescent reproductive health outcomes.

REFERENCES

1. Kann L, Kinchen S, Shanklin SL, et al. Youth risk behavior surveillance—United States, 2013. MMWR Surveill Summ 2014; 63(suppl 4):1-168.
2. Gibson EJ. All adolescents deserve routine conversations about sexual activity and pregnancy prevention. Pediatrics 2016; 137(1):e20153826
3. Guttmacher Institute. New government data finds sharp decline in teen births: Increased contraceptive use and shifts to more effective contraceptive methods behind this encouraging trend. News in Context. Accessed at the web site http://bit.ly/1Wb0yR5.
4. Coles MS, Lau M, Akers A. If you do not ask, they will not tell: Evaluating pregnancy risk in young women in pediatric hospitals. J Adolesc Health 2016; 58:251-252.
5. Stancil SL, Miller M, Briggs H, et al. Contraceptive provision to adolescent females prescribed teratogenic medications. Pediatrics 2016; 137(1):e20151454.
6. Fridy RL, Maslyanskaya S, Lim S, et al. Pediatricians’ knowledge and practices related to intrauterine devices (IUDs) and subdermal implants for adolescent girls. Presented at the North American Society for Pediatric and Adolescent Gynecology Annual Clinical and Research Meeting. Toronto; April 2016.
7. Ott MA, Sucato GS; Committee on Adolescence. Contraception for adolescents. Pediatrics 2014; 134(4):e1257-e1281.
8. U.S. Selected Practice Recommendations for Contraceptive Use, 2013: Adapted from the World Health Organization selected practice recommendations for contraceptive use, second edition. MMWR Recomm Rep 2013; 62:1-60.
9. Department of Labor. Facts about Affordable Care Act Implementation (part XXVI). Accessed online at http://1.usa.gov/1Hd0D0Z.