Teen pregnancy — Time to talk about long-acting reversible contraception
While teen birth rates have fallen, about 1 in 5 births is a repeat
While teen pregnancies are declining in the United States, the nation still leads the world’s high-income countries in live teen births, points out a recent Centers for Disease Control and Prevention (CDC) Public Health Grand Rounds session.1
A closer look at the statistics show that among teens who get pregnant, about half do so due to contraceptive failure.2 Of particular concern is repeat births among teens. According to just-released CDC data, about one in five teen births is a repeat birth.3 More than 365,000 teens ages 15-19 gave birth in 2010; almost 67,000 (18.3%) of those were repeat births.3 (See further statistics in the information box below.)
Data from the new report indicate that while nearly 91% of teen mothers who were sexually active used some form of contraception in the postpartum period, only 22% used top-tier contraceptives such as the contraceptive implant and intrauterine contraception.
The CDC is working to improve provider education on long-acting reversible contraception safety and effectiveness and remove logistical barriers to contraceptive use. Long-acting reversible birth control methods such as an implant or intrauterine devices (IUDs) can be a good option for a teen because they do not require action on a regular basis.
Long-acting reversible contraceptive (LARC) methods are safe and effective in teens, says Wanda Barfield, MD, MPH, a pediatrician and director of the CDC’s Division of Reproductive Health. “That is really an important message, because I think providers have been led to believe that teens might not be good candidates for those types of contraceptives, but they actually are,” notes Barfield. “That is an important opportunity, because for teens, often remembering to take a pill every day may not be the most effective contraceptive for them.”
With the publication of the “U.S. Medical Eligibility Guidelines For Contraceptive Use,” providers can make evidence-based decisions in safely using the contraceptive implant or intrauterine devices in teenagers,4 says Barfield. The guidelines ranks use of the Copper T-380A and the levonorgestrel IUDs as a “2” (a condition for which the advantages of using the method generally outweigh the theoretical or proven risks) for women under age 20, with the same rating for nulliparous women. The contraceptive implant is rated as a “1” (no restrictions on use) for women of all ages.4 The upcoming “Selected Program Recommendations” will offer even more concrete evidence affirming LARC method use in adolescents, Barfield notes. (Contraceptive Technology Update reported on the guidance. See “The New Year will bring new recommendations,” January 2013, p. 5.)
Too many providers have misconceptions about which contraceptive methods are safe and appropriate for teens, notes Barfield. Education about today’s LARCs being different from the infamous Dalkon Shield that caused all other IUDs available at that time to drop out of use is critical. Today’s intrauterine contraceptives “are not your mother’s IUD,” she points out.
CHOICE shows LARCs work
The Contraceptive CHOICE project, which was designed to evaluate reversible birth control methods, found that LARC methods are more effective than pills, patches, or rings in preventing unplanned pregnancy. The CHOICE project found that women using pills, patches, and rings were more than 20 times as likely to become pregnant as women using an IUD or an implant.5 (To read more about the research, see the CTU article “The ‘Get It and Forget It’ methods are here: Remove obstacles to use,” April 2012, p. 37.)
The rate of teen births within the CHOICE cohort was 6.3 per 1,000, compared with the U.S. rate of 34.3 per 1,000,6 points out Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta. “Anyone serious about reducing teen-age births in a community, a state, or in the country as a whole needs to study exactly what those affiliated with the Contraceptive CHOICE project in St. Louis have done,” says Hatcher. “It is carefully documented, and all of us must study the approaches they used to encourage participants to use the LARC methods and all the other steps they followed to provide high-quality contraceptive services to women in St. Louis.”
The Contraceptive CHOICE team is planning an upcoming launch of its online Resource Center, confirms Gina Secura, PhD, MPH, project director and adjunct assistant professor of epidemiology and senior scientist/epidemiologist in the Department of Obstetrics and Gynecology in the Division of Clinical Research at Washington University in St. Louis. “Our goal is to get it up by July, but we are pushing for it to be sooner than that,” says Secura. “We have received about 80 calls in the last month for our materials, and we are sharing those as best we can.”
Clinicians who are interesting in obtaining CHOICE material prior to the Resource Center web site launch can contact the team by telephoning (314) 747-0800 or e-mailing [email protected], says Secura. The materials will be posted on the project web site at www.choiceproject.wustl.edu.
Partners work together
The CDC is working with such national organizations as the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Academy of Family Practitioners to get the word out on use of LARC methods in teens, says Barfield. (The agency has partnered with the online medical resource site Medscape in presenting an expert commentary on teen pregnancy and reproductive health. Web: http://bit.ly/XibNcp.)
There are more than knowledge barriers to overcome with providers when it comes to teens using long-acting methods, notes Barfield. Many providers struggle with reimbursement issues for such devices.
Many repeat births in teens could be prevented through postpartum use of IUDs and implants, notes Barfield. Counseling women during prenatal visits about postpartum contraception, and offering them LARC methods in the hospital after delivery makes it easier for them to avoid unintended pregnancy.
The CDC worked with South Carolina public health officials in the Medicaid Health Initiative. The program reimburses for LARC insertion in the hospital before women who have just given birth leave the facility. (Check it out at http://1.usa.gov/14XN2H8. Select “South Carolina’s Medicaid Health Initiative.”)
Removing barriers so that postpartum contraceptives can be used, particularly postpartum LARC methods, is an important step in combatting repeat teen pregnancies, says Barfield.
“We are really missing opportunities to help teens make good choices after they have had a baby and to really get them into a situation where they are able to plan the next pregnancy,” she notes. “It’s been really important to work with our clinical providers so they can help us to understand the context of their practice.”
References
1. Centers for Disease Control and Prevention. Reducing Teen Pregnancy in the United States. Webcast. Accessed at http://1.usa.gov/11I6Lty.
2. Santelli JS, Morrow B, Anderson JE, et al. Contraceptive use and pregnancy risk among U.S. high school students, 1991-2003. Perspect Sex Reprod Health 2006; 38(2):106-111.
3. Centers for Disease Control and Prevention (CDC). Vital signs: repeat births among teens — United States, 2007-2010. MMWR Morb Mortal Wkly Rep 2013; 62:249-255.
4. Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-6.
5. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012; 366(21):1,998-2,007.
6. Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012; 120(6):1,291-1,297.
What do we know about teen births? • Nearly 1 in 5 births to teens, ages 15-19, are repeat births. • Most (86%) are second births. • Some teens are giving birth to a third (13% of repeat births) or fourth up to sixth child (2% of repeat births). • American Indian and Alaskan Natives, Hispanics, and black teens are about 1.5 times more likely to have a repeat teen birth, compared to white teens. • Infants born from a repeat teen birth are more likely to be born too small or too soon, which can lead to more health problems for the baby. Source: Centers for Disease Control and Prevention (CDC). Vital signs: repeat births among teens — United States, 2007-2010. MMWR 2013; 62:249-255. |
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