EXECUTIVE SUMMARY
Foster youth are vulnerable and at high risk of pregnancy. Reproductive health providers need to work with the youth and their caregivers to build a trusting relationship when discussing contraception.
- Caregivers want to build trauma-informed relationships with the youth in their care, a new study finds.
- The provider’s role is to be a coach who helps the foster families feel safe, confident, and comfortable talking about contraception.
- Foster caregivers may have strong feelings about long-acting reversible contraception (LARC), which could play a role in the foster youth’s
decision-making.
Foster care youth are an extremely vulnerable population. They are twice as likely to become pregnant as a teen than are youth who are not in foster care. They also are more likely to engage in riskier sexual behaviors, with one in five reporting consensual sex before age 13.1
In Texas, nearly half of sexually active youth entering foster care reported never having used contraception.2
Discussing reproductive health and contraception with youth in foster care needs to focus on relationship-building and acknowledge the attitudes and concerns of their foster caregivers, according to the authors of a recent study.2
The study authors recruited a convenience sample of caregivers of youth at an academic center in North Texas and conducted in-person interviews — with bilingual research coordinators — at the foster care center in late 2019.2
They found that caregivers who chose to enroll in the study were concerned about building relationships with the young people in their care and understanding how the youths’ past trauma needed to be managed. Some caregivers said they needed to build trust with youth before discussing contraception.2
The caregivers also had a great deal of experience with youth in need of reproductive healthcare. Nearly half of the caregivers recruited for the study said they previously had cared for an adolescent who was pregnant or parenting.2
“Nearly every caregiver we interviewed talked about how it was important to build that relationship with the adolescent before jumping into something important like contraception,” says Shelby Edmondson, MA, lead study author and a fourth-year medical student at UT Southwestern Medical School in Dallas.
“Once they had the relationship, there was caregiver comfort in having this conversation,” Edmondson says. “Some wanted the adolescent to come to them, while others wanted to initiate the conversation themselves to prevent pregnancy.”
Caregivers sometimes wanted to start these conversations after developing a relationship with the youth.
“The take-home message is how important it is to have trusting relationships with youth,” says Jenny Francis, MD, MPH, study co-author and an associate professor of pediatrics and adolescent medicine specialist at UT Southwestern Medical Center and Children’s Health.
Reproductive health providers will want their teen patients to trust adults in their lives and have conversations to build trust between them, she adds.
“We are not just birth control providers. We’re coaches on how to feel safe, and that’s one of the main findings about relationship-building,” Francis explains. “We want them to feel confident and comfortable talking about contraception.”
The point of the study is to help providers working with youth in foster care to know what to expect when they are having these conversations in the exam room, Francis explains.
In reading what caregivers said, it was clear they wanted to become a support network and sounding board for the adolescents in their care, Edmondson says.
“The thing that stuck out to me was the value that all the caregivers placed on building those relationships,” she explains. “They each seemed to want to work to become the support network and sounding board that their adolescents needed.”
Edmondson, Francis, and colleagues also found caregivers felt strongly about long-acting reversible contraceptives (LARCs), both for and against LARC. “Often, the opinions against LARC had vivid horror stories related to LARC,” Edmondson says. “These could be side effects, where the contraceptive was removed early. There were personal stories about LARC not going well for them or for people they had known.”
Caregivers who were pro-LARC thought about it being long-acting, how it did not require upkeep, and how it would benefit the youth when there were changes in their lives, including living with new caregivers, Edmondson explains.
Providers can expect to encounter foster youth and caregivers who hold strong opinions either for or against LARC, Francis notes. For example, one caregiver talked about an intrauterine device (IUD) that led to an infection and caused problems. Another worried the young person would not be in a safe place for continued care when it was time to remove and replace the IUD.2
Still another person said, “Not having to take the pill every day is awesome. Not having to think about it for five years is fabulous.”2
In limited cases, a caregiver would mention religious beliefs, but not necessarily that they would apply them to their foster child, Edmondson says.
When religion came up in the interviews, it was more about the training caregivers went through and how they sometimes believed the foster care agency might have a religious agenda that did not match the caregivers’ beliefs, Francis says.
“When it didn’t align, it was the point of an opportunity to make sure training is neutral and respectful of everyone’s beliefs and how to have conversations about contraception,” Francis adds.
Some foster agencies were religious-based, but they needed to be considerate of the reproductive health needs of youth.
“When I read these statements, it made me feel the next study or next step would be to evaluate caregiver training both from the agency’s perspective and also from the caregiver’s perspective to see how they can align and to make sure youth get what they need from the agency, caregiver, and medical provider,” Francis says.
Reproductive health providers also should keep in mind that not all foster caregivers desire the same level of involvement in the youth’s contraceptive decision-making.
Some caregivers desired heavy involvement in deciding contraception for the youth in their care. Others were more focused on adolescent autonomy and wanted the team to make all the decisions, Francis says.
“As a provider, you want to validate everyone in the room to make sure all voices are heard and respected,” Francis explains. “The person using birth control — it’s their body, and we always say there is adolescent autonomy.”
If the youth declines contraception, providers can help caregivers understand their point of view and serve as a mediator between the caregiver and foster youth.
“Help them understand both the pros and cons of the situation,” Francis says. “With this study, when you have caregivers with an extreme reaction, you help the patient understand that. Caregivers play such a key role in helping them make decisions.”
But caregivers also must balance their pre-existing beliefs, including the youth’s perceived maturity level, with the youth’s autonomy in making decisions. Providers should watch for the potential of caregiver coercion to start contraception for youth in care, Edmondson, Francis, and colleagues noted.2
The findings were reassuring because it showed how loving the caregivers were and how they wanted to be supportive, involved, and connect with the youth in their care, Francis says.
“As a clinician, I recognized that each team [of youth and caregiver] may be different. Some were supportive and others were not, and you need to be able to handle those conversations,” Francis adds.
REFERENCES
- Brooks K. Teen pregnancy and foster care. National Center for Health Research. July 21, 2023.
- Edmondson S, Conrado AB, Loria H, et al. Caregivers of youth in foster care in Texas and their role in contraception decision-making for adolescents in care. Contraception 2023; Jun;122:109993. doi: 10.1016/j.contraception.2023.109993. Epub 2023 Feb 24.
Foster youth are vulnerable and at high risk of pregnancy. Reproductive health providers need to work with the youth and their caregivers to build a trusting relationship when discussing contraception.
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