The Pandemic Did Not Affect Single-Visit LARC Insertion
March 1, 2024 6 minutes read
EXECUTIVE SUMMARY
Adolescents who used public insurance and were seeing a non-OB/GYN provider had lower odds of a single-visit placement of long-acting reversible contraception (LARC), new research shows.
- Single-visit LARC is the gold standard, but it is not always accessible to those who seek it.
- Young people and those in rural areas face the most challenges to obtaining LARC.
- Research found that while LARC initiation by OB/GYNs increased for adolescents, most pediatricians did not increase LARC initiation despite a policy statement by the American Academy of Pediatrics recommending LARC for adolescents.
Researchers hypothesized that single-visit placement of long-acting reversible contraception (LARC) for adolescents could have been affected by the COVID-19 pandemic. They found that while fewer adolescents received single-visit LARC during COVID-19 when compared to before the pandemic, the odds of single-visit LARC were not statistically significant. The researchers also found that certain groups of young people encountered obstacles to obtaining single-visit LARC.1
For instance, adolescents using public insurance and those seeing a non-OB/GYN provider had lower odds of single-visit LARC placement during the pandemic compared to before the pandemic. Even those who did receive single-visit LARC may have experienced more hurdles and hassles to obtaining LARC during the pandemic years when clinic visits were more challenging to navigate.
“Single-visit LARC is the gold standard for what we should be doing for all patients if they come in for a visit or specific counseling and express interest in LARC,” says Bianca A. Allison, MD, MPH, lead study author and an assistant professor in the department of pediatrics, division of general pediatrics and adolescent medicine at the University of North Carolina (UNC) School of Medicine in Chapel Hill. “We should be placing the implant or IUD during that same visit, and we should not ask them to return for another visit. We were interested in how it’s done across the UNC health system.”
Provider Proximity Is an Issue
Allison and colleagues wanted to understand if single-visit LARC placement occurred. They wanted to see how frequently it occurred and learn more about patient characteristics associated with single-visit LARC initiation. They found that where a person lives and how close they are to their care provider is tied to the odds of receiving single-visit LARC. Youth living in the same county as their provider had greater access to single-visit LARC placement.
“There are challenges with transportation for folks who live farther away,” Allison says. “It was disheartening to have that finding because it feels like there’s disproportionately low access to a population that would benefit from same-day placement.”
This calls for further inquiry or policy practice changes to convince providers to express a preference for same-day LARC placement — even if patients come in for other health concerns.
“Extend their time during a visit or add them on — even if they’re waiting in the clinic for a bit — to make sure [patients] have access that same day,” Allison suggests. “Maybe they could have different providers in the practice so patients don’t have to travel to clinics multiple times. Clinics may have to come up with multiple solutions.”
Giving some patients more time is an option. “Some clinics have discussed allowing more time for patients traveling farther,” Allison says. “That’s one thing that UNC is starting to do — place a flag in the patient chart that certain patients get extra time when they come in because of the complexity of care.”
That is one way to increase the likelihood of same-day LARC placement. “It could be the patient comes from farther away and has multiple concerns that come up at the visit,” Allison adds. “There are lots of different reasons why a provider might add that time to the patient chart.”
In a different study, Allison and colleagues focused on LARC initiation among adolescents before and after the American Academy of Pediatrics (AAP) issued a policy statement recommending LARC for this age group. They found that more than half of LARC was placed by OB/GYNs and only 5% was placed by pediatricians.2
“We studied North Carolina Medicaid trends data for LARC initiation before and after a policy statement which recommended LARC as a first-line contraception for adolescents,” Allison says.
Less Effect on Pediatric Providers
Allison and colleagues looked for a change in LARC use and found a significant increase in IUD initiation among all providers, with the majority placed by OB/GYNs. But there appeared to be less effect on pediatric providers, at least as far as LARC placement.
It was possible pediatricians were providing more counseling on contraceptives and LARC but were not placing LARC because of a lack of training and confidence, Allison says. “Other literature shows pediatricians don’t feel comfortable placing IUDs and could have made referrals to OB/GYNs to do that, but we didn’t look at the claims data for referrals and couldn’t say if that’s what happened,” she explains. “What we propose is to increase pediatrician training and comfort with placement of LARC — both implants and IUDs.”
Training should include information about reproductive coercion and techniques for ensuring contraceptive counseling is delivered in a patient-centered way. “When we looked at all providers, IUD insertions increased from 4.1 per month to 10.5 per month,” Allison says. “That’s a pretty big increase.” Implants decreased between the period before the AAP policy statement (15 per month) and the period after the AAP policy statement (7.7 per month).
Focus on Conversations
Providers seeing adolescents could help improve their access to LARC and any contraceptive of their choice by asking them about their needs, Allison suggests. “Adolescents may not come to a visit stating they need contraception, so the onus might be on us as providers to ask them what their needs might be around contraception,” she says. “A lot of providers do not initiate those conversations unless the patient is coming in for a full annual wellness exam and they’re expressing sexual activity.”
Pediatric providers and other physicians need to make conversations about sexual health needs more routine with adolescents. They can offer to speak with the patient alone without a parent present if the patient wants this. Those private sessions also could be used to discuss mental health and substance use.
“They’re able to consent to care with their pediatrician without the parent being involved,” Allison says. “Make space for conversations and increase [your] comfort with discussing sexual health and normalizing it.”
Pediatric providers also should seek out opportunities to update and improve their training on patient-centered contraceptive counseling, Allison adds. “Adolescents are a special population who may not only experience bias because of race and gender, but also because of their age,” she says. “It’s unfair to patients and could create reproductive coercion in the healthcare system if we don’t center their values in the visit.”
Adolescents can make the best decision for themselves. Providers need to allow them to do that by holding respectful conversations about their needs and what is most important to them, Allison adds.
Another tactic would be to place posters in the clinic and distribute letters to families promoting the idea of allowing adolescents to spend time alone with the provider during visits. “Our clinic has a letter distributed to all families once the child turns 13,” Allison explains. “It says, ‘Your child now has his own portal access and will have time alone with the doctor during visits.’”
The clinic also informs parents that their children will be tested annually for chlamydia and gonorrhea and will have discussions about sexual risk behaviors. “We let everyone know this is part of the care that’s provided,” Allison says. “We give a brief education on minor consent laws because teens can consent to their own healthcare and can consent to physician-provided treatments around contraception and substance use treatments and mental healthcare.”
Adolescent patients in North Carolina can start any kind of contraception without their parents’ knowledge, Allison says. Some states, including Texas, require parental permission for contraception.
“If they have a positive pregnancy test, we have a confidential conversation with that young person,” Allison says. “We let them know their options; they cannot consent to an abortion, but they can go to an OB/GYN without their parents knowing, or they can pursue adoption without parental involvement.”
Allison also could tell her pregnant adolescent patients how to obtain medication abortion online, such as through a safe organization like Aid Access.
“In the post-Roe era, that is one of the big things — making sure you’re giving young people all of their options,” she says. “You’re saying the word ‘abortion’ and giving them resources if that’s the route they’ve decided to go.”
The information given to adolescents must be appropriate for their age and circumstances. It may have to be stated in coded language or indirectly in states where providers are banned from free speech regarding abortion care.
“It elevates to me how important this [information] is in this political environment,” Allison says. “If you take options off the table, we need to be better at having conversations with patients.”
REFERENCES
- Allison BA, Yates L, Tadikonda A, et al. Single-visit long-acting reversible contraception initiation among adolescents before and during COVID-19. J Adolesc Health 2024;74:367-374.
- Allison BA, Ritter V, Lin F-C, et al. Long-acting reversible contraception initiation among adolescents after an American Academy of Pediatrics policy statement. JAMA Pediatr 2024;e235932.
Adolescents who used public insurance and were seeing a non-OB/GYN provider had lower odds of a single-visit placement of long-acting reversible contraception, new research shows.
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