ORLANDO – The decision to use long-acting reversible contraception appears largely reactionary among adolescent girls, as the only factors significantly associated with the decision in a recent cross-sectional study were increased parity and postpartum status.
The findings could help with future efforts to identify and remove barriers to long-acting reversible contraceptive (LARC) use among adolescents, according to Dr. Lisa Moon, a third-year resident at the University of Oklahoma, Oklahoma City.
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Of 209 adolescents included in the study, 66 used oral contraceptive (OC) pills, and 143 used LARC methods. Levonorgestrel intrauterine devices were used most often (77 subjects), followed by etonogestrel implants (61 subjects). Five of the adolescents used a copper intrauterine device (IUD), Dr. Moon reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
A breakdown of the findings by age showed that with the exception of those aged 15 years, LARC use increased with increasing age; 1 subject was aged 14 years, and she used OCs; 5 were aged 15 years, and all used a LARC; 15 were aged 16 years, and 9 (60%) used a LARC; 44 were aged 17 years, and 28 (64%) used a LARC; 62 were aged 18 years and 44 (71%) used a LARC; and 82 were aged 19 years, and 57 (70%) used a LARC.
Multivariate analysis showed that having previously given birth and postpartum status were significant predictors of LARC vs. OC use (odds ratios, 3.5 and 3.9, respectively). Age, race, marital status, and documented citizenship were not associated with choice of contraception.
The vast majority of adolescent pregnancies – about 82% – are unplanned, and 50% of teens with unplanned pregnancies report having used some form of contraception at the time of pregnancy. LARC methods have the potential to improve teen pregnancy rates because non-LARC methods have been reported to have a more than 20-fold greater risk of failure; that risk was almost doubled in adolescents, but while 8.5% of U.S. women use such methods, 4.5% of those aged 15-19 years do so, Dr. Moon said (N. Engl. J. Med. 2012;366:1998-2007).
Lack of familiarity with LARCs, misperceptions, cost, lack of access, health care provider concerns, and confidentiality concerns are possible barriers to increased LARC use, she noted.
Confusion about recommendations for LARC use also may play a role, she said, noting that as recently as 2004, a World Health Organization report stated that “While there are no restrictions based on age or parity for IUDs, many adolescents still will not qualify as candidates, because of the risk of exposure to STIs [sexually transmitted infections]. Ideal candidates for IUDs are in long-term mutually monogamous relationships, are parous, and do not have unexplained vaginal bleeding,”
That view has changed. In 2012, both the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists released recommendations promoting LARC use among adolescents, and a 2013 WHO report stated that “LARC methods are appropriate for most women, including adolescent and nulliparous women.”
The ACOG recommendation specifically notes that LARC methods should be first line for all women (Obstet. Gynecol. 2012;120:983-8).
“It takes a little bit of time for that information to percolate out to our community clinics, which is where we get a little bit behind sometimes in our recommendations,” Dr. Moon noted.
That is concerning, given that a 2010 survey of physicians showed that 30.7% agreed that IUDs were appropriate for teenagers, 49.6% said they would offer an IUD to an unmarried teenager with one child, and 19% said they would offer an IUD to a nulliparous unmarried teenager (Contraception 2010;81:112-6).
“There’s kind of this disconnect between what we know is effective and reliable for preventing pregnancy in our teen population, and what we recommend to them,” Dr. Moon said.
The findings have prompted a deeper look into barriers to adolescent LARC use in Oklahoma, which ranks 48th in the nation for teen pregnancy rates among 15- to 17-year olds (22.8 births per 1,000 vs. 14.1 nationally), 50th for unplanned pregnancies among 18- and 19-year olds (83.1 per 1,000 vs. 51.4 nationally), and 49th overall (MMWR 2013;62:249-55).
“What’s most staggering to me is that 20% of those are to teens who are already parents, which highlights this unmet need that we have in our state,” she said.
The current findings demonstrate that parity and postpartum status predict LARC choice, but they don’t explain why that is, Dr. Moon said.
To characterize barriers to LARC use, as well as biases on the part of both patients and physicians, researchers are currently meeting with focus groups of primary care practitioners to identify provider biases, and focus groups of adolescent are planned, she said.