Adolescent pregnancy is a big concern in the United States, which has the highest adolescent birth rate of any developed country at 18.8 births per 1,000 females, aged 15 to 19 years.
More than 75% of adolescent pregnancies are unplanned, many of which end in abortion, and often disproportionately involve women from low-income or minority populations. Adolescent pregnancy has significant financial, social, educational and medical costs to mothers, infants and society. For example, each unplanned teen pregnancy is estimated to cost the national health care system $5,000, which amounts to $1.5 billion of U.S. taxpayer dollars each year. Furthermore, teen mothers are more likely to experience maternal depression and physical violence during pregnancy than older females; they also are less likely to complete their education. In fact, the American College of Obstetricians and Gynecologists estimates that 60% of teen mothers do not graduate from high school and only 2% earn a college degree by the age of 30 years.
So how can this issue be addressed? As the most effective and user-independent method of contraception, LARC has the potential to notably lower the adolescent birth rate. However, several unique barriers to LARC exist for adolescents, including issues of confidentiality and consent, lack of access, low parental approval and high cost of initiation. Although LARC has been shown to be cost-effective over time and can save money as early as 12 months after initiation, the total bill for initiating LARC often easily exceeds $1,000.
Previous research has shown that offering LARC to adolescents free of charge through government- or state-sponsored programs may help minimize barriers and notably increase patient use. In addition, for adolescent patients who are not deterred by issues of confidentiality or parental consent, LARC is covered by most commercial insurance plans. While the Affordable Care Act attempted to ensure that health insurance plans cover all contraceptive methods, there are religious and medical exceptions resulting in very few plans allowing for same-day access to LARC.
The study by Wilkinson and colleagues is significant because their model suggests that counseling the patient and then placing their selected LARC at the same visit is associated with lower overall costs for Medicaid payers compared with LARC placement at a subsequent visit (more than $2,000 in savings per patient). These savings include lowering the rate of unplanned pregnancy among adolescents by 34% and thus removing the costs of abortion services, prenatal appointments, and vaginal and cesarean deliveries. The study makes an especially strong case for Medicaid to increase access to same-day LARC placement, as it serves an at-risk, low-income population and covers 50% of U.S. births.
The study also alludes to the fact that same-day LARC placement would save providers money by eliminating the need for follow-up visits to place LARC, reducing the number of prenatal appointments for pregnant adolescent patients and decreasing the time needed to confirm insurance reimbursement for LARC. Additional benefits of maintaining a supply of LARC within clinics would be to increase provider awareness and acceptance of LARC for
adolescents, and to encourage widespread training on LARC placement for providers. By demonstrating the cost-effectiveness of same-day LARC placement for payers, this study encourages widespread distribution of, and increased access to, LARC for adolescents.
Increased adolescent use of LARC would ultimately lower the rates of unintended teen pregnancy, decrease the number of abortions and reduce the financial and social burdens of unintended birth on all of society.
CDC. About teen pregnancy. https://www.cdc.gov/teenpregnancy/about/index.htm. Accessed Sept. 12, 2019.
Committee on Adolescent Health Care. Obstet Gynecol. 2017;doi:10.1097/AOG.0000000000002045.
Francis JKR, Gold MA. JAMA Pediatr. 2017;doi:10.1001/jamapediatrics.2017.059.
Han L, et al. Am J Obstet Gynecol. 2014;doi:10.1016/j.ajog.2014.03.015.
Pritt NM, et al. J Pediatr Adolesc Gynecol. 2017doi: 10.1016/j.jpag.2016.07.002.
Henry (Hank) Bernstein, DO, MHCM, FAAP
Member, Advisory Committee on Immunization Practices
Professor of pediatrics
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
Disclosures: Bernstein reports being editor of the Office Pediatrics series of Current Opinion in Pediatrics.