Removing barriers to contraceptive access reduced teen pregnancy, abortion rates

Teenagers who were given free access to a variety of birth control methods, along with counseling about the risks and benefits of each, were significantly less likely to have an unwanted pregnancy or induce an abortion and were more likely to be adherent to treatment, particularly those on long-acting, reversible contraception methods, new research shows.

The study, named the Contraceptive CHOICE Project, was conducted with 1,404 sexually active teens aged 14 to 19 years from the St. Louis region, who were followed for 2 to 3 years, depending on their enrollment date.

On the day of enrollment, a 1.5- to 2-hour session was spent to obtain consent, medical history, conduct a baseline survey, contraceptive counseling and perform screening for STDs. After being educated about the risks and benefits of each method, teens were prescribed their choice of contraceptive method. In most cases, the chosen method of contraception was supplied at the time of enrollment. Counseling was also provided in a relaxed setting.

“The counseling was done by a trained health educator in plain clothes, and not to a teen sitting in a paper gown. The environment was much more welcoming,” said study researcher Gina M. Secura, PhD, MPH, who is now retired from the division of clinical research in the department of obstetrics and gynecology at Washington University in St. Louis.

Gina Secura

Gina M. Secura

The decisions about which method to use was left entirely up to each teen participant, and the research team was expecting only 10% would choose long-acting, reversible contraception (LARC).

“We were really surprised that over 70% of our teens chose these methods,” Secura told Healio.com/Psychiatry in an interview, adding that each participant was informed they could change methods at any time during the study.

Participant history and demographics

Of all participants in CHOICE, 97% were sexually active or had sexual experience at baseline, and by 12 months of enrollment, 99% were sexually experienced. Almost half reported a previous unintended pregnancy and 18% reported a prior abortion. Of the participants aged 14 to 17 years (n=484), 67.8% were black, 24.6% were white and 7.6% were of another race; 33.7% were living under low socioeconomic status. Of the participants aged 18 to 19 years at enrollment (n=920), 59.7% were black, 32.3% were white 8% were of another race; 50% were of low socioeconomic status.

Results

Compared with other sexually active teens, those enrolled in CHOICE had significantly lower rates of pregnancies and induced abortions during the study dates between 2008 and 2013 vs. rates of sexually active teens in the United States based on 2008 data. The mean number of teen enrollees per 1,000 who became pregnant was 34 (95% CI, 25.7-44.1) vs. 158.5 of sexually experienced teens nationally. The abortion rate for participants was 9.7 per 1,000 teens (95% CI, 13.3-27.4) compared with 41.5 of sexually active teens per 1,000 in the United States and 14.7 per 1,000 of all teens in the United States.

Adherence

“Teens who chose LARC used them much longer than any of the refillable methods,” Secura said.

Because teens often have busy, complicated lives, Secura said adherence to taking daily or other refillable birth control methods is not an ideal choice, so LARC methods may be more reliable.

“Most people aren’t good about doing something every day at the same time, or the same time every week. That’s why these methods are good, because it doesn’t matter who you are. Once they’re placed, they work,” she said.

Teens aged 14 to 17 years were more likely to choose implanted contraceptive devices, whereas older teens aged 18 to 19 years were more likely to select a hormonal IUD. Other methods offered included nonhormonal IUDs, depot medroxyprogesterone acetate (DMPA) injections, oral contraceptives, hormonal patches and cervical rings.

Barriers broken

When the study was designed, the researchers hypothesized that cost would be the only barrier to access, but when the first enrollee came in and was asked what kind of birth control she wanted to use, the participant responded by saying she did not know anything about birth control, according to Secura.

“We realized we needed to come up with some kind of counseling for every one of our participants,” Secura said. “Typically, many women go in [to a clinic or doctor’s office], and they are handed a prescription for birth control pills, and then they leave. We thought we would reframe the conversation; we’re going to flip it over, and base it all on level of effectiveness.”

The research team developed a standardized script, and every participant, regardless of age, race, socioeconomic background or other demographic was given the same information about the different methods available.

However, new barriers became apparent even after participants were counseled and offered choices.

“As we started actually providing the methods and we partnered with community clinics, the third barrier started coming up,” Secura said.

The researchers learned that clinics had different standards by which they would prescribe certain methods of contraception, such as waiting for certain tests results, including STD screening, to be returned, or whether a participant was menstruating, or biases about whether the method was preferred for use in teens.

In other cases, because of high upfront costs of many LARC products, many clinics did not carry the selected method. Lack of access presented challenges to adherence early on in the study because teens and young women who are required to make several appointments may be more likely to miss one or more appointments.

“Even when we increase the demand, it’s problematic because someone will go in and say, ‘That’s what I want,’ but because these methods have these high upfront costs, it’s hard for clinics to justify having $20,000 worth of methods sitting on the shelf waiting for someone to come in and want one,” Secura said.

Once the barriers were recognized, Secura and her research team made an effort to provide the contraceptive method during the initial enrollment session so the teen only had to keep one appointment.

“It’s not just cost: it’s cost; it’s education; it’s access,” Secura said.

Study limitations

Several factors potentially confound the results. Because minors were enrolled, all but four minors had parental consent, and parents were welcomed to the counseling sessions at the discretion of the teen. The researchers wrote that regular monitoring via phone interviews may also have increased adherence, and parental involvement may have influenced the high rate of adherence.

Another limitation in interpreting the data is enrollment: by the third year, only 75% were still enrolled.

“That’s always a concern. Typically, we try to achieve an 80% follow-up rate,” Secura said during the interview. “We always worry about the ones that we’ve lost — how are they different? Are they the ones who could have gotten pregnant? And we don’t know,” she said. “But of the 25% we lost, even if half of them got pregnant, compared to the sexually active rates nationally, it’s still not going to bring it up to 158 per 1,000.”

Other limitations include issues with the US pregnancy rates, which rely on composite birth data, the abortion surveillance system and self-reporting. Further, national data from 2008 may not be representative of the study period. The researchers wrote that from 2008 to 2010, the pregnancy rate dropped by 15% nationally, and the most recent data from 2012 show that the rate dropped to 29.4 per 1,000 among 15- to 19-year-old teens, the lowest rate ever reported in the United States.

A change in attitudes

There is much work to do to change personal biases about which methods are best for teens or women who have never had children, according to Secura, but changes are underway.

“What’s most exciting is the policy statement from the American Academy of Pediatrics. They just came out on [Sept. 29] and said LARC methods should be first-line contraceptive options for teens. So all of these professional organizations — the American Congress of Obstetricians and Gynecologists, the CDC — they’re all stacking up and saying these are the methods we should at least be considering first. At the very least, every teen should know that these are a real option.”

Changes will likely come slowly. “It’s overwhelming and hard to change practices. It’s hard to get rid of all these barriers,” Secura said. “If it was easy, it would already have been done. It’s a matter of starting to chip away at the problems, and here is a model to use.”  – by Shirley Pulawski

Disclosure: Please see the full article for a list of researchers’ financial disclosures.

Teenagers who were given free access to a variety of birth control methods, along with counseling about the risks and benefits of each, were significantly less likely to have an unwanted pregnancy or induce an abortion and were more likely to be adherent to treatment, particularly those on long-acting, reversible contraception methods, new research shows.

The study, named the Contraceptive CHOICE Project, was conducted with 1,404 sexually active teens aged 14 to 19 years from the St. Louis region, who were followed for 2 to 3 years, depending on their enrollment date.

On the day of enrollment, a 1.5- to 2-hour session was spent to obtain consent, medical history, conduct a baseline survey, contraceptive counseling and perform screening for STDs. After being educated about the risks and benefits of each method, teens were prescribed their choice of contraceptive method. In most cases, the chosen method of contraception was supplied at the time of enrollment. Counseling was also provided in a relaxed setting.

“The counseling was done by a trained health educator in plain clothes, and not to a teen sitting in a paper gown. The environment was much more welcoming,” said study researcher Gina M. Secura, PhD, MPH, who is now retired from the division of clinical research in the department of obstetrics and gynecology at Washington University in St. Louis.

Gina Secura

Gina M. Secura

The decisions about which method to use was left entirely up to each teen participant, and the research team was expecting only 10% would choose long-acting, reversible contraception (LARC).

“We were really surprised that over 70% of our teens chose these methods,” Secura told Healio.com/Psychiatry in an interview, adding that each participant was informed they could change methods at any time during the study.

Participant history and demographics

Of all participants in CHOICE, 97% were sexually active or had sexual experience at baseline, and by 12 months of enrollment, 99% were sexually experienced. Almost half reported a previous unintended pregnancy and 18% reported a prior abortion. Of the participants aged 14 to 17 years (n=484), 67.8% were black, 24.6% were white and 7.6% were of another race; 33.7% were living under low socioeconomic status. Of the participants aged 18 to 19 years at enrollment (n=920), 59.7% were black, 32.3% were white 8% were of another race; 50% were of low socioeconomic status.

Results

Compared with other sexually active teens, those enrolled in CHOICE had significantly lower rates of pregnancies and induced abortions during the study dates between 2008 and 2013 vs. rates of sexually active teens in the United States based on 2008 data. The mean number of teen enrollees per 1,000 who became pregnant was 34 (95% CI, 25.7-44.1) vs. 158.5 of sexually experienced teens nationally. The abortion rate for participants was 9.7 per 1,000 teens (95% CI, 13.3-27.4) compared with 41.5 of sexually active teens per 1,000 in the United States and 14.7 per 1,000 of all teens in the United States.

Adherence

“Teens who chose LARC used them much longer than any of the refillable methods,” Secura said.

Because teens often have busy, complicated lives, Secura said adherence to taking daily or other refillable birth control methods is not an ideal choice, so LARC methods may be more reliable.

“Most people aren’t good about doing something every day at the same time, or the same time every week. That’s why these methods are good, because it doesn’t matter who you are. Once they’re placed, they work,” she said.

Teens aged 14 to 17 years were more likely to choose implanted contraceptive devices, whereas older teens aged 18 to 19 years were more likely to select a hormonal IUD. Other methods offered included nonhormonal IUDs, depot medroxyprogesterone acetate (DMPA) injections, oral contraceptives, hormonal patches and cervical rings.

Barriers broken

When the study was designed, the researchers hypothesized that cost would be the only barrier to access, but when the first enrollee came in and was asked what kind of birth control she wanted to use, the participant responded by saying she did not know anything about birth control, according to Secura.

“We realized we needed to come up with some kind of counseling for every one of our participants,” Secura said. “Typically, many women go in [to a clinic or doctor’s office], and they are handed a prescription for birth control pills, and then they leave. We thought we would reframe the conversation; we’re going to flip it over, and base it all on level of effectiveness.”

The research team developed a standardized script, and every participant, regardless of age, race, socioeconomic background or other demographic was given the same information about the different methods available.

However, new barriers became apparent even after participants were counseled and offered choices.

“As we started actually providing the methods and we partnered with community clinics, the third barrier started coming up,” Secura said.

The researchers learned that clinics had different standards by which they would prescribe certain methods of contraception, such as waiting for certain tests results, including STD screening, to be returned, or whether a participant was menstruating, or biases about whether the method was preferred for use in teens.

In other cases, because of high upfront costs of many LARC products, many clinics did not carry the selected method. Lack of access presented challenges to adherence early on in the study because teens and young women who are required to make several appointments may be more likely to miss one or more appointments.

“Even when we increase the demand, it’s problematic because someone will go in and say, ‘That’s what I want,’ but because these methods have these high upfront costs, it’s hard for clinics to justify having $20,000 worth of methods sitting on the shelf waiting for someone to come in and want one,” Secura said.

Once the barriers were recognized, Secura and her research team made an effort to provide the contraceptive method during the initial enrollment session so the teen only had to keep one appointment.

“It’s not just cost: it’s cost; it’s education; it’s access,” Secura said.

Study limitations

Several factors potentially confound the results. Because minors were enrolled, all but four minors had parental consent, and parents were welcomed to the counseling sessions at the discretion of the teen. The researchers wrote that regular monitoring via phone interviews may also have increased adherence, and parental involvement may have influenced the high rate of adherence.

Another limitation in interpreting the data is enrollment: by the third year, only 75% were still enrolled.

“That’s always a concern. Typically, we try to achieve an 80% follow-up rate,” Secura said during the interview. “We always worry about the ones that we’ve lost — how are they different? Are they the ones who could have gotten pregnant? And we don’t know,” she said. “But of the 25% we lost, even if half of them got pregnant, compared to the sexually active rates nationally, it’s still not going to bring it up to 158 per 1,000.”

Other limitations include issues with the US pregnancy rates, which rely on composite birth data, the abortion surveillance system and self-reporting. Further, national data from 2008 may not be representative of the study period. The researchers wrote that from 2008 to 2010, the pregnancy rate dropped by 15% nationally, and the most recent data from 2012 show that the rate dropped to 29.4 per 1,000 among 15- to 19-year-old teens, the lowest rate ever reported in the United States.

A change in attitudes

There is much work to do to change personal biases about which methods are best for teens or women who have never had children, according to Secura, but changes are underway.

“What’s most exciting is the policy statement from the American Academy of Pediatrics. They just came out on [Sept. 29] and said LARC methods should be first-line contraceptive options for teens. So all of these professional organizations — the American Congress of Obstetricians and Gynecologists, the CDC — they’re all stacking up and saying these are the methods we should at least be considering first. At the very least, every teen should know that these are a real option.”

Changes will likely come slowly. “It’s overwhelming and hard to change practices. It’s hard to get rid of all these barriers,” Secura said. “If it was easy, it would already have been done. It’s a matter of starting to chip away at the problems, and here is a model to use.”  – by Shirley Pulawski

Disclosure: Please see the full article for a list of researchers’ financial disclosures.

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