It's hard to think of a segment of the American population that could benefit more from long-acting contraceptives than the teenager. Effectively using birth control can be difficult no matter how old you are, but preventing pregnancy presents singular challenges for adolescents. There's the mortification of fitting a condom over an unripe banana in front of your peers in health class. There's not necessarily wanting your parents to know that you're having sex, and so not using their insurance to pay for birth control. Then there's maintaining consistency in anything—from condom use to SAT prep—a feat that is hard when you're overwhelmed by homework, hormones, and the demands of being almost old enough to be in charge of yourself.
These experiences aren't universal, but they're common enough to form a canon of teenage clichés, encoded into the script of what it means to come of age in early 21st-century America. The pregnancy scare is a rite of passage in this country, and although teenage pregnancy is on the decline nationwide, it's still more prevalent in the United States than in other industrialized nations. Part of the reason for this is that access to long-acting reversible contraceptives, or LARCs—by far the most effective form of birth control—is limited, for teens more than any other group. Despite the obvious benefits of LARCs for teenagers, the option remains relatively inaccessible, rarely discussed and even more rarely put into action.
Long-acting reversible contraceptives (LARCs) refer to intrauterine devices (IUDs)—either the hormonal Mirena or non-hormonal Paragard—and under-the-skin implants in the upper arm. Depending on the particular device, LARCs provide the most effective form of contraception for three to 10 years, requiring no further action from the patient after insertion. According to the CDC, their efficacy rate is over 99 percent, compared to a 9 percent failure rate in birth control pills and an 18 percent failure rate in condoms.
Increasingly, organizations like the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, The World Health Organization, and the Centers for Disease Control recommend LARCs as the first choice of hormonal birth control for sexually active adolescents, but these recommendations have yet to fully translate to the mainstream.
"LARCs are a great option for women of all ages because they're so effective, but they're particularly good for teenagers because they're a tough group to find contraception methods that work," said Dr. Eve Espey, chair of the Department of Obstetrics and Gynecology at the University of New Mexico and chair of the LARC work group at the American College of Obstetricians and Gynecologists (ACOG). (New Mexico currently has the highest teen pregnancy rates in the nation.) "Although most teens want to avoid pregnancy, they have a hard time with the most commonly used short-acting methods: birth control pills and condoms," Espey said.
The Mirena works by releasing a small amount of progesterone into the uterus, where it acts locally, instead of going throughout the entire body, as the hormones in birth control pills do. The implant also works by releasing progestin, a synthetic form of progesterone. The Paragard is a copper IUD that contains no hormones at all, but prevents pregnancy through a copper filament, which creates a uterine environment that's toxic to sperm.
Dr. Eduardo Lara-Torre, a Virginia-based member of ACOG's executive board and a practicing expert on gynecologic care for adolescents, agreed that making birth control as simple as possible for teenagers is key in preventing pregnancy. "The vulnerability of the teenage population is what makes LARCs so wonderful," he said. "Teenagers tend to not be great planners, and having a method that's reliable, appropriate for their age, safe, long-acting and reversible makes birth control so much easier for them."
And teens themselves are on board with the idea of simplifying their birth control. Tika, a 17-year-old in Boulder, Colorado, has a Paragard IUD and said it's much easier than other birth control methods she'd used before. "When I was using the patch, even a week into it, I was already forgetting to change it at the same time every week, and the hormones in it made me crazy," she said. "I wanted something that I wasn't going to have to remember very often and that wasn't going to mess with my hormones. The 10 years that the Paragard lasts was also a big appeal. I was 16 when I got it, and I don't see myself wanting kids by the time I'm 26. And if I do want kids before that, I can have it taken out."
Of course, LARCs don't protect against sexually transmitted infections. Among Tika's peers, condom use is spotty. "They're widely used, but at the same time, I don't think it's enough," she said. "Like there have been way too many instances where one of my friends will call me up in the middle of the night like, 'Oh, I just had unprotected sex but he pulled out, are we OK?'"
When LARCs are widely available, the results among adolescents are dramatic. Just north of New Mexico, (remember, highest teen pregnancy rates nationwide) Colorado reduced its teen pregnancy rate by 40 percent between 2009 and 2013 largely by providing over 30,000 LARCs for free at 68 family planning clinics statewide. The Colorado Family Planning Initiative (CFPI) accomplished this through a grant of $23.5 million from the Susan Thompson Buffett Foundation, which allowed CFPI to fully fund Title X, the federal family planning program.
Young women like Tika who got IUDs or implants for free through teen clinics across the state were well-informed about their sexual health and made educated, prudent choices. Colorado is one of 21 states that explicitly allow minors to consent to contraceptive services, which means that teens are able to obtain birth control on their own without approval from or having to inform a parent or guardian. For many teenagers, a guarantee of anonymity is crucial.
"My guardian, the person who holds my insurance, would not be super excited about the fact that I have an IUD, and that's what's so cool about the teen clinics here is that they're free and confidential," said Ana, also a 17-year-old high school senior in Boulder. She got a Paragard in 2013 without using her private insurance. "I think everyone with a vagina and a uterus should be aware of ways to protect themselves and to keep their bodies their bodies," she said.
However, according to an opinion published in 2012 by the American College of Obstetricians and Gynecologists, only 4.5 percent of young women aged 15-19 currently using a method of contraception choose a LARC. This is because the barriers to access are also significant: the up-front cost is high (usually between $300 and $900); many providers are reluctant to stock them because of reimbursement issues and the outdated notion that they're unsafe for younger women; lack of education among teens about their birth control options, especially among uninsured or underinsured populations; and the sheer logistics of getting to a clinic for at least one appointment make obtaining a LARC difficult. Plus, many teens who haven't yet had a pelvic exam (routine exams aren't recommended until age 21) are freaked out about the idea of having a device inserted into their uterus or are afraid of the pain that comes during and after the procedure.
Allana Cartier is a nurse in the Santa Fe Public School system. For several years, she worked with teen moms at Santa Fe High School's Teen Parent Center. A large part of Cartier's job was helping her students obtain and use birth control. "I pushed IUDs quite a bit," she said of her tenure with the teen parents. "My students weren't very good at taking their birth control pills or getting their Depo-Provera shots on time. During my last year working with the teen parents, I'd say about 90% of them had IUDs. The only downfall was the price. Many of our students don't have social security numbers and so are ineligible for Medicaid. There are free or low-cost IUDs available through the Department of Health, but teens need help maneuvering the system and knowing what their options are."
For sexual health advocates, there's still a great deal of work to be done to inform the public and providers about the benefits of LARC use in teens. "The CDC just released the most recent numbers on LARC use in the US, and both the percentage of women using the implant and IUD has increased dramatically, but levels for teenagers and for younger women still lag pretty far behind the numbers for older women," Espey explained. "Much of the bad feelings about IUDs come from a particular device used back in the 1970s called the Dalkon Shield which led to a lot of litigation and gave IUDs a bad name in general. There's still this belief that IUDs are not good for younger women, although there's good data that shows that today's IUDs don't cause pelvic infections… There needs to be a major emphasis on education to understand the advantages of LARC. Like every method, it's not for everybody, but the disadvantages of LARC have really been emphasized over the advantages."
"I really don't think the concerns about IUDs and implants hold up any longer," Lara-Torre said. "There's an old myth that women who have never had a baby shouldn't get one, that it's more difficult to insert and more potential for it to come out. The data does show that it might be a little more difficult to put in and there's perhaps a small increased chance for expulsion, but the overall numbers did not justify not offering LARC to the adolescent population."
"It seems like it takes a lot of convincing to get teenagers to consider an IUD," Tika said. Along with Ana, she volunteers with Sexual Health AIDS Awareness Peer Education (SHAPE) a in-school peer education program administered by Teen Clinic in Boulder Valley. "I've tried to convince my friends who've had multiple pregnancy scares and who can't seem to take a pill every day or don't have time to go into the clinic every month for a Depo-Provera shot, and they're just like 'Oh, I can't handle things being in my vagina,' and I'm like, 'They're quick procedures.' But there's a stigma against IUDs, and that sets them off. They say that the pill is easy, that it's talked about on TV and it's more normalized."
Finding the money to pay for LARCs and making sure that providers are reimbursed for both the cost of the device and insertion is complex. While the up-front cost of an implant or an IUD is high, over time, they're extremely cost-effective because they last for so long, and are almost always cheaper than taking birth control pills monthly. For those with private insurance, a provision of the Affordable Care Act states that all FDA-approved contraceptives must be reimbursed without a co-pay, but implementing this part of the law isn't instantaneous. Medicaid reimburses the cost of LARCs in a handful of states, with more to come, but this policy isn't homogenous, and varies widely state-to-state.
And if you're uninsured and ineligible for Medicaid (which is the case for undocumented women around the country, but particularly in border states with high teen pregnancy rates like Texas and New Mexico) the cost of a LARC and seeing a provider for insertion is almost certainly prohibitive.
"Reducing the insurance and reimbursement barriers would be tremendously helpful, and coverage of undocumented women would be a huge step in the right direction for states like New Mexico," Espey said. "Right now, Title X is the only program that helps fund contraceptives for uninsured, undocumented women, and Title X is underfunded, so many undocumented women don't have access to LARC."
For women who've just given birth or had an abortion, the best time to insert an IUD is immediately postpartum or postabortion, when the patient is physically with the provider and highly motivated to get birth control, but this isn't always possible because of reimbursement policies. "Only in a very limited number of states can you actually be reimbursed as a hospital for an insertion immediately after delivery," Lara-Torre explained. "In Virginia, where I practice, we can be reimbursed after an abortion, but not after a delivery, which is challenging because IUDs are costly devices and we can't absorb the cost of the device and insertion if insurance won't help us out… There are still a lot of socioeconomic barriers in terms of patient access and coverage, and that should be where our focus is concentrated. We need to make sure that when we convince a patient to get a LARC, we can actually do it."
The Colorado Family Planning Initiative demonstrated such dramatic results precisely because it was able to remove the LARC cost barrier. "Being able to provide these devices for free to anyone who was interested was huge," said Greta Klingler, unit supervisor for CFPI. "But that was only part of it. We also worked a lot on provider training: on the hands-on skill piece of being able to do the insertion, but also, how do you counsel around these methods? How do you talk about the side effects, what bleeding patterns are going to look like? We also saw the importance of training all of the clinic staff about these methods to create a consistent message that LARCs are good, safe, viable options for just about anybody to consider."
Klingler said that the majority of teens who got LARC through the free clinics had never been pregnant, and that prior to the Affordable Care Act, most of the patients were uninsured. Initially, most teenagers chose a Mirena IUD, but implants are becoming more popular; Klingler speculated that this was largely because they don't require a pelvic exam.
"We learned just how much word of mouth matters," Klingler said of getting teens to come to the clinics. "It mattered what people heard from their friends or their sisters about their method satisfaction. Particularly in some of our smaller communities, you would hear about one young woman who chose one of these methods, and then over the next couple of months, all of her friends would come in and be like, 'so and so got this and she loves it, this is what I want, too.'"
Anecdotal evidence bears out this trend. Sara, a 20-year-old who got a Mirena IUD two years ago in a Longmont, Colorado clinic said that not many of her friends have LARCs, but two recently got them, in part because of what she told them about her experience.
"I wish I'd been told [about LARC] during my first sexual education class in middle school," Tika said. "I also wish parents would talk to their kids more about long-acting birth control methods. Personally, I recommend it 100 percent."
The $23.5 million grant from the Susan Thompson Buffett Foundation runs out this June. In January, Colorado state Reps. Don Coram, R-Montrose and KC Becker, D-Boulder introduced a bill that would provide $5 million to continue funding CFPI's LARC program. The bill is currently being heard in committee, and is not without opposition: state Sen. Kevin Lundberg, R-Berthoud, who chairs the state's Senate Health Committee, told the Ft. Collins Coloradoan that he (erroneously) believes that IUDs work by "stopping a small child from implanting," and hopes to defeat the bill.
Family planning services are expensive, but so are unplanned pregnancies. And teenagers are sexual beings, whether their parents, teachers, and political representatives like it or not. Having the information and ability to choose a contraceptive that's right for them is healthy for the individual and their community.
For providers and sexual health advocates like Espey, increased access to free (or even low-cost) LARCs for teenagers is only one piece of improving sexual and reproductive health practices in this country. She noted that the hospital at the University of New Mexico has an inexpensive LARC option, but it's an outlier—the funding simply isn't there in in New Mexico (or across most of the country) to provide LARCs broadly and for free.
A stronger central position on family planning—or, less conservative resistance to the idea—might render the question of state funding less decisive. Harvard research fellow J.M. Ian Salas wrote, in a 2013 study of subsidized contraceptives in countries with shifting economic states and family planning policies, that "countries with strong family planning programs may be able to withstand unexpected decreases in public funding, and that high contraceptive use could be sustained after a critical point has already been reached."
Espey agreed. "I mean, what we really need to do is offer all methods of contraception to all women, free of charge," she said. "We'd save so much money by doing that, and we'd have a huge impact on the health of women and their families."
Adele Oliveira is a freelance writer in Santa Fe, New Mexico.
Illustration by Tara Jacoby