Elizabeth Futrell is an associate technical officer at FHI, where she works on activities related to community-based family planning and youth sexual and reproductive health.
A study published nearly 10 years ago in Family Planning Perspectives noted an interesting trend: the modern contraceptive methods most relied upon among sexually active American teens ages 18-19 were the least effective methods for this age group. Almost nine percent of teens using highly popular oral contraceptive pills got pregnant within the first year. Male condoms yielded a 17.7 percent pregnancy rate in the same time period. Failure rates are particularly high among teens because they are less likely than adults to use these methods consistently and correctly. To make matters worse, half of condom users and one-third of pill users discontinue use within a year. Meanwhile, teen users of long-acting reversible contraceptives (LARCs)—the injectable contraceptive Depo-Provera, the intrauterine device (IUD), and the contraceptive implant—only experienced a 4.3 percent pregnancy rate within the first year. In general, among people who correctly and consistently use these LARCs, the pregnancy rate is less than one percent. However, far fewer teens rely on these methods than on pills and condoms. As a result, the U.S., with one of the worst family planning records in the developed world, experiences 800,000 annual teen pregnancies, 80 percent of which are unintended.
These trends ring true in many parts of the world, and not much has changed in the 10 years since the study described above was published. Globally, young people use less effective contraception and use contraception less consistently than adults, although unintended pregnancy often poses far more negative consequences for adolescents than adults. Adolescent girls ages 15-19 are twice as likely to die during pregnancy as women in their 20s, and the risks are much higher for girls younger than 15. In fact, pregnancy and childbirth-related complications are the leading cause of death of girls ages 15-19 worldwide, killing 70,000 girls annually and leaving millions more with lifelong disabilities or chronic ailments. Yet each year, 16 million girls ages 15-19 give birth, and up to 4 million more adolescent pregnancies end in unsafe abortion.
LARCs have been proven to be highly effective, acceptable, convenient, and cost-effective, and the World Health Organization has deemed them appropriate for youth. So why aren’t more young people using LARCs? Among the barriers are:
- Misinformation and lack of information among providers. Many providers avoid presenting IUDs as an option for young clients due to unsubstantiated concerns about risks related to STIs, infertility, postpartum use, side effects, and patient acceptability. Concerns about the negative effect of Depo-Provera on bone mineral density in adolescents are also common, although the Society of Adolescent Medicine issued a position paper in 2006 stating that the pregnancy posed greater health risks to adolescents than Depo-Provera and recommending that physicians continue to prescribe it with proper counseling to adolescents who wish to prevent pregnancy.
- Inadequate training. Though many providers are trained to insert and remove IUDs and implants, some report a low level of comfort or experience with these tasks.
- Low demand due to misinformation and lack of information among patients. Recent studies have shown that many women have little or no knowledge about LARCs and that unfounded concerns about their safety, effect on fertility, and side effects are widespread.
- High up-front cost. While these methods are cost-effective in the long-term, their up-front cost is often significantly higher than that of condoms or pills.
To increase access to LARCs for young people who wish to prevent pregnancy, the public health community must conduct research to understand provider biases and youth barriers, including policies dictating access to contraception for youth. We must use these findings to develop and implement strategies to better serve the contraceptive needs of youth. We must continue to publish and promote clear, medically accurate information and training materials to bridge knowledge gaps and dispel misinformation among both providers and patients. To embrace LARCs, young people need to understand what they are and how they work. They must be able to access them and afford them. Expanding access to long-acting reversible methods for young people will drastically reduce the rate of unintended pregnancies, unsafe abortions, and maternal and infant morbidity and mortality across the world. The benefits of offering these options to young people far outweigh the risks.