1 Health Disparities Research Scholars Program, Department of Obstetrics & Gynecology—Division of Reproductive & Population Health, School of Medicine and Public Health, University of Wisconsin-Madison, 667 WARF, 610 Walnut Street, Madison, WI 53726
Find articles by C. Emily Hendrick2 Health Behavior & Health Education Program, Department of Kinesiology & Health Education, The University of Texas at Austin, 2109 San Jacinto Blvd., D3700, Austin, TX 78712-1415
Find articles by Joshua N. Cone2 Health Behavior & Health Education Program, Department of Kinesiology & Health Education, The University of Texas at Austin, 2109 San Jacinto Blvd., D3700, Austin, TX 78712-1415
Find articles by Jessica Cirullo2 Health Behavior & Health Education Program, Department of Kinesiology & Health Education, The University of Texas at Austin, 2109 San Jacinto Blvd., D3700, Austin, TX 78712-1415
Find articles by Julie Maslowsky1 Health Disparities Research Scholars Program, Department of Obstetrics & Gynecology—Division of Reproductive & Population Health, School of Medicine and Public Health, University of Wisconsin-Madison, 667 WARF, 610 Walnut Street, Madison, WI 53726
2 Health Behavior & Health Education Program, Department of Kinesiology & Health Education, The University of Texas at Austin, 2109 San Jacinto Blvd., D3700, Austin, TX 78712-1415
CEH designed and coordinated the study, participated in the extraction and interpretation of the data, and drafted the manuscript; JNC participated in the extraction and interpretation of the data, and helped to draft the manuscript; JC participated in the extraction and interpretation of the data, and helped to draft the manuscript; JM conceived of the study, participated in its coordination, participated in interpretation of the data, and helped to draft and critically revise the manuscript for important intellectual content. All authors read and approved the final manuscript.
Corresponding Author: C. Emily Hendrick, ude.csiw@2kcirdnehe, Phone: 608-262-8600Keywords: Long-acting reversible contraception, LARC, adolescent pregnancy, adolescents, women, facilitators, barriers, systematic review
Despite steady declines in adolescent pregnancy rates over the past decade, the United States consistently reports high rates compared to other high-income nations throughout the world (Sedgh, Finer, Bankole, Eilers, & Singh, 2015). The declines in U.S. adolescent pregnancy rates have largely been attributed to the increased use of effective forms of contraception among adolescents (Lindberg, Santelli, & Desai, 2016). Accordingly, adolescent health practitioners and organizations have expressed support for highly effective, long-acting reversible contraception (LARC) as a promising strategy for preventing unintended pregnancies among both nulliparous and parous adolescent women. Despite this support, concerns about and barriers to LARC use among adolescents remain (Hopkins, 2017; Pritt, Norris, & Berlan, 2017). Consequently, LARC use among adolescents remains low compared to women in their 20s. Specifically, data from the 2015-2017 National Survey of Family Growth (NSFG) reveal that only 8.2% of U.S. women ages 15-19 currently use a LARC as their method of contraception compared to 13.1% of women in their 20s (Daniels & Abma, 2018). The reasons behind this disparity are not well understood. Understanding the specific determinants of adolescent LARC initial and continued use is needed for adolescent health practitioners to effectively help adolescents meet their contraceptive needs.
At the time of this review, there were three available types of LARC in the United States: levonorgestrel-releasing, intrauterine system (LNG-IUS), the copper intrauterine device (IUD), and/or the hormonal implant. The LNG-IUS (e.g., Mirena) is a synthetic progesterone-releasing IUD that prevents pregnancy for up to seven years. The copper IUD (e.g., Paraguard) is an IUD wrapped in copper coils that does not release any hormones in the uterus and prevents pregnancy for up to 12 years. Finally, the implant (e.g., Implanon, Nexplanon) is a synthetic progesterone-releasing, single-rod device implanted under the skin in the upper arm and prevents pregnancy for up to five years. All three types have been approved for use by both nulliparous and parous adolescent women in the United States (Committee on Adolescent Health Care Long-Acting Reversible Contraception Work Group, 2018; Curtis, 2016; Lohr, Lyus, & Prager, 2017; Ott & Sucato, 2014).
In recent years, LARC has gained attention as a promising strategy for effectively reducing the adolescent pregnancy rate in the United States. Nearly all commonly-used contraceptive methods (outside of non-reversible methods such as male vasectomy and female sterilization) rely on users to take some action (take a daily pill, put on a condom, change a ring, receive an injection, etc.) on a varying basis and have consistently shown higher real-world failure rates than methods that do not require regular user participation (Davis, 2011; McNicholas & Peipert, 2012). LARC methods eliminate many of the barriers associated with low real-world effectiveness rates of shorter-term methods (e.g., forgetting to take a pill) (Fontenot & Fantasia, 2015; Secura & McNicholas, 2013), and the Centers for Disease Control and Prevention (CDC) have reported one-year IUD and implant failure rates of less than 1% (Romero et al., 2015).
LARC methods may be used, and have been shown to be effective, in preventing both first-time and repeat unintended pregnancy among adolescent women. One example has been with the CHOICE project. The CHOICE project provided no-cost IUDs or implants to women in Missouri and followed their reproductive history for two to three years (Peipert, Madden, Allsworth, & Secura, 2012). The adolescent women in this sample had pregnancy, birth, and abortion rates significantly lower than national rates among sexually-experienced adolescents (34.0 v. 158.5, 19.4 v. 94.0, and 9.7 v. 41.5 per 1,000 adolescents, respectively) (Secura et al., 2014). Further, in a study of 396 (treatment n = 171, control n = 225) 14 – 24-year-old postpartum Colorado Adolescent Maternity Program participants, adolescents who had an implant placed immediately postpartum were significantly less likely to experience a rapid repeat pregnancy (within one year) than control participants (those who chose no or short-term contraception methods, those who had an IUD placed more than six weeks postpartum, and those who had an implant placed more than four weeks postpartum) (Tocce, Sheeder, & Teal, 2012a). Relatedly, multiple studies have documented that adolescents who have a LARC method placed after an abortion procedure have significantly lower rates of subsequent abortion requests within two years, compared to women choosing other, shorter-term contraceptive methods, or no contraception after an abortion procedure (Baldwin & Edelman, 2013; Heikinheimo, Gissler, & Suhonen, 2008; Rose & Lawton, 2012).
LARC methods have been demonstrated to be acceptable for use among adolescent women. LARC use among adolescents, including nulliparous adolescents, is generally considered safe (Brodie, Silberholz, Spector, & Pattishall, 2016). Further, adolescents and young women up to 25 years old, including postpartum adolescents, who have LARC methods (IUDs or implants) placed have shown high, one-year continuation rates. One review of 12 studies including retrospective, prospective, and randomized controlled trials found that 84% of LARC users younger than 25-years-old maintained their chosen method at 12-months post-placement (Diedrich, Klein, & Peipert, 2017). Similarly, Cohen and colleagues (2016) observed a combined (IUD and implant) 86% continuation rate among 13 to 22-year-old postpartum adolescents and young women.
Despite the increasing evidence supporting LARC as an effective and safe approach to preventing unintended adolescent pregnancies, rates of adolescent LARC use in the United States continue to be low. Overall adolescent LARC use in the U.S. has increased from less than 3% in 2006-2010 to over 8% in 2015-2017 (Abma & Martinez, 2017; Daniels & Abma, 2018). However, the most recently available nationally-representative data reveal that adolescent LARC use has remained low compared to women in their 20s (8.2% v. 13.1% in 2015-2017) (Daniels & Abma, 2018). Further, when national estimates have been restricted to only women who were at risk for unintended pregnancy (e.g., those who had ever had penile-vaginal intercourse and were not currently nor trying to become pregnant), adolescent women’s LARC use remained steady at around 3% from 2006 to 2013 while use among women aged 20-24 increased from approximately 3% to over 11% during the same time period (Pazol, Daniels, Romero, Warner, & Barfield, 2016). The low rate of LARC use among adolescent women is likely due to the many concerns about, and barriers to, LARC use among young and nulliparous women.
Despite recommendations from the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the Society of Family Planning, and the CDC, many clinicians do not prescribe LARC for adolescent patients due to misconceptions about eligibility for LARC and/or concerns about elevated risks for adverse consequences associated with LARC placement (Committee on Adolescent Health Care Long-Acting Reversible Contraception Work Group, 2018; Curtis, 2016; Lohr, Lyus, & Prager, 2017; Ott & Sucato, 2014). Among the reasons that providers fail to offer LARC, specifically the IUD, to younger women is the perception that IUD placement increases the risk of developing pelvic inflammatory disease (PID), which may result in infertility, ectopic pregnancy, or pelvic pain (Carr & Espey, 2013). Provider concerns around IUD use are even more prevalent when considering nulliparous adolescent patients (Diaz, Hughes, Dickerson, Wessell, & Carek, 2011; Stanwood, Garrett, & Konrad, 2002). Providers may also be hesitant to recommend IUDs to younger and nulliparous women due to a perceived increased risk of IUD expulsion, particularly with copper IUDs (Jatlaoui, Riley, & Curtis, 2017). IUD expulsion is concerning as it may result in pregnancy if not addressed quickly. Providers may also be concerned about an increased risk of STI transmission among adolescents who choose to use a LARC contraceptive method only, and do not supplement their protection through condom use (O’Sullivan, Udell, Montrose, Antoniello, & Hoffman, 2010; Williams & Fortenberry, 2013).
Even when providers have up-to-date knowledge about the eligibility criteria for and safety of LARC methods, their recommendation rate of LARC methods to younger women continues to be low. Kohn and colleagues reported that just over half (55%) of participating providers would recommend an IUD to a woman under 20 years old in a study among school-based health center providers (Kohn, Hacker, Rousselle, & Gold, 2012). Additionally, a review of studies conducted between 1998-2012 reported that while providers believed that IUDs were safe for nulliparous adolescents, only one third of surveyed providers recommended an IUD to nulliparous women (Stanwood et al., 2002; Teal & Romer, 2013). Relatedly, awareness and knowledge surrounding LARC methods are limited among adolescents (Dodson et al., 2012; Teal & Romer, 2013). In a review including multiple studies from years 1998 to 2012, in most studies, only half of adolescents aged 14 to 25 had heard of specific LARC methods, and many underestimated both the safety and effectiveness of LARC (Teal & Romer, 2013).
Another commonly cited concern about, and barrier to, providing LARC to younger women is cost. Cost is a shared concern among both the providers and potential young users of LARC methods. Kumar & Brown reported that the significant initial costs of approximately $1,000 can be a difficult obstacle for adolescents aged 15-19 years that are uninsured or have insurance that does not cover contraception (Kumar & Brown, 2016). Further, the combination of additional clinic time, provider time in the form of counseling, and limited support funding from outside sources in the form of grants or Medicaid contribute to additional cost concerns for providers (Kavanaugh, Frohwirth, Jerman, Popkin, & Ethier, 2013).
Adolescent women in the United States are different from women in their early 20s in ways that are potentially linked to their reproductive healthcare and behaviors. This review therefore focuses specifically on adolescents (women under the age of 20). When addressing the contraceptive needs of adolescents, confidentiality and consent require special consideration. In places where minors’ rights to consent to their own contraceptive care without parental involvement are limited, providing confidential contraceptive care to adolescent patients may not be possible. Consequently, many sexually active adolescents identify minor consent limitations as specific barriers to obtaining contraceptive care (Kumar & Brown, 2016; Reddy, Fleming, & Swain, 2002). Presently, 21 states allow all minors to consent to their own contraceptive care, and 25 states allow minors to consent to their own care only under special circumstances (e.g., the minor is married or a parent) (Guttmacher Institute, 2019). Also, adolescent women are more likely to live with their parents than women in their early 20s, and younger adolescents do not yet have drivers’ licenses. Thus, adolescents’ parents are likely more involved in their healthcare access and decisions, even in places where adolescents may consent to their own reproductive healthcare. Further, women in their early 20s, on average, have more sexual experience than adolescents, have more experience with contraception methods, and have a higher probability of having already experienced a pregnancy in their lifetime (Finer & Philbin, 2014; Horwitz, Ross-Degnan, & Pace, 2019). The lower autonomy and sexual and reproductive experience levels of adolescent women could uniquely impact the facilitators of and barriers to their use of LARC methods.
Much of the literature to date examining adolescent LARC use also includes women in their early 20s (Kavanaugh, Frohwirth, Jerman, Popkin, & Ethier, 2013; Kumar & Brown, 2016; Pritt et al., 2017; Teal & Romer, 2013). As such, it is difficult to distinguish the specific determinants of adolescent LARC use from the determinants of LARC use among women in a later stage of life, with distinctive social-environmental influences of their contraception use. Thus, there are likely determinants of LARC use specific to adolescent women that would be helpful for adolescent health clinicians and educators to know in order to better serve the unmet contraceptive needs of adolescents.
The authors searched five databases for relevant articles: PubMed/Medline, PsycINFO, CINAHL, Web of Science, and Scopus using a combination of search terms related to adolescents and LARC methods ( Table 1 ). The search criteria were restricted to articles that did not contain “cochlear” as a keyword as several articles initially included in the search referred to adolescent cochlear implant research. The database search yielded a total of 593 non-duplicate articles ( Figure 1 ).
Flow diagram of literature review
