WWS Reacts: Are IUDs the Most Effective Form of Contraception for Teens?
While condoms remain a popular birth control choice among teens, long-acting contraceptives like intrauterine devices should be the "first line" of contraceptives used to prevent teen pregnancy, according to the American Academy of Pediatrics.
Announced this week in the journal Pediatrics, the organization urges pediatricians to share with teens the "efficacy, safety and ease of use" of IUDs and progestin implants. The academy also stands behind the use of condoms, which reduces the risk of sexually-transmitted diseases.
We discussed the new recommendations with James Trussell, the Charles and Marie Robertson Professor of Public and International Affairs, and Abigail Aiken, postdoctoral research associate and lecturer at the Office of Population Research, for WWS Reacts.
Q. The American Academy of Pediatrics announced that intrauterine devices should be the "first line" of contraceptives in preventing teen pregnancy. Do you agree?
Answer: Yes, implants and IUDs should be a very high priority in preventing teen pregnancy because they are in the top-tier of effectiveness (see chart below). These are "fit and forget" contraceptives that require no active adherence on the part of the user. They have excellent safety records and are also long-acting: at least five years for the Mirena Levonorgestrel (LNg)-releasing IUD, three years for the Skyla LNg-releasing IUD, ten years for the copper-releasing IUD and three years for the implant. The Mirena and Skyla IUDs have the additional advantage of reducing menstrual pain and blood loss for many users.
Q. The last set of recommendations from AAP was announced in 2007. How have IUDs advanced since then? Is this what may have prompted the new guidelines?
A: There is one new Levonorgestrel releasing IUD called Skyla that is smaller and has a smaller diameter inserter than Mirena. It was developed specifically for teens. Recently, the insertion tube for Mirena has also been decreased in diameter. While these advances may have had some influence on the new guidelines, the main impetus is likely to have been the shift in clinical practice norms that has occurred. Until relatively recently, teens and nulliparous women were not typically considered to be good candidates for IUDs. Thanks to a recent surge of research from the reproductive health field, there is now evidence that IUDs and implants are safe, acceptable, and effective options regardless of age. In particular, the Contraceptive CHOICE project in St. Louis found that continuation rates for IUDs and implants were the same for teens and older women.
Q. It seems there may be misconceptions about long-acting reversible contraceptives, which discourages use by teens. What kind of outreach is needed to explain the efficacy of these contraceptives? What can policy makers do?
A. Tiered effectiveness counseling based on the chart should be encouraged. In this kind of counseling, although the full range of methods is mentioned, the most effective methods are discussed first. Moreover, in addition to offering information, providers also need to listen to and engage with the beliefs, questions, and concerns their teen patients (and indeed all of their patients) may have about these methods.
The main role for policy makers is probably to help make IUDs and implants more accessible. These methods, although cost effective, can be expensive at the point of access and may be out of reach for many teens because of out-of-pocket costs. Increasing public funding for contraception, or in the current political climate at least preventing it's further reduction, would likely go a long way towards increasing access for uninsured or underinsured teens. This is especially important for patient confidentiality, as many teens may not want to use parental insurance coverage to obtain contraception. Laws regarding parental consent for contraception provision to teens also vary widely by state, and may be another potential avenue for policy makers wishing to increase access.
Q. Given the implementation of the ACA, will that increase the number of people who have access?
A. Yes definitely, although it's unlikely that access will be universal. In particular, undocumented immigrants are not covered, and the universal fee that hospitals receive for Medicaid deliveries inhibits provision of IUDs and implants before discharge from the hospital.
Q. Might there be any unintended consequences from recommending IUDs? For example, could it lower the use of condoms, thereby increasing sexually-transmitted infections (STIs) among teens?
A. We would expect that responsible providers placing IUDs would counsel teens (and indeed women of any age) that IUDs do not protect against STIs, and that condoms should always be used in situations where there is doubt about a partner's STI status. If there is any reason to suspect that an STI might already have been contracted, the woman should be tested for STIs before IUD placement. But once an IUD is in place, a woman using an IUD is no more likely to get an STI than a woman using any other type of contraception.
WWS Reacts is a series of interviews with Woodrow Wilson School experts addressing current events.