As young people grow up and begin to take more ownership of decisions that affect their health, it is important to look at how they approach their health care decisions. Understanding the ‘how’ can help health providers, parents and other adults support decisions that are consistent with a young person’s values and aligned with their self-determined goals, such as succeeding in high school and having healthy relationships. One health decision that has far-reaching implications for a young person’s life trajectory is the decision of whether to use birth control and what type to use.
In 2015, about 230,000 babies were born to U.S. mothers ages 15-19. While this number has been in decline for several years, the U.S. has one of the highest rates of teen pregnancy in western industrialized nations. In addition, low-income and minority women comprise a disproportionate percentage of teen mothers, and 20 percent of teen moms have another child before they turn 20.
These startling statistics stem from a number of factors, including limited access to contraception and comprehensive sex education. However, other considerations emerge when we look deeper into these factors: adolescents who use birth control are more likely to use methods that require significant effort on behalf of the patient and are less effective, such as the pill or patch, rather than long-acting reversible contraceptive (LARC) methods like intrauterine devices or subdermal implants. While the latter are 20 times more effective at preventing pregnancy, less than 10 percent of women under the age of 24 use them.
In our clinical practices, we regularly observe that among young women with access to contraceptives through private or public insurance, or third-party payers (e.g., Title X or federally qualified health centers), relatively few are willing to give a long-acting method a try, even when they express a strong desire to avoid pregnancy.
So, what’s going on?
What affects young women’s willingness to try different contraceptive methods?
If policymakers and public health advocates want to reduce the number of unintended teen pregnancies, understanding what teens think about birth control, expanding their knowledge about methods like LARC, and helping them make the healthiest decision possible based on their unique preferences and life circumstances will be vital.
A recent study by investigators at PolicyLab, Kaiser Permanente Washington and the University of Colorado at Denver surveyed 1,100 young women ages 14 to 24 years to understand why young women may avoid certain birth control methods, particularly those most effective at preventing an unintended pregnancy. The study found that, despite their efficacy, women were less aware of LARC methods than the shot and pill.
Yet, while fewer women had heard about longer acting methods, they were less hesitant to try these methods than the shot or the pill, suggesting that reducing barriers to knowledge of and access to these methods will be huge to increasing their uptake. Teens cannot seek out a service that they don’t know exists.
Interestingly, young women with a friend or family member who had a bad experience with a specific birth control method were least likely to find that method acceptable. This is consistent with an important aspect of the pubertal development process – a heightened desire for social conformity and influence of a peer group or family members.
Willingness to use each method also varied by age and pregnancy history. Younger women found intrauterine devices less acceptable, while older respondents found the subdermal implant less acceptable. Women who had experienced a prior pregnancy found pills less acceptable, while those who had never been pregnant found intrauterine devices less acceptable. These differences suggest a one-size-fits-all approach to counseling may not sufficiently address the sexual health needs of all women.
As young people grow older and more familiar with their bodies, their preferences become less susceptible to peer influences and more informed by their own experiences. At younger ages, methods that are placed in the arm, may be more familiar, such as an immunization shot, and therefore more acceptable than a method that must be placed in the uterus. That ‘yuck’ factor or unfamiliarity with certain medical treatments is developmentally normal, and we should acknowledge that.
This study highlights how the influence of social networks and life experiences on young women’s contraceptive choices changes over time. For better or for worse, opinions from young people’s peers and loved ones shape their views on health care choices. While these conversations are outside of a provider’s control, they should acknowledge and explore the messages that patients hear by asking them directly about what birth control information their friends and family members have shared with them. Providers must strike a delicate balance between addressing misconceptions, while being careful not to dismiss patient concerns.
How else can health providers and other youth-serving adults help a young woman choose the right birth control method for her?
Providers should be equipped to use patient-centered counseling strategies when helping young women choose a birth control method. Such strategies recognize that when choosing a birth control method, women seek to balance many factors like a method’s effectiveness, ease of use and personal and social acceptability. When young women feel safe and comfortable with their provider, they’re more likely to make the best contraceptive decision for themselves.
Beyond the health care realm, the findings in this study support the importance of comprehensive sexual education in schools and in public health campaigns that increase young people’s knowledge and awareness about the benefits and safety of various contraceptive methods. Of course, the next logical step is to ensure that young women maintain access to high-quality, affordable sexual and reproductive health care services, especially LARC and other methods that are proven to be most effective.
Ensuring access to comprehensive sexual health education and access to contraceptive services requires commitment from voters and lawmakers to protect programs like Title X, Medicaid and the Children’s Health Insurance Program. It will also require continued support for research aimed at improving adolescent sexual and reproductive health outcomes.
In the end, young women will be the ones making decisions about their health, but those who care for and about youth must continue to advocate for their ability to choose the safest, most effective preventive health options.
Andrea J. Hoopes, MD, MPH, FAAP is an adolescent physician at Kaiser Permanente Washington. She collaborates with Dr. Akers on a number of projects.