Disparities in Contraceptive Access and Provision
Disparities in Contraceptive Access and Provision
Despite a significant decrease in births to 15 to 19 years old in the past two decades, the teen pregnancy rate in the United States remains one of the highest among developed nations and more than 80% of these are unintended. These rates are even higher among black and Hispanic teens. This is a significant social issue as there are long-term consequences of teen pregnancy. Pregnant teens are less likely to finish school or increase their work experience and are more likely to remain single parents, continuing a cycle of low socioeconomic status (SES). After adjusting for age and race/ethnicity, low parental educational attainment and family structure are associated with early sexual initiation and less condom use at last intercourse. Although the usage rates of highly effective contraceptive methods have increased, there is disparity in contraceptive usage, with lower rates in black or Hispanic teens compared with white teens. These alarming rates of low contraceptive use and high unintended pregnancy rates exist despite parental and provider support for sex education that includes contraceptives. Multiple studies have demonstrated that the majority of parents, especially in areas of disparity, and providers support comprehensive sex education inclusive of, but not limited to, abstinence. Providers can play a unique role by both counseling the teens themselves and supporting parents in their efforts. Studies have demonstrated that providers can positively impact contraceptive usage across adolescent ethnicities through open-ended, culturally sensitive counseling. Negative attitudes equally affect, but unfortunately limit, contraceptive choice. Many providers, for example, still feel uncomfortable offering intrauterine contraception (IUC) to teens, citing misperceptions of parity eligibility and increased risk for pelvic inflammatory disease. These practices continue despite current guidelines supporting benefits of IUC use and studies demonstrating IUC safety and effectiveness in adolescents. The Contraceptive Choice project that included large numbers of adolescents demonstrated a 20-fold risk of contraceptive failure among women using contraceptive pills, patch, and vaginal ring when compared with long-acting methods such as IUC and implant. Thus the practice of withholding long-acting reversible contraception, such as IUC, significantly increases the adolescent's risk of pregnancy. It is also important to maximally use the opportunities to provide effective contraceptive counseling. Young women seeking pregnancy tests or emergency contraception (EC) are an opportunity for provider counseling toward longer acting methods as the risk of unintended pregnancy in this group of women is high.
Another potential option for addressing failure to use contraception or method failure is EC. Over-the-counter EC has been federally approved for women 17 years and older, but studies also demonstrate that EC is safe and effective for women of all ages including teens younger than 17. Despite the approval for over-the-counter dispensation, a combination of factors including low knowledge of EC and poor understanding of pregnancy risk among young women, stigma associated with EC request, lack of provider discussion of or advanced prescription of EC, state and institutional restrictions including pharmacy refusal as well as age restriction, and religious exclusion from contraceptive provision and/or insurance coverage decreases access and use of EC for pregnancy prevention. As with other methods, these factors impose limitations on low-income minorities the most.
In addition to provider counseling of the patient, assessing partner support or involving partners in contraceptive decision making can be an important predictor of future use. Finally, modernizing educational materials including websites, online videos, and even contraceptive applications have been suggested as ways to improve adolescent uptake.
Although our focus is on unintended pregnancy, rates of chlamydia, gonorrhea, syphilis, and human immunodeficiency virus (HIV) also disproportionately burden non-Hispanic black teens, and any contraceptive counseling must include recommendations for sexually transmitted infection (STI) protection. Condoms can be effective against STI and HIV, but are inherently reliant upon couple agreement and correct, consistent use. Consistent provider messaging and assessment can be effective in increasing condom use for dual protection among teens.
Adolescents
Despite a significant decrease in births to 15 to 19 years old in the past two decades, the teen pregnancy rate in the United States remains one of the highest among developed nations and more than 80% of these are unintended. These rates are even higher among black and Hispanic teens. This is a significant social issue as there are long-term consequences of teen pregnancy. Pregnant teens are less likely to finish school or increase their work experience and are more likely to remain single parents, continuing a cycle of low socioeconomic status (SES). After adjusting for age and race/ethnicity, low parental educational attainment and family structure are associated with early sexual initiation and less condom use at last intercourse. Although the usage rates of highly effective contraceptive methods have increased, there is disparity in contraceptive usage, with lower rates in black or Hispanic teens compared with white teens. These alarming rates of low contraceptive use and high unintended pregnancy rates exist despite parental and provider support for sex education that includes contraceptives. Multiple studies have demonstrated that the majority of parents, especially in areas of disparity, and providers support comprehensive sex education inclusive of, but not limited to, abstinence. Providers can play a unique role by both counseling the teens themselves and supporting parents in their efforts. Studies have demonstrated that providers can positively impact contraceptive usage across adolescent ethnicities through open-ended, culturally sensitive counseling. Negative attitudes equally affect, but unfortunately limit, contraceptive choice. Many providers, for example, still feel uncomfortable offering intrauterine contraception (IUC) to teens, citing misperceptions of parity eligibility and increased risk for pelvic inflammatory disease. These practices continue despite current guidelines supporting benefits of IUC use and studies demonstrating IUC safety and effectiveness in adolescents. The Contraceptive Choice project that included large numbers of adolescents demonstrated a 20-fold risk of contraceptive failure among women using contraceptive pills, patch, and vaginal ring when compared with long-acting methods such as IUC and implant. Thus the practice of withholding long-acting reversible contraception, such as IUC, significantly increases the adolescent's risk of pregnancy. It is also important to maximally use the opportunities to provide effective contraceptive counseling. Young women seeking pregnancy tests or emergency contraception (EC) are an opportunity for provider counseling toward longer acting methods as the risk of unintended pregnancy in this group of women is high.
Another potential option for addressing failure to use contraception or method failure is EC. Over-the-counter EC has been federally approved for women 17 years and older, but studies also demonstrate that EC is safe and effective for women of all ages including teens younger than 17. Despite the approval for over-the-counter dispensation, a combination of factors including low knowledge of EC and poor understanding of pregnancy risk among young women, stigma associated with EC request, lack of provider discussion of or advanced prescription of EC, state and institutional restrictions including pharmacy refusal as well as age restriction, and religious exclusion from contraceptive provision and/or insurance coverage decreases access and use of EC for pregnancy prevention. As with other methods, these factors impose limitations on low-income minorities the most.
In addition to provider counseling of the patient, assessing partner support or involving partners in contraceptive decision making can be an important predictor of future use. Finally, modernizing educational materials including websites, online videos, and even contraceptive applications have been suggested as ways to improve adolescent uptake.
Although our focus is on unintended pregnancy, rates of chlamydia, gonorrhea, syphilis, and human immunodeficiency virus (HIV) also disproportionately burden non-Hispanic black teens, and any contraceptive counseling must include recommendations for sexually transmitted infection (STI) protection. Condoms can be effective against STI and HIV, but are inherently reliant upon couple agreement and correct, consistent use. Consistent provider messaging and assessment can be effective in increasing condom use for dual protection among teens.