No one birth control method fits everyone, but today young women have better options than ever before. Across the United States, from New York to South Carolina to Texas to Oregon, health advocates and providers are scrambling to get the word out about long-acting yet easily reversible contraceptive methods that are now approved for use by teenagers and well liked by most who use them. (See this earlier Sightline series, Twenty Times Better Than the Pill.)
Some of the energy has gone into creating youth-friendly information sources online such as Bedsider, followed by SexEtc, SafeAndEffective, and StayTeen. Other energy is targeted at bringing age-appropriate sexual health information and services to teens wherever they may congregate and whenever they may have contact with the health care system.
The Family Doctor
The American Congress of Obstetricians and Gynecologists recommends that any contact between a young person and a medical provider be treated as an opportunity to invite conversation about family planning and top-tier long-acting reversible contraceptive methods specifically. Sexually active young people face a high pregnancy risk but may be reluctant to seek out sexual health services, especially if this could involve a parent’s insurance company. They do see doctors for everything from sports physicals to acne to chronic medical conditions such as diabetes, however.
One of the mechanisms for improving teen health broadly is a trend toward school-based health clinics that bring practitioners to kids rather than vice versa. Reproductive health and mental health make up a large portion of the service mix at most high school clinics. Multnomah County, home to Portland, created its first school-based health clinic 30 years ago with the goal of reducing teen pregnancy, which is the number one reason that girls drop out of high school. Today almost every public high school in the city has one, and students at Benson Polytechnic, a school with a high poverty rate, are lobbying for one of their own.
In King County, Washington, 17 clinics operate as partnerships between public high schools or middle schools and health partners including Swedish, Group Health, Children’s, and Neighborcare, which also runs a clinic for homeless youth. Together, the clinics serve over 5,000 youth. A series of legislative battles in Washington established and defended a right to privacy for youth, enabling them to seek reproductive and mental health care if need be without parental involvement. For teens whose parents may be addicted or abusive or otherwise struggling, these laws allow them to seek care they might otherwise forgo, and having services on site means that knowledgeable adults are there when needed.
As a model, school-based care has caught the attention of youth advocates. In 2013, Kaiser Permanente announced a program that will make grants available to start or expand school-based clinics in underserved areas of Washington and Oregon, with an emphasis on health equity and integration of primary care and behavioral health. Kaiser notes, “Many communities are still without SBHCs [school-based health clinics], and families in those communities experience more missed work time, increased school absenteeism, and more limited access to health care services for children and youth.” In July, Seattle will host the national School-Based Health Alliance, where local health systems will share their work with colleagues from across the region.
Prenatal and Well-Baby Care
One high-risk group of teens who may not have access to school-based care consists of girls who are already pregnant or parenting. Despite improvements in care for teen moms, almost half of the girls who give birth as adolescents will conceive again within two years. Rapid repeat pregnancy increases both complications for the mother and risk factors like low birth weight for the babies (premature births triple). And a second birth makes it less likely that a young woman will ever attain economic self-sufficiency. Most girls with babies say they don’t want to get pregnant again anytime soon—some say never—but after they give birth, the dynamics that put them at risk for the first pregnancy don’t go away. In fact, they may be amplified.
This lends a special urgency to reproductive health care for teens in the postpartum period, but helping young moms to manage their fertility can be tough. Women typically ovulate for the first time around 45 days after giving birth, and providers often aim to have family planning conversations at follow-up medical appointments. But young mothers may not show up for these appointments, and there’s a lot to discuss even if they do: breastfeeding, sleep, diaper rashes, colic, coparenting, and more.
“Every day was a challenge for me,” says Leslie Gonzales, who had her first birth at 15 and then another. “I had to get up extra-early in the morning to get ready for school and get my daughter ready. I had to take car seats onto a bus, buckle them in and then unbuckle them and take them into a day care, and then get them all set up in a day care, and then go to school, and then come back, and then do the same thing all over again.”
A highly successful program called the Nurse Family Partnership meets these girls where they are by pairing young and poor first-time moms with visiting nurses who provide home-based services during the prenatal period and the first two years of a child’s life. The nurses provide preventive care and parenting advice, but they also work with the young mothers on setting goals for themselves, a process they call “finding your heart’s desire.” Rigorous research shows that the program improves the mothers’ prenatal health, reduces subsequent pregnancies, and increases the interval between births. For the children, it measurably decreases injuries and increases school readiness. Moms who participate have higher earnings and so are better able to provide for their families.
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In Washington State, the Nurse Family Partnership serves clients in 10 counties, spanning urban and rural communities, and independent policy analysts estimate that each dollar spent on the service saves five dollars down the road on needed social services, an imperfect but tangible measure of improved family well-being. In Oregon, the program began in Multnomah County in 1999 and now operates in nine counties under local public health districts/departments. British Columbia has trained nurses and is currently conducting a scientific evaluation of the program with support from Simon Fraser University, the provincial government, and five regional health authorities.
Labor and Delivery
A pilot program in Colorado shows additional promise in addressing the challenge of rapid repeat pregnancy. The work is grounded in evidence-based medicine and practice guidelines from relevant bodies of experts.
- Client-centered family planning conversations are integrated into prenatal visits, so that girls can set goals and choose a contraceptive to fit their reproductive plan. (The Association of Reproductive Health Professionals recommends this practice for all women.)
- Because teen parents find it exceptionally difficult to use every-day or every-time contraceptives consistently, providers offer long-acting methods to girls who are interested. (Even young women without babies typically miss five pills per month; fewer than half continue to use an oral contraceptive 12 months after starting one. Long-acting reversible contraceptives are the only contraceptive methods shown to substantially reduce rapid repeat pregnancy in teens.)
- Girls who want the implant receive their method of choice as a part of labor and delivery services, prior to going home from the hospital. (The Centers for Disease Control recommends this practice because outpatient visits have poor contraceptive follow-through. Immediate “post-placental” IUD insertion also can be offered safely as a part of the labor and delivery package. All top-tier methods are compatible with breastfeeding.)
- Well-baby visits provide opportunities for girls to ask any additional questions, express concerns, or change methods if desired. (Long-acting reversible contraceptives have higher satisfaction rates than any other kind, around 75 percent for teens, but no one method fits everyone.)
Barriers to Best Practices
The kinds of integrated, accessible medical care described here are best practices, meaning they reflect the best information we have about how to help young women plan their lives and have healthy, wanted babies when they’re ready. But regulatory barriers, cultural norms, and outdated medical practices prevent many girls from getting care that meets this standard. Research both in Canada and in the United States shows that primary care providers often have outdated perceptions of long-acting reversible contraceptives, sometimes dating back to the defective Dalkon Shield of the 1970s. Some don’t know that today’s IUDs and implants are safe for young women or that they’re total game-changers when it comes to accidental pregnancy.
In the United States, cultural conservatives continue to oppose even disease-prevention techniques such as HPV vaccines or condom distribution in school-based settings, let alone access to more-effective contraceptives. In addition, Catholic health care corporations are buying up hospitals and clinics at an unprecedented rate, and their religious directives erect barriers to contraceptive information and access. For example, Catholic hospital pharmacies may refuse to stock hormonal IUDs or implants, and Catholic systems may not support continuing education trainings for providers who want to use top-tier methods.
Insurance plans that bundle labor and delivery costs may not allow doctors to bill the substantial cost of a long-acting reversible contraceptive. But even in an outpatient setting, transitioning to better birth control can be a logistical nightmare. Clinic practices and billing codes are optimized for short, frequent family planning visits, when what a provider may need is reimbursement for a long conversation and an insertion procedure, followed by many years when no medical intervention is required.
All of these are challenges that must be overcome to give young women the best chance to fulfill their pregnancy intentions and their dreams.