IUD for the win Part 2

A recurrent issue in healthcare today is the increasing prevalence of teen and unintended pregnancy rates. Although teenage initiation of sexual activity is similar throughout much of the world, the United States remains the leader in rates of teen pregnancy amongst the developed world (Guttmacher Institute, 2011a). Advances in contraceptive technology have most likely contributed to the slight decline in this trend over the past five years, however, teenagers are still facing significant barriers in obtaining quality reproductive health and contraceptive services. In surveys of adolescent contraceptive use in the last five years, only 84% indicated use of any method at the time of last sexual intercourse. Although condoms and birth control pills are the most commonly used methods amongst teens, only 68% actively used condoms, and 55% reported taking the pill (Guttmacher Institute, 2011a). Additionally, these contraception methods that have been made readily available to teenagers usually require consistent user compliance and responsibility, with higher failure and discontinuation rates than other methods. Studies have revealed roughly 48% of women who experienced an unintended pregnancy reported having used a contraceptive method in the same month they conceived (Finer & Henshaw, 2006). This is suggestive that nearly half of these unintended pregnancies were related to contraceptive failure.

The long-term contraceptive efficacy and convenient lack of daily involvement required by the Intrauterine Device (IUD) suggests a promising solution for preventing unintended pregnancy, especially in teens. Unfortunately, high up-front costs, limited reimbursement policies, and negative historical misconceptions have led to provider reluctance and contributed to the inadequate accessibility of the IUD to the adolescent population.

Aside from issues with adequate user compliance of available methods, recent political controversies regarding adolescent access and awareness of reproductive healthcare presents a crucial obstacle to teenagers seeking effective family planning services. Several states have prohibited the implementation of sexual education resources in public school systems. Consequently, perceived barriers and lack of knowledge on how to obtain available resources often deters teens from seeking these services (American Academy of Pediatrics [AAP], 2007). State laws governing parental consent and adolescent confidentiality have resulted in healthcare provider apprehension in providing reproductive services to minors (Guttmacher Institute, 2001b). Furthermore, much of the available contraceptive coverage is limited to minimum reimbursement of methods that have lower efficacy and greater user dependency, contributing to more contraceptive failure rates. Even with federal equity laws that mandate coverage of top tier methods such as the intrauterine device, high up front costs have deterred many contraceptive providers from even offering this method in their practice. Despite the growing demand for IUD contraception, more than half of family planning agencies reported not keeping IUDs stocked in their practice due to high costs (Lindberg, Frost, Sten, & Dailard, 2006).

In a time of economic struggles, rising rates of poverty and inflation have heightened the socioeconomic burden of unintended and teen pregnancy. The needs for optimal efficacy methods of contraceptives have opened a window of opportunity for cost saving innovations in health care. Improving adolescent access and affordability of IUD contraceptives offers a strategic approach to achieve quality reproductive health services to teenagers. Because less expensive forms of birth control are user dependent and have higher failure rates, IUD contraception has proven to be the most cost effective strategy to avoid unintended pregnancy and pregnancy related costs (Trussell et al., 2009). Designating provisions of the federal budget to fund programs to offer IUD contraception at little to no cost to teenagers can result in superior cost saving outcomes. Furthermore, barriers that restrict adolescents from seeking contraception can be eliminated through implementation of health policies that will encourage and protect clinicians providing reproductive services to minors without parental consent.

Public perception and actions toward issue.

In revisions to strict historical guidelines for appropriate IUD candidates, the American College of Obstetrics and Gynecology (ACOG) released an updated Committee Opinion in 2007, stating “intrauterine devices offer safe, effective, long-term contraception…appropriate for select nulliparous [women] and adolescents” (American College of Obstetrics and Gynecology [ACOG], 2007).


A 2008 survey exploring young women’s knowledge and perceptions of IUDs revealed that less than half of adolescent females had ever heard of the method, of which only 37% reported having a positive attitude about it (Whitaker, et al., 2008). California State Legislature established the Family PACT (Planning, Access, Care, and Treatment) program to improve adolescent access to affordable, confidential contraceptive services. Policies have set forth standards to ensure the provision of quality family planning services, offering coverage for top tier forms of contraception, including IUDs and implants (Brindis et al., 2003). Surprisingly, even after removing cost-related barriers, a review of the service utilization patterns revealed less than 0.5% of adolescents received an IUD contraceptive, possibly reflecting the limited awareness and accessibility in community clinics. Further, it seems it is not only the prospective patients that lack accurate knowledge of the IUD. A recent survey of contraceptive providers serving the Family PACT program revealed that only 39% perceived adolescents to be appropriate candidates for IUD contraception (Speidel, Harper & Shields, 2008). In an effort to correct previous beliefs, the UCSF Bixby Center for Global Reproductive Health LARC Project has funded provider-training courses to re-introduce to the IUD as a reliable form of contraception for most women, regardless of age or parity. The project also aims to increase opportunities for IUD provision by encouragement for immediate post-abortion IUD insertion, and implementation of a simplified criteria screening tool to quickly assess eligibility for IUD contraception to initiate same day insertion (Speidel, et al., 2008).

Examples of events illustrating the problem

The federally funded Title X family planning program offers financial assistance to adolescents and low-income individuals for free or reduced costs healthcare services that are not otherwise covered by Medicaid or private insurance companies (Lindberg, Frost, Sten, & Dailard, 2006). However, high up-front costs have resulted in limited the availability of top tier contraceptives to family planning agencies, and IUDs are not provided in nearly half of publicly funded clinics and health departments (Lindberg et al., 2006). A recent survey of federally funded family planning services in California found nearly half of contraceptive providers in the program did not dispense or kept IUDs in stock (Speidel, et al., 2008).

Current legislation aimed at the issue:

Amendments to Title V of the Social Security Act have included the addition of Sec. 2953. Personal responsibility education, which has allotted $75 million in federal funding to support evidence based programs to reduce teen pregnancy (H.R. 3590: Patient Protection and Affordable Care Act, 2010).

Contraceptive equity laws supported by the Pregnancy Discrimination Act have been established prevent employer insurance plans from discriminating against women seeking prescription contraception. This policy mandated that insurance companies providing prescriptive drug coverage be required to provide the same benefits for prescription contraceptives (Equal Employment Opportunity Commission [EEOC], 2010).  However, some states allow insurers to impose restrictions on what types of contraceptive are covered, and for whom. For example, 2 states do not require coverage of emergency contraceptives, and West Virginia allows insurers to exclude dependent minors from contraceptive coverage (Guttmacher Institute, 2011c). Additional exemption policies permit some insurance companies and employer plans to refuse contraceptive coverage based on religious grounds and “conscience clauses” (Association of Reproductive Health Professionals [ARHP], 2008; Guttmacher Institute, 2011c).

Adolescent confidentiality laws allow explicit minor access to contraceptive services without parental consent in 21 states and the District of Colombia (Guttmacher Institute, 2011b). However, some state “refusal clauses” permit many insurance companies and employer insurance plans to exempt themselves from federal contraceptive equity laws (ARHP, 2008).

The manufacturer of the LNG IUS has established the ARCH (Access and Resources in Contraceptive Health) Foundation: a not for profit financial assistance program that offers free or reduced costs of IUDs to low-income women (Hubacher, Finer, & Espey, 2010).

Medicaid family expansion programs offer waivers to expand access to coverage by raising the income criteria threshold required for Medicaid eligibility (Guttmacher Institute, 2011a).

Recommendations to fix the problem.

            With an open window of opportunity for political streaming, stakeholders have recommended a number of policy proposals to improve the availability of high quality reproductive care to adolescents to reduce the number of teen pregnancies and subsequent pregnancy-related costs. Amongst the highest priorities is to expand adolescent access and affordability to effective contraceptive methods. This can be accomplished by the development of more research initiatives to better understand the barriers to access, limitations in funding, and negative perceptions of youth and providers (Speidel, et al., 2008). With these findings, innovators can publish updated, accurate information to reestablish family planning services as an essential value to the public health system (Butler & Clayton, 2009). Further, programs offering providers with IUD education and skills training can improve accessibility by expanded provider base for these services. This base can better promote and facilitate IUD contraception by implementing simplified tools for candidate criteria screening, allowing better opportunities for same day insertions, and reducing the number of follow up visits (Speidel, et al., 2008). Because multiple pregnancies are becoming increasingly prevalent, stakeholders have proposed the establishment of federally funded programs to provide teenagers free IUD insertions immediately follow abortions or childbirth to prevent subsequent pregnancies (Yen, Saah, & Hillard, 2010). The Contraceptive CHOICE Project, in an effort to encourage the use of long-acting reversible contraception (LARC), sought to eliminate previously determined barriers to IUD contraceptives. Because high initial costs of the most effective methods, this program offered a full range of contraceptive choices to women enrolled in the project at no cost, thus removing financial obligations. Findings revealed that without the influence of cost barriers, 56% of participants chose IUD contraception (Secura, Allsworth, Madden, Mullersman, & Peiper, 2010).

As the demand for family planning continues to skyrocket, healthcare providers, policymakers, and funding agencies must collaborate to fill gaps between barriers and knowledge bases regarding effective contraception. Consequences of today’s youth serve as a determinant for future outcomes, thus making teenagers a particularly important population to target future innovations in contraceptive care. Goals for future projects should seek to eliminate barriers to access by addressing contraceptive supply shortages, correcting provider biases, maximize reimbursement coverage, raising contraceptive awareness, and reduce limitations on eligibility for contraceptive provisions amongst qualified health care professionals (Blumenthal, Voedisch, & Gemzell-Danielsson, 2011). Utilizing these strategies to improve the availability of affordable and effective contraceptives can reduce the risk long term pregnancy-related costs and consequences, and can provide an enhanced quality of life amongst the nation.

References

American Academy of Pediatrics. (2007). Contraception and adolescents. Pediatrics120(5):1135-1147. 

American College of Obstetrics & Gynecology. (2007). ACOG Committee Opinion No. 392, December 2007. Intrauterine device and adolescents. Obstetrics & Gynecology110(6):1493-5.

Association of Reproductive Health Professionals [ARHP], (2008). Contraception. ARHP Policy Committee Position Statement on Contraceptive Access. Retrieved from: http://www.arhp.org/about-us/position-statements#11 

Blumenthal, P., Voedisch, A., & Gemzell-Danielsson, K., (2011). Strategies to prevent unintended pregnancy: increasing use of long- acting reversible contraception. Human Reproduction Update,17(1):121–137

Brindis, C., Llewelyn, L., Marie, K., Blum, M., Biggs, A., & Maternowska, C., (2003). Meeting the reproductive health care needs of adolescents: California’s family planning access, care, and treatment program. Journal of Adolescent Health, 32S(62): 79-90 

Butler, A. & Clayton, E., (2009). A review of the HHS Family Planning Program: Mission, management, and measurement of results. National Academies Press: Washington, DC

Equal Employment Opportunity Commission (2000). Decision on coverage of contraception. Retrieved from: http://www.eeoc.gov/policy/docs/decision-contraception.html

Finer, L., & Henshaw, S., (2006). Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health, 38:90-96.

Guttmacher Institute, (2011a). Facts on American teens’ sexual and reproductive health.

Guttmacher Institute, (2011b). Minors’ access to contraceptive services. State Policies in Brief. 

Guttmacher Institute, (2011c). Insurance coverage of contraceptives. State Policies in Brief. 

6H.R. 3590: Patient Protection and Affordable Care Act, 2010). Public Law 111–148 111th Congress, 42 USC 18001 

Hubacher, D., Finer, L., & Espey, E., (2011). Renewed interest in intrauterine contraception in the United States: Evidence and explanation. Contraception, 83(4): 291-294. 

Lindberg, Frost, Sten, & Dailard, (2006). Provision of contraceptive and relatedservices by publicly funded family planning clinics, 2003. Perspectives on Sexual and Reproductive Health, 38(3):139-147.

Secura, G., Allsworth, J., Madden, T., Mullersman, J., & Peiper, J., (2010). The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. American Journal of Obstetrics & Gynecology, 203:115.e1-7.

Speidel, J., Harper, C., & Shields, W., (2008). The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception, 78(3):197-200 

Thompson, K., Speidel, J., Saporta, V., Waxman, N., Harper, C., (2011). Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception 83:41–47

Trussel, J., Lalla, A., Doan, Q., Reyes, E., Pinto, L., & Gricar, J., (2009). Cost effectiveness of contraceptives in the United States. Contraception, 79:5-14.

UN Millennium Project 2005 Investing in development: a practical plan to achieve the millennium development goals. New York, NY: United Nations Development Programme. 

Whitaker, A., Johnson, L., Harwood, B., Chiappetta, L., Creinin ,M., & Gold, M., (2008).

 Adolescent and young adult women’s knowledge of and attitudes toward the intrauterine device. Contraception, 78:211 

Yen, S., Saah, T., & Hillard, P., (2010). IUDs and adolescents: An under-utilized opportunity for

 pregnancy prevention. Journal of Pediatric and Adolescent Gynecology, 23 

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One thought on “IUD for the win Part 2

  1. Nice topic Kait. I too see you involved in this matter as an advocate pushing government to help more with contraception to lower income families. I also see you giving speeches, counseling and teaching young teens safe sex practices. You will do a great job at.

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