Analysis Contraception

Study: Teen Moms Face Unnecessary Obstacles Accessing IUDs

Lee Hasselbacher & Dr. Melissa Gilliam

Researchers at the University of Chicago interviewed African-American, first-time adolescent mothers to determine what obstacles (other than cost) preventing them from obtaining IUDs. 

Reforms stemming from the Affordable Care Act (ACA) are set to lower birth control costs for many women. For instance, new HHS guidelines require insurance plans to cover FDA-approved contraception without cost-sharing. The ACA also expands Medicaid eligibility and offers ways to simplify enrollment so that more low-income Americans can receive needed coverage, which includes family planning services and supplies.

Ideally, reducing costs should give women more freedom to choose the birth control method that is best for them, including methods with higher upfront prices. For example, intrauterine devices (IUDs) are considered one of the most effective methods, but they are also one of the most expensive.

The IUD is becoming more popular (it was even featured in a recent issue of Wired magazine), but only 5.5 percent of women in the United States are currently using one.[1] While one reason for this low rate may be high upfront costs, research shows there are other barriers, particularly for teens. For example, some providers may follow outdated guidelines that recommended against offering IUDs to unmarried women who have not yet had children. However, with additional research and improvements made to a new generation of IUDs, the American College of Obstetricians and Gynecologists (ACOG) now supports the IUD for adolescents and women who have not had children.[2]

In fact, IUDs may be particularly suited for teen mothers, many of whom experience repeat pregnancies during their teen years. Teens raising one child already face increased risks of poverty, unemployment, and delayed educational attainment; subsequent births may exacerbate these struggles.[3] Rates of repeat teen births are lower today than in the 1990s, but they are still higher for African American and Hispanic girls compared to Whites.[4]

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The University of Chicago’s Section of Family Planning wanted to know about the obstacles adolescent mothers face when choosing the IUD as their birth control method. As part of a larger NIH-funded study, we interviewed 40 African-American, first-time adolescent mothers, 20 of whom said they were interested in using an IUD. Eight of these young women ended up getting an IUD within six months of giving birth, leaving 12 teens who did not get one. Most used condoms or withdrawal as a back-up method, but struggled with these and other methods like the pill or the vaginal ring. Three of the teens who did not get an IUD became pregnant within 12 months of giving birth.

Obstacles to Obtaining IUDs

Some of the biggest barriers for the teens included service-level obstacles (such as insurance, clinic access, provider inexperience), influence from their partners, and fears about side effects influenced by friends and family members.

Misinformation from Providers
One teen was incorrectly told by a provider that she had to be 18 or have parental consent while another was told that “only certain doctors” will provide IUDs. A third teen was informed that her doctor could not provide an IUD because his clinic was connected with a Catholic hospital. For another teen, it was hard to work out a time to get in for an appointment: “I missed my appointment . . .last month, . . . I couldn’t do it ‘cause I couldn’t afford to miss any more days out of school.”

Fears of Side Effects and Procedures
Many general misconceptions about IUD side effects continue to exist.  Even though IUDs have an excellent safety record[5], several participants had fears about complications and side effects that strongly affected their decision. The prevalence of misinformation among the study participants was concerning, suggesting that teens are in need of clearer counseling from providers.

One 16-year-old said, “Well they gave me a packet . . . and I read the side effects and I was like ohhh . . . I don’t know if I want to get this. It can fall out and get all these infections.” Another teen reported, “Cause [my doctor] said it was going to rip. I don’t want nothing to rip inside of me. So I got scared. . . I’m still thinking about getting it, but that scared me.”

A number of teens expressed fears about infections or infertility that they had heard from friends and family members. One young woman who had heard of a relative who couldn’t have kids after having an IUD said: “the doctor was saying… it’s different now, but, you know, if something [could] happen like that, I don’t even want to try it.”

General fears about the insertion procedure were also influential: “I don’t know what they do, they might stick me with something and I’m scared of needles and stuff like that.”

Resistance from Partners
A few participants faced resistance from their partners, with one teen reporting that her partner didn’t “want anything inside” her for five years and feared the presence of the IUD during sex. One partner wanted another baby and resisted a long-acting method: “He say he want another baby. But I’m, I’m not ready. I don’t want one . . . he got mad at me because I wanted to get on the 5-year thing.”

Support for Obtaining an IUD

The teens who obtained IUDs talked about the support they received from clinics, providers, family, friends and partners.

Support from Providers
Provider support and help in planning for the IUD during the pregnancy was a strong factor. As one participant reported, “When [I was] pregnant . . . I found out about a 5-year IUD and that’s when I started wanting it. As soon as I went to [my next prenatal visit] they asked me, ‘what did I want?’, and I told them and they ordered it then.”

Another teen said, “…they had it ready for my 6-week check up . . . I was 6 months pregnant, they had asked me. . . ‘did I plan on using the birth control method?,’ and the doctor had ordered it for me.”

Support from Family and Friends
Encouragement from family and peers was also valuable. One teen had a sister who liked her IUD while another talked to other people who had positive experiences with the method. This same teen noted that her partner encouraged her to consider birth control and agreed with her that the IUD was a good option.

At the same time, a strong sense of reproductive autonomy also influenced IUD choice, with one young woman reporting, “Cause he want to have a baby, another one, at least 3, and me . . . no. But it don’t matter, it’s me, it’s my body . . . that’s my decision.”

Careful Comparison
Some teens made their decision after comparing their options, with one commenting, “I don’t think the other methods would be good for me and this is something that I don’t have to worry about. So with the IUD I can just insert it and then I can go about my life.”

Another teen recognized that the IUD would offer consistent protection: “I missed my shot in February because I didn’t go to the doctor, I forgot I had an appointment and I didn’t go . . . and then I got on the IUD.”

As a result of health care reform, more women will be able to choose the best birth control method for them, not just the most affordable. Our study, which is set to be published in an upcoming issue of the American Journal of Obstetrics & Gynecology, suggests that health care providers can play a big role in supporting women’s birth control choices. Providers should be encouraged to stay up-to-date with information and research evidence on the full range of contraceptive methods.

Given the influence of family and peers, providers might start by asking young women what they have heard about different methods in order to address fears and provide comprehensive information. Where appropriate, including partners in birth control counseling may also prove helpful.

In these ways, they can counsel women – such as teens at high risk for repeat pregnancy – in choosing a safe and effective method.

 

 


[1] Mosher WD and Jones J, Use of contraception in the United States: 1982–2008, Vital and Health Statistics, 2010, Series 23, No. 29.

[2] Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 121. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:184–96.

[3] Hoffman, S. D. and R. A. Maynard (Eds.) Kids Having Kids: Economic & Social Consequences of Teen Pregnancy. Washington, D.C., Urban Institute Press, 2008.

[4] Schelar E, Franzetta K, Manlove J. Repeat teen childbearing: differences across states and by race and ethnicity. Washington, DC: Child Trends; 2007.

[5] Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 121. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:184–96.

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.

News Human Rights

Lawsuit: Religious Groups Are Denying Abortion Care to Teen Refugees

Nicole Knight Shine

The suit accuses the federal government of paying millions to religious grantees that refuse to provide unaccompanied minors with legally required reproductive health services.

Two years ago, 17-year-old Rosa was raped as she fled north from her home country in Central America to the United States. Placed in a Catholic shelter in Florida, the teen learned she was pregnant, and told shelter officials that if she couldn’t end the pregnancy, she’d kill herself. She was hospitalized for suicidal thoughts. Upon her release, the facility in which she’d been originally placed rejected her because of her desire for an abortion, according to a federal lawsuit filed Friday. So did another. Both, reads the lawsuit, were federal contractors paid to care for unaccompanied minors like Rosa.

Rosa’s story is one in a series sketched out in a 16-page complaint brought by the American Civil Liberties Union (ACLU) against the U.S. Department of Health and Human Services (HHS). The suit accuses the federal government of paying millions to religious grantees—including nearly $20 million over two years to the U.S. Conference of Catholic Bishops (USCCB)—that refuse to provide unaccompanied minors with legally required reproductive health services, including contraception and abortion. The grantees are paid by the federal Office of Refugee Resettlement (ORR) to house and care for young refugees.

The lawsuit, brought in U.S. District Court in San Francisco, amounts to a fresh test of the degree to which Catholic organizations and other faith-based groups can claim exemptions from federal laws and regulations on religious grounds.

“Religious liberties do not include the ability to impose your beliefs on a vulnerable population and deny them legal health care,” said Jennifer Chou, attorney with the ACLU of Northern California, in a phone interview with Rewire. “The government is delegating responsibility … to these religiously affiliated organizations who are then not acting in the best interest of these young people.”

Mark Weber, a spokesperson for the HHS, which includes the ORR, told Rewire via email that the agency cannot comment on pending litigation.

Escaping turmoil and abuse in their home countries, young refugees—predominantly from Central America—are fleeing to the United States, with 33,726 arriving in 2015, down from 57,496 the year before. About one-third are girls. As many as eight in ten girls and women who cross the border are sexually assaulted; it is unknown how many arrive in need of abortion care.

The federal ORR places unaccompanied minors with organizations that are paid to offer temporary shelter and a range of services, including reproductive health care, while the youths’ applications for asylum are pending. But documents the ACLU obtained indicate that some groups are withholding that health care on religious grounds and rejecting youths who request abortion care.

The 1997 “Flores agreement” and ORR’s contracts with grantees, which the ACLU cites in its lawsuit, require referrals to “medical care providers who offer pregnant [unaccompanied immigrant minors] the opportunity to be provided information and counseling regarding prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination.”

In 2016, the federal government awarded 56 grants to 30 organizations to provide care to unaccompanied minors, including 11 that the ACLU claims impose religious restrictions on reproductive health care.

In one case, ORR officials struggled to find accommodations for 14-year-old Maria, who wanted to end her pregnancy, according to the complaint. An ORR official wrote, according to a document the ACLU obtained, that the agency would have liked to transfer Maria to Florida to be near family, but “both of the shelters in Florida are faith-based and will not take the child to have this procedure,” meaning an abortion.

In another, the complaint reads, 16-year-old Zoe was placed with Youth for Tomorrow, a faith-based shelter in Virginia, where she learned she was pregnant. She asked for abortion counseling, which was delayed nearly two weeks, the complaint says. Learning of her decision to end the pregnancy, Youth for Tomorrow asked to transfer Zoe elsewhere because of its abortion prohibition, even though Zoe said she was happy at the shelter.

For vulnerable youths, such transfers represent a form of “secondary trauma,” according to the ACLU’s Chou.

“These women have already endured so much,” she told Rewire. “The process of transferring these youths from shelter to shelter tears them away from their only existing support system in the U.S.”

Federal officials, according to the complaint, were aware that the religious grantees would withhold abortion referrals. In one case, the Archdiocese of Galveston-Houston was awarded more than $8 million between 2013 and 2016, although it stated in its grant application that rape survivors wouldn’t be offered abortion care, but instead permitted to “process the trauma of the rape while also exploring the decision of whether to keep the baby or plan an adoption.”

The lawsuit also claims that a contract with the U.S. Conference of Catholic Bishops included language requiring unaccompanied minors who were pregnant to be given information and counseling about pregnancy termination, but the ORR removed that language after the USCCB complained.

The USCCB did not respond to Rewire‘s request for comment. But in a letter last year to the ORR, the USCCB and five religious groups, including some ORR grantees, wrote they could not facilitate health-care services for unaccompanied minors that run contrary to their beliefs.

The lawsuit is the second the ACLU has filed recently against the federal government over religious privileges.

Last month, the ACLU filed a Freedom of Information Act suit demanding that the federal Centers for Medicare & Medicaid Services release complaints against federally funded Catholic hospitals, where patients have reported being denied emergency medical care in violation of federal law.

In 2009, the ACLU also sued the federal government for allowing USCCB to impose religious restrictions on a taxpayer-funded reproductive health program for trafficking survivors. In 2012, a district court ruled in the ACLU’s favor, and the government appealed. The First Circuit Court of Appeal later dismissed the case as “moot” because the government did not renew USCCB’s contract.