To further reduce the incidence of teenage pregnancy, U.S. health policymakers should adopt strategies that promote and support the use of long-acting reversible contraceptives (LARC), Tina Rosenberg writes in an opinion piece for the New York Times.
Teenage pregnancy in the U.S.
In 2014, the U.S. teenage birth rate fell to "a historic low," according to Rosenberg. She notes that the 2014 rate, at 24.2 per 1,000 women ages 15 to 19, marks a 40 percent decline since "its modern peak in 1991," when the rate was 61.8 per 1,000. Rosenberg calls the decline "excellent news," noting that teenagers who become pregnant "are less likely to finish their education, and their babies are at high risk for health problems, incarceration, academic troubles and, yes, teenage pregnancy."
While "[n]o one really knows why these birthrates have dropped," Rosenberg suggests that "[t]he most important reason appears to be increased contraceptive use." She notes that media depictions of the challenges of teenage pregnancy may also have played a role.
Nonetheless, despite the decline, "the United States has a far higher rate of teenage pregnancies than most developed countries," Rosenberg writes. She adds that according to the Guttmacher Institute, three-quarters of teenage pregnancies are unintended.
Colo. LARC initiative
In terms of what can be done to help teenagers avoid unintended pregnancy, Rosenberg highlights a Colorado initiative that provides LARC to low-income women at no cost.
In the last seven years, Colorado has seen the birth rate among 15-to-19-year-old women "cut ... by nearly half," while "[r]epeat teenage births have dropped by 58 percent," Rosenberg writes. She adds that as a result, "the state has saved tens or perhaps hundreds of millions of dollars."
The LARC initiative is "a main reason for Colorado's success," Rosenberg states. She notes that since the program began, the rate of teenagers seeking family planning services at clinics for low-income or uninsured individuals and receiving LARC has increased from 2.5 percent to 28.9 percent.
Promoting LARC
While the effectiveness of the 7-year-old program "ha[s] been widely reported," Rosenberg writes that "other states are getting off to a slow start in replicating the program." According to Rosenberg, 13 states have joined an Association of State and Territorial Health Officials working group to "brin[g] officials from states seeking to provide LARCs to women who have just given birth."
Rosenberg explains, "The challenges illustrate how difficult it is to spread new medical practices." She quotes Lisa Waddell, the community health and prevention chief program officer at the health officials' association, who cites a need for education about LARCS. To address misconceptions about LARCs and promote their use, Rosenberg writes, paraphrasing Waddell, that "the best remedy is word of mouth from women who are happy with their birth control."
However, Rosenberg cautions, "Health workers must use care when talking about LARCs, as with other forms of birth control." She notes, "America has a sorry history of coercing young minority women into sterilization or birth control."
Accessing a physician to discuss LARC poses another obstacle to care, Rosenberg writes. According to Amy Crockett -- a maternal-fetal medicine specialist at the Greenville Health System in South Carolina and clinical lead for the Birth Outcomes Initiative, a state program -- "'The biggest barrier is access to care.'" Crockett explained that in some cases, obtaining LARC can entail two separate appointments if a physician does not have LARC in stock on the day of the initial visit.
Noting these barriers, Rosenberg writes, "This is one reason many states focus on women who have just given birth." However, "while many state governments wanted hospitals to insert LARCs, state Medicaid systems initially discouraged the procedure with their disbursement system," Rosenberg continues, explaining that Medicaid bundled payments for birth did not include extra payment for LARCs. Nonetheless, she notes that starting with South Carolina in 2012, many states have since adopted payment policies that reimburse for LARCs in a separate payment, while "Blue Cross and Blue Shield, the dominant insurer, quickly followed."
According to Rosenberg, the state Medicaid programs' "policy change was necessary but far from sufficient." For example, she notes that while Montana's "Medicaid added a separate payment for LARC on" Jan. 1, 2015, "10 months later, only four women had received LARCs immediately after giving birth, because providers hadn't been told that they could get paid."
Rosenberg concludes by quoting Crockett, who, acknowledging the "'logistical issues'" of promoting LARC use, says, "'I learned it really takes leadership'" (Rosenberg, New York Times, 7/19).
