Teen pregnancy: LARCs not “one-size-fits-all”

LONG-acting reversible contraceptives (LARCs) are an effective and acceptable contraceptive choice for some adolescents, says an Australian expert, but should not be considered a “one-size-fits-all” option.

Dr Deborah Bateson, medical director at Family Planning NSW, said that women of all ages should be informed of the benefits of LARCs within a suite of contraceptive options.

“We want to promote awareness of LARCs across the reproductive ages, including for adolescents, but it’s always within that context of shared decision making and fully informed choice,” she said.

Dr Bateson was commenting on a Viewpoint, published recently in JAMA Pediatrics, that questioned the American Academy of Pediatrics’ recommendation of LARCs as a first-line contraceptive for adolescents.

The author, Dr Maya Michelle Kumar of the University of California’s Department of Pediatrics, said that contraceptive efficacy was highly valued by women and adolescent girls, but was not the only factor driving decision making. Other considerations for teenagers included menstrual control, acne treatment, cost and personal preference, she said.

Also, Dr Kumar said, it was important for clinicians to consider the possibility that young women seeking contraception had been sexually abused.

“Childhood sexual abuse is strongly associated with adolescent sexual risk taking and pregnancy; a meta-analysis found that a history of childhood sexual abuse more than doubles the risk of adolescent pregnancy and that almost 50% of adolescent girls who become pregnant have a history of childhood sexual abuse,” Dr Kumar wrote.

She said that adolescents with a history of sexual abuse may perceive the lack of easy reversibility with LARCs as a loss of reproductive autonomy. Moreover, she said that insertion of an intrauterine device may be triggering for some adolescents.

Dr Kumar also pointed to the US’s “dark history of forced sterilization among women of color, women with mental health problems or developmental disabilities, incarcerated women, and unmarried mothers” as an important consideration in contraception counselling.

“To be truly effective, contraceptive [counselling] should be tailored to each adolescent and should prioritize more than pregnancy prevention alone,” she wrote.

Dr Bateson agreed, and said that the JAMA Pediatrics article highlighted important issues that were also relevant in Australia.

“LARCS have many benefits and we are seeing more and more young women asking for implants and intrauterine devices,” she said, adding that LARC uptake remained relatively low in Australia compared with other high income countries. “It is important to acknowledge that LARC is not for everyone – it sits within the whole suite of contraceptive options.”

In July 2017, the Australian Healthcare and Hospitals Association issued a consensus statement calling for greater access to LARCs to reduce the rate of unintended pregnancies among Australian women. The statement, which has been endorsed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, was developed with funding from Merck Sharp and Dohme, which participated as an observer in the stakeholder forum, along with Bayer and Medical Industries.

Australia’s rate of teenage fertility hit historic lows in 2015 – at 11.9 births per 1000 – but Dr Bateson said that it was important to look beyond the averages.

“We do have some areas with relatively high rates of teenage fertility,” she said, noting that this was primarily in rural and remote Australia. “Sometimes, of course, these are wanted pregnancies that go on to be part of successful families, but it is important to look at the issue as a whole.”

Dr Patricia Moore, head of the Early Pregnancy and Contraception Unit at the Royal Women’s Hospital in Melbourne, said that the issues raised in the US article were consistent with the emphasis on choice and informed consent in Australia’s consensus statement.

“There are lots of other things going on in young people’s lives that you need to think about,” Dr Moore told MJA InSight. “It’s about choice, it’s about informed consent, it’s about treating young people as they should be treated as individuals, and allowing them to make their own contraceptive decisions.”

She added that when young women were provided with information about the effectiveness and non-contraceptive benefits of the various contraceptive options – and had all financial barriers removed – most choose LARCs.

Dr Bateson said that awareness of a possible history of sexual abuse among adolescents seeking contraception, as well as recognition of Australia’s own history of coerced contraception, was vital in conversations about contraceptive choices.

“It is essential that young women, including the most marginalised adolescents such as those who are homeless or in out-of-home care, are provided with information about the different contraceptive methods, their [advantages and disadvantages], so they can make a fully informed choice,” she said. “And, as the [JAMA Pediatrics] author points out, contraceptive choice is determined by much more than just effectiveness.”

Dr Bateson said that an empathic, non-judgemental approach was crucial when discussing contraceptive options, particularly with teenagers who may have a history of sexual abuse or trauma.

“As health professionals, we need to be able to listen very carefully to every young person’s needs and concerns, including any trauma they may have experienced,” she said.

Dr Bateson added that young women should be informed that they also have the right to remove a LARC or change contraceptive methods if they so choose.

“There can sometimes be well intentioned paternalism [in supporting young women to make contraceptive choices], and we have to ensure we are listening to the young people themselves.”

Dr Bateson said that Australia had come a long way in its recognition of reproductive autonomy, but it was important not to forget past injustices.

“We too have a history of human rights injustices when it comes to coerced contraception, particularly among adolescents in institutions, women with intellectual disabilities and in some Indigenous communities,” she said. “We now recognise the importance of self-determination in relation to reproductive health, but we do have to remember those lessons of the past as well.”

Dr Bateson also pointed to recent Australian research in three remote Indigenous communities, which showed the importance of whole-of-community engagement in the uptake and acceptability of LARCs.

Dr Moore agreed that for some young women with a history of sexual abuse, implants – particularly intrauterine devices – could be triggering. However, she said, bleeding could also be a trigger for some teenagers with a history of abuse.

“We are also aware of transgender individuals for whom bleeding really increases their dysphoria,” Dr Moore said. “So, there are many things that go into the mix. It’s perhaps a more complex than people thought, and there is more skill required in talking to young people about their options, but I don’t see this as a controversy.”

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