Adolescent Contraception

General Use

Overall, American adolescent female contraception usage has improved from 79.9% in 1988 to 85.6% today (Centers for Disease Control and Prevention (CDC), 2011). The overall rate is comparable with available data for Canada, England, and France whose rates were 82.3, 82.8, and 89.5 respectively (Godeau et al., 2008). However, use of contraception at last intercourse still varies considerably depending on race and ethnicity: 89.3% of non-Hispanic white adolescent females reported using some method of contraception at last intercourse while only 81.1% of non-Hispanic Blacks and 79.5% of Hispanic/Latinas reported doing so (CDC, 2011). Even of those women using contraception, 23% of U.S. women experience relatively high risk of pregnancy due to inconsistent use (Frost, Singh, & Finer, 2007). Additionally, early sexual debut increases the odds of gaps in the use of contraception by two times compared to women who debuted at 18 years of age or later and increases likelihood of nonuse at most recent intercourse (Magnusson et al., 2011, 2012; Cavazos-Rehg et al., 2010). Family conflict is also associated with not using contraception at last intercourse and an increased number of sexual partners (Lyerly & Brunner Huber, 2013). Though ambivalence to pregnancy contributes to a woman’s odds of pregnancy, women with high levels of ambivalence have not been found to differ in contraceptive use from non-ambivalent women (Yoo, Guzzo, & Hayford, 2014). As with pregnancy, attitudinal factors play a significant role in use of contraception: in a worldwide systematic review of qualitative studies, authors found a number of universal themes in adolescent beliefs regarding sexual behavior. Themes included: condoms are stigmatizing and indicate lack of trust, partners and societal norms influence behavior, adolescents tend to assess their partners as “clean” or “dirty”, and social norms may hinder communication about sex (Marston & King, 2006). These attitudinal factors may help to explain low usage of birth control methods among adolescents despite a high degree of knowledge.

Adolescent Knowledge of contraception

Condoms and OCPs are the most common forms of contraception in the adolescent population, however this may not constitute a preference, but a lack of knowledge regarding other types of contraception as women are unlikely to choose a method with which they are unfamiliar (CDC, 2011; Spies, Askelson, Gelman, & Losch, 2010). Though most adolescents have heard of OCPs and condoms, misconceptions persist, even among OCP users (Craig, Dehlendorf, Borrero, Harper, & Rocca, 2014; Hamani et al., 2007). However, increased knowledge of oral contraceptives was associated with significantly higher 6 month continuation rates (Hall, Castaño, & Westhoff, 2014). Lesser known methods of SARC, such as the ring and the patch, benefit particularly from provider counseling, which is associated with higher rates of women choosing these methods (Harper, Brown, Foster-Rosales, & Raine, 2010). Hispanic women are considerably less likely to have heard of the patch, the ring, and IUDs while Black women were less likely to have heard of the ring (Craig et al., 2014). Differences in awareness about contraceptive methods remain: 87% of adolescents have heard of IUDs and only 52% have heard of implants, as opposed to near 100% awareness of OCPs and condoms (Craig et al., 2014). Women are frequently misinformed about IUDs and are unaware that nulliparous women are eligible to use them, though this may in part be due to the fact the most popular form of hormonal IUD, Mirena®, is not labeled for use in nulliparous women in the U.S. (Craig et al., 2014; Finer, Jerman, & Kavanaugh, 2012). Younger women and non-native English speakers were significantly less likely to have heard of LARC and have low level knowledge of LARC methods (Craig et al., 2014; A. R. Dempsey, Billingsley, Savage, & Korte, 2012; Sokkary et al., 2013). Nulliparous women are initially less likely to be interested in an IUD, but are more likely to consider an IUD after provider counseling (Fleming, Sokoloff, & Raine, 2010). The largest prospective observational study to date, which offered counseling followed by a choice of all reversible types of contraception, shows that improved knowledge about LARC leads to increased use and acceptability in the adolescent and young adult population (Mestad et al., 2011). Overall, 70% of participants chose a LARC method. A significant majority of 14-17 year-olds preferred the implant while a significant majority of 18-20 year-olds chose hormonal or copper IUDs (Mestad et al., 2011). Despite the generally high awareness of SARC, continued emphasis should be placed on increasing knowledge of all forms of contraception to increase uptake and continuation rates among adolescents and young adults.

Adolescent Usage of Contraception

Nearly sixty percent of sexually active school-attending adolescents reported they or their partner used a condom at last intercourse to prevent pregnancy, 19% reported OCP use, and 1.6% reported IUD or implant use (Kann et al., 2014). Overall, these usage rates still fall behind most European nations (United Nations, 2011). Racial differences in LARC usage vary for adolescents as compared to young adults; adolescent Black women are significantly less likely to use LARC than their white counterparts, while among young adults, Asian women are the only group significantly less likely to use a LARC method (Dehlendorf et al., 2014; Dempsey et al., 2012). The disparity in contraceptive usage rates between white women and women of color has broadened in recent years (Dehlendorf et al., 2014; Jacobs & Stanfors, 2013). Parous women are considerably more likely to use an IUD than nulliparous women (Whitaker, Sisco, Tomlinson, Dude, & Martins, 2013; Xu et al., 2011). Predictive factors for current LARC usage in young women (18-29 years of age) include higher age, earlier onset of sexual activity, less than four sexual partners in the last year, and higher education level of the mother of the user (A. R. Dempsey et al., 2012; Xu et al., 2011). Women with previous history of discrimination are more likely to use SARC, but when barriers to contraception were removed, women tend to choose LARC (Kossler et al., 2011). Research regarding the indication for LARC usage in the adolescent female population is also lacking. In a review of clinical trials and observational studies examining female contraceptives, studies that examined LARC methods were significantly less likely to recruit nulliparous females than trials examining OCPs, instead limiting recruitment to white women of more advanced age (Mansour et al., 2010). Adolescent beliefs regarding bleeding patterns may also influence contraceptive choice. Adolescent women noted irregular bleeding as a common concern, especially the disruption of menses as it was frequently seen as a process necessary for the “cleansing” of the body or otherwise in opposition to cultural beliefs (Clark, Barnes-Harper, Ginsburg, Holmes, & Schwarz, 2006; Kavanaugh, Frohwirth, Jerman, Popkin, & Ethier, 2013). Changes in menstruation also caused the adolescents to doubt the effectiveness of the contraceptive method (Clark et al., 2006).