Mandy S. Coles

Factors associated with provision of long-acting reversible contraception among adolescent health care providers

PURPOSE To identify provider and practice characteristics associated with long-acting reversible contraception (LARC, either progesterone contraceptive implants or intrauterine devices [IUDs]) provision among adolescent health care providers. METHODS We used data from a previously conducted survey of US providers on reproductive health to predict provision of any form of LARC as well as progesterone contraceptive implants or IUDs specifically using Chi-square and multivariate logistic regressions. RESULTS One third of providers reported any LARC provision. In logistic regressions, residency training in obstetrics/gynecology or family medicine (rather than internal medicine/pediatrics) was the strongest predictor of LARC provision, particularly for IUDs. CONCLUSIONS A minority of providers reported offering IUDs or contraceptive implants, most of whom had received procedural womens health training. Increasing the number of providers offering this type of contraception may help to prevent adolescent pregnancies and may be most easily accomplished via training in contraceptive implant provision.

Contraceptive experiences among adolescents who experience unintended birth.

BACKGROUND Adolescents are at high risk of unintended pregnancy due to contraceptive nonuse and inconsistent use. STUDY DESIGN We examined associations between contraception and mistimed/unwanted birth among adolescents. For contraceptive nonusers, we analyzed factors contributing to unintended birth. RESULTS Half of adolescents with unintended births did not use contraception at conception. Those ambivalent about pregnancy reported fewer unwanted [relative risk (RR)=0.06] compared to wanted births. Amongst contraceptive nonusers, difficulty accessing birth control was the only factor associated with more unwanted birth (RR=3.05). For Black adolescents, concerns of side effects (RR=7.03), access issues (RR=10.95) and perceived sterility (RR=3.20) were associated with unwanted birth. For younger teens, falsely perceived subfertility increased unwanted birth (RR=2.74), whereas access issues were significant for older teens (RR=3.97). CONCLUSIONS Access issues and misconceptions around contraceptive side effects and fertility place adolescents at higher risk for unintended pregnancy, especially among younger and Black teens. Ambivalence represents an additional area for intervention.

Addressing the Challenges of Clinician Training for Long-Acting Reversible Contraception

Long-acting reversible contraceptive (LARC) methods are gaining greater popularity in the United States as both patients and health care professionals become educated about their high contraceptive efficacy, relatively few contraindications, and ease of use. In fact, LARC is recommended by the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics as a first-line contraceptive option for adolescents.1,2 Use of LARC among 15to 19-year-olds increased from 1% to 4.5% between 2007 and 20093 and studies suggest that the uptake of these methods would significantly increase if access and cost barriers were removed.3,4 As experts in pediatric and adolescent medicine, we believe it is our duty to be trained and proficient in providing all contraceptive options to our patients, including LARC methods. We believe that LARC education and hands-on training are paramount for all adolescent medicine fellows and interested pediatric residents. Adolescents receive the majority of their medical care from primary care clinicians, including pediatricians, family medicine clinicians, and adolescent medicine–trained clinicians. There has been a call for the expansion of LARC services in primary care settings.5 However, few primary care clinicians, especially those outside of family medicine, have received the procedural women’s health training necessary to offer these highly effective contraceptive methods.6 Despite an upsurge of interest in LARC, there is no standardized LARC training in pediatric residency programs or adolescent medicine fellowships. This lack of training poses one of many barriers to young women trying to access these methods. One study found that only one-quarter of adolescent medicine clinicians were trained to insert intrauterine devices (IUDs) or implants.6 Given the lack of adequate knowledge about LARC among general pediatricians, this number is likely much lower for clinicians without specific adolescent training.7 Lack of onsite insertion presents a significant barrier to LARC use in young women. Adolescent patients often do not follow through with referrals to specialists outside of their medical home in part owing to concerns around confidentiality. In addition, lack of on-site insertion precludes an opportunity to quick start (same-day start) LARC on the day of service, a method that provides faster protection from unintended pregnancy. Without present required or even elective opportunities for LARC training, motivated medical trainees often encounter challenges to LARC training, despite their interest. These include the paucity of pediatric-trained and adolescent medicine–trained clinicians who offer LARC, lack of official channels to receive LARC training, low volume of LARC devices typically placed during a clinical session, and lack of procedural women’s health training for pediatricians. We believe that improving education and hands-on training is essential for adolescent medicine fellows and interested pediatric residents to improve the availability of LARC. Attending training sessions focused on IUDs and contraceptive implants similar to those held at recent Society for Adolescent Health and Medicine annual meetings is a first step, but such trainings do not replace the need for hands-on patient experience. For this reason, pediatric residency and adolescent medicine fellowship programs should strongly consider creating models for LARC training within their current training curriculum. We propose the following potential solutions to improve LARC training among pediatric and adolescent medicine trainees: • Develop a curriculum spearheaded by experts in family planning and adolescent medicine to provide both didactic and hands-on training in LARC provision that can be disseminated across adolescent medicine fellowship programs. • Incorporate standardized training in counseling and provision of LARC in adolescent medicine fellowships and as an optional component of pediatrics residency training. • Improve collaborations between adolescent medicine and family medicine/obstetrics and gynecology to allow for the colocation of services and crosstraining of medical students, residents, and fellows. • Share resources and create official pathways by which adolescent fellows can be trained by faculty skilled in family planning and LARC provision who are comfortable working with nonsurgically trained clinicians. • In institutions where LARC training is not available onsite, offer additional clinical experiences at sites where there is a high volume of LARC provision for teens or with local abortion clinicians where trainees can learn procedural skills (eg, tenaculum placement, uterine sounding, cervical blocks, and cervical dilation). Adolescent medicine fellowship programs currently share resources to accomplish other necessary training in areas where adolescent medicine faculty might not have specific expertise (eg, substance abuse, sports medicine, human immunodeficiency virus care, and psychiatry training). Until LARC provision becomes widespread among adolescent medicine faculty, it is paramount to find alternative venues for pediatricians and adolescent medicine specialiststobetrainedinLARCprovision.High-volumesettings may also help clinicians gain exposure to potentially challenging cases. The amount of training in LARC provision should vary basedontheeducationlevelandinterestofthelearner.One VIEWPOINT

How Are Restrictive Abortion Statutes Associated With Unintended Teen Birth

PURPOSE Legislation that restricts abortion access decreases abortion. It is less well understood whether these statutes affect unintended birth. Given recent increases in teen pregnancy and birth, we examined the relationship between legislation that restricts abortion access and unintended births among adolescent women. METHODS Using 2000-2005 Pregnancy Risk Assessment Monitoring System data, we examined the relationship between adolescent pregnancy intention and policies affecting abortion access: mandatory waiting periods, parental involvement laws, and Medicaid funding restrictions. Logistic regression controlled for individual characteristics, state-level factors, geographic regions, and time trends. Subgroup analyses were done for racial, ethnic, and insurance groups. RESULTS In our multivariate model, minors in states with mandatory waiting periods were more than two times as likely to report an unintended birth, with even higher risk among blacks, Hispanics, and teens receiving Medicaid. Medicaid funding restrictions were associated with higher rates of unwanted birth among black teens. Parental involvement laws were associated with a trend toward more unwanted births in white minors and fewer in Hispanic minors. CONCLUSIONS Mandatory waiting periods are associated with higher rates of unintended birth in teens, and funding restrictions may especially affect black adolescents. Policies limiting access to abortion appear to affect the outcomes of unintended teen pregnancy. Subsequent research should clarify the magnitude of such effects, and lead to policy changes that successfully reduce unintended teen births.

Adolescent immunization update.

Since 2005, 3 new vaccines have been added to schedule for routine administration at the 11 to 12-year-old well-child visit. There is also a new recommendation for annual influenza vaccination of all children and adolescents. This update will provide an overview of the vaccines recommended during adolescence: human papillomavirus vaccine (HPV), tetanus and diphtheria toxoid and acellular pertussis vaccine (Tdap), meningococcal conjugate vaccine (MCV4), and influenza vaccine (Table 1). We will also discuss the factors affecting immunization rates, strategies to improve immunization rates, and briefly touch upon recommendations for catch-up vaccinations for this age group (Table 2). HPV is a highly transmissible sexually transmitted infection (STI). Oncogenic HPV types 16 and 18 can lead to vaginal, vulvar, and cervical precancers and cancers, as well as anal, penile, oropharyngeal, and oral cavity cancers. Nononcogenic HPV types 6 and 11 can cause genital warts and recurrent respiratory papillomatosis. Infection often occurs shortly after coitarche. Because approximately one-third of ninth graders have had sexual intercourse and HPV prevalence is around 40% in 14to 19-year-old sexually active females, adolescence is the ideal time to administer this vaccine. There are 2 licensed HPV vaccines (Table 1). The bivalent vaccine (HPV2), Cervarix, protects against the oncogenic HPV types 16 and 18 that cause 70% of cervical cancer, and was licensed in 2009 for administration to females aged 10 to 25 years (Table 2). The quadrivalent vaccine (HPV4), Gardasil, offers protection against HPV types 16 and 18, as well as 2 nononcogenic HPV types, 6 and 11, that cause 90% of genital warts. HPV4 was originally licensed in 2006 for administration to 9to 26-year-old females, and in 2009 received an expanded license for administration to 9to 26-year-old males. The Advisory Committee on Immunization Practices (ACIP) recently provided a permissive recommendation for HPV4 to be given to males, but has not yet recommended routine administration. Pertussis, caused by Bordetella pertussis, is the only vaccine preventable disease that is currently increasing in incidence in the United States. This is, in part, due to waning immunity from childhood vaccines. Infected adolescents and young adults generally have a chronic cough lasting several weeks that can result in lost days of work or school, and in disease transmission to infants. As adolescents and young adults are commonly siblings, parents, or caretakers for young children, achieving adequate vaccination coverage for this age group is an important step in protecting infants from infection. In a study of infants with pertussis, cough illness was reported in a parent or sibling in 28% of cases. For these reasons, in 2006, ACIP began recommending routine Tdap vaccination, in place of the tetanus and diphtheria toxoid vaccine (Td), for 11 to 12 year-olds. There are currently 2 vaccine products that provide added protection against pertussis and tetanus and are recommended for adolescents and young adults—Adacel and Boostrix (Table 1). One Tdap at age 11 years is considered adequate protection against pertussis into adulthood (Table 2); additional tetanus boosters can be given as Td. Tdap can be administered regardless of the interval since the last tetanus and diphtheria toxoid– containing vaccine. Invasive meningococcal infection results in severe disease including pneumonia, meningococcemia, meningitis, and death. While this serious infection occurs rarely, it tends to affect infants and youth aged 11 to 19 years. Adolescents and young adults living in close proximity, such as college dorms or military barracks, are at greater risk for acquiring infection. The meningococcal conjugate vaccines, Menactra and Menveo, provide protection against N. meningitidis serogroups A, C, Y, and W-135 (Table 1). In 2010, the ACIP recommended routine vaccination of 11to 12-year-olds with quadrivalent MCV4 with a booster dose given at age 16 years (Table 2). If not previously vaccinated, ACIP recommends MCV4 vaccination at age 13 to 18 years. Persons who received their first dose at age 13 to 15 years From the *Division of Adolescent Medicine, Department of Pediatrics, Golisano Childrens Hospital at Strong, Rochester, NY; and †Division of Adolescent Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Pediatrics Associates, Buffalo, NY. Reprints: Meera S. Beharry, MD, FAAP, Division of Adolescent Medicine, Department of Pediatrics, Golisano Children’s Hospital at Strong, 601 Elmwood Avenue, Box 690, Rochester, NY 14642. E-mail: meera_beharry@urmc.rochester.edu. Copyright

If You Do Not Ask, They Will Not Tell: Evaluating Pregnancy Risk in Young Women in Pediatric Hospitals

Adolescents experience some of the highest rates of unintended pregnancy among women of all reproductive age groups. And despite the fact that adolescents often receive care in pediatric hospital settings, evaluation of pregnancy risk is inconsistent. Pregnancy risk assessments can identify opportunities to deliver reproductive health services, allow earlier pregnancy diagnoses, and reduce morbidity and mortality for medically complex adolescent patients and their pregnancies. In this commentary we discuss some of the challenges and potential solutions to performing pregnancy risk assessments in pediatric hospital settings.