“The thing in my arm”: Providing contraceptive services for adolescents in primary care

Abstract

Background:

Due to high rates of unintended pregnancies in Delaware, the state launched a public health initiative in 2014 to increase access to contraceptive services.

Objectives:

This study was designed to assess the practice-level barriers and facilitators to providing contraceptive care, particularly long-acting reversible contraceptives (LARCs), to adolescents in primary care settings.

Design:

This qualitative study was part of a larger process evaluation of the Delaware Contraceptive Access Now (DelCAN) initiative.

Methods:

In-depth, semi-structured qualitative interviews were conducted with 16 practice administrators at 13 adolescent-serving primary care sites across the state of Delaware. A process of open, axial, and selective coding was used to analyze the data.

Results:

Despite the interest in LARC among their adolescent patients, administrators described numerous barriers to providing LARC for adolescents including confidentiality in patient visits and billing, preceptorship, and provider discomfort and assumptions about the need for contraception among adolescent patients.

Conclusion:

Findings from this study reveal substantial barriers to providing contraception to adolescents, even in primary care practices that were committed to comprehensive contraceptive access for their adolescent patients. This study supports the need for contraceptive care to be integrated into training of pediatricians at every stage of their education. Such training must go beyond education about contraceptive options and the clinical skills necessary for LARC insertion and removal, to include counseling skills based in a reproductive justice framework. Additional changes in policies and practices for adolescent patients would further increase access to contraceptive care.

Introduction

The United States has high rates of unintended pregnancies compared to other developed countries, ¹ including among adolescents.^2,3 Teen pregnancies are associated with an increased risk for a range of negative outcomes for adolescents and their children.^{4 –7} One important strategy to address unintended teen pregnancies is improved access to contraceptive care. In 2014, the American Academy of Pediatrics issued a policy statement recommending long-acting reversible contraception (LARC) as a first-line contraceptive choice for adolescents because of their efficacy, safety, and ease of use. ⁸ Since that time, there has been significant pushback from pediatricians and advocates for reproductive justice ⁹ who caution against clinicians controlling adolescent reproduction in the name of public health and point out the ways in which reproductive control has been used to enact and perpetuate structural violence against marginalized communities. Instead of uniformly recommending LARCs as a first choice of contraception for adolescents, they advocate for the use of a reproductive justice framework in which providers offer education and respect for adolescents’ reproductive and bodily autonomy through shared decision-making. ¹⁰ Subsequent articles by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists explicitly incorporated the reproductive justice framework and counseled pediatricians to use a patient-centered approach to contraceptive care in which the priorities of the adolescent patient are prioritized.^11,12

The attention over the last decade to questions of LARC provision for adolescents may explain a recent increase in adolescent use (ever) of LARCs for pregnancy prevention from 5.8% in 2011–2015 to 19.2% in 2015–2019. ¹³ However, adolescents continue to use LARCs at much lower rates than other forms of contraception such as the condom (95.4%), withdrawal (64.8%), and the pill (52.0%). ¹³ There are likely several reasons for this more limited uptake of LARC by adolescents, and one may be that many pediatricians are not trained to provide LARCs and are therefore not able to offer them to their patients as a part of routine care. ¹⁴

A number of initiatives targeting adolescents have proved to be successful in expanding access to LARCs for teen populations. The Colorado Family Planning Initiative (CFPI) trained providers, financed LARC methods provision at Title X–funded clinics, and increased patient caseload. ¹⁵ This state-wide intervention in Colorado was associated with increased LARC placement for adolescents in primary care. ¹⁶ LARC delivery services were integrated into an academic pediatric primary care practice in Baltimore, likewise showing feasibility, acceptability, and increases in LARC access and placement for African American adolescents and young adults from families with lower incomes. ¹⁷ Research in three school-based health centers (SBHCs) in New York City and Seattle showed the need to communicate information with adolescents that directly addresses misconceptions about LARC, ¹⁸ while not overwhelming them with information at the same time. ¹⁹

Despite the successes of these initiatives, barriers persist in providing LARCs to adolescents on a larger scale. The failure of insurers to adhere to Affordable Care Act mandates and to offer access to LARCs in pediatric hospitals has impacted coverage for adolescents, ²⁰ which is critical with the high cost of these methods. Pediatric offices may have inadequate equipment and other infrastructure for on-site placement of LARC, as well as inconvenient clinic hours. ²¹ Studies routinely highlight low patient interest and limited staff motivation for LARC provision and referrals, both of which may be related to staff concerns about intrauterine device (IUD) use among teens.^21,22 Pediatric care providers also lack training about LARC provision. ²¹ Such perceived lack of provider procedural skills, and provider bias and negative attitudes about LARC methods, can clearly impede LARC provision for adolescents.^{18,23 –25} However, studies have linked provider training to increased access to LARC for adolescents.^17,26 One study found that, although pediatricians prefer familiar options (Depo Provera injections, birth control pills), education and increased familiarity with LARC changed their viewpoints on LARC. ²⁷ Research in SBHCs specifically found that provider training, alongside clear communication strategies and contraceptive counseling practice changes, facilitated integration of LARC services. ²⁸

In the early 2010s, Delaware had the highest rate of unintended pregnancy in the nation.^29,30 In 2014, then-Governor Jack Markell launched the Delaware Contraceptive Access Now (DelCAN) statewide initiative as part of a public-private partnership with Upstream USA. ³¹ The initiative’s goal was to reduce the rate of unintended pregnancies and increase access to family planning services for all women of reproductive ages, including adolescents. An important component of the DelCAN initiative was the preparation of primary care providers, including pediatric and family medicine providers, across the state to offer same-day access to all contraceptive methods, including LARC, at negligible or no cost to patients (“All Methods Free”). Toward this end, the program focused on (1) policy change and implementation at the state level; (2) a statewide public awareness campaign; and (3) statewide clinician and staff training. Health centers and medical practices that provided care for adolescents, such as pediatric and youth-friendly clinics, as well as Title X clinics and Planned Parenthood sites, received training and technical assistance from Upstream. Between 2016 and 2019, Upstream-trained healthcare providers and support staff on clinical, counseling, and administrative processes necessary to deliver comprehensive contraceptive services, including asking adolescents about their pregnancy intentions at every primary care visit and offering contraceptive counseling, insertion, removal, and management of LARC and provision of other contraceptive methods. After the first training, clinicians were required to complete preceptor-supervised LARC insertions, according to the device manufacturer’s training specifications. The full initiative has been described in greater detail elsewhere. ³²

The present study capitalizes on process-evaluation data collected as part of the larger evaluation of the DelCAN initiative. The purpose is to explore the perspectives of practice administrators and clinical providers in an effort to better understand the practice-level barriers and facilitators to providing comprehensive and patient-centered contraceptive care to adolescent patients across a variety of primary care settings. This study provides unique qualitative data that allow for a more nuanced description of practice-based procedures, facilitators, and challenges.

Methods

Study design

As part of a larger mixed-method process evaluation of DelCAN, we conducted qualitative interviews with 32 administrators from 26 healthcare settings across Delaware, who were designated as “champions” or leaders of the initiative at each site. ³³ This study included a subsample of 16 administrators in 13 sites that served significant numbers of adolescents. Most of the administrators were also clinical providers. Our goal was to understand the implementation experiences, successes, and barriers across different practice settings around providing contraceptive care, particularly LARC, for adolescents. We therefore created a purposive sample, including administrators from a variety of clinical settings including larger and smaller settings, in urban and rural communities, and across pediatric, women’s health, and school-based settings. Interviews were conducted until thematic saturation was reached.

Sample and recruitment

We utilized a purposive sampling strategy to recruit participants for the study. At each trained practice site, the eligible participant was the person the site identified as a leader who could speak about the implementation of the intervention. Our sample used the following inclusion criteria: (1) All participants were leaders (administrators or clinician administrators) at a DelCAN primary care site; (2) all participant sites provided reproductive health care for adolescent patients either exclusively or in large numbers; (3) all participants were 18 years old or older and provided written informed consent.

Respondents in this study had already opted into the program by participating in training and patient care related to the initiative. In order for us to carry out our evaluation activities, Upstream sent out an informational email, describing the study as a way of learning from their implementation experiences, and notifying potential respondents that we would contact them directly to participate in the study. They then provided our evaluation team with a list of contact information for site champions.

We recruited participants from June through December 2018, contacting them by email to ask permission for an interview. The goal was to develop a sample that captured variation by practice types, size, and location. In sum, all 26 practice sites that were contacted agreed to participate, and interviews were conducted with champions or other designated administrators in each of these practices, including 16 participants (10 in single interviews, and six in dyadic interviews). The 13 practices included in this subsample were distributed across the state and in urban, suburban, and rural communities. Just over half of the practices were general primary care health clinics (n = 4) or women’s health (ob-gyn) practices (n = 3) that served adolescents as part of their patient population, and the other half (n = 6) were exclusively pediatric, adolescent medicine, or school-based practices. All participants were women, and all worked in administrative roles at practices trained by Upstream for the DelCAN initiative. We stopped recruiting participants when we achieved a full range of variation in clinic settings and observed data saturation.

Data collection

The research team, which included an experienced family planning and adolescent health researcher (female, Associate Professor, PsyD), a qualitative methodologist (male, Professor, PhD), and a doctoral student with reproductive health and qualitative research training (female, doctoral student in maternal and child health), developed a semi-structured interview protocol based on a review of the literature on contraceptive care and contraceptive access interventions. The two faculty researchers adapted the protocol and conducted initial pilot interviews in-person with champions at their place of work.

Between June and December 2018, all three authors, that is, members of the research team, conducted interviews with participants. All interviews were conducted in English, by pairs of interviewers either in person (50%) or by phone. Interview length ranged from 45 to 90 min. Interviews were audio recorded, and participants were advised to not use individual or practice names during the interview. Identifying information was deleted for each interview. Audio files were transcribed verbatim and imported into the Dedoose qualitative software program for analyses.

Data analysis

Utilizing grounded theory techniques, ³⁴ we first utilized sensitizing concepts from existing literature on contraceptive access initiatives and then integrated emergent codes from four initial interviews to develop a codebook. We applied these codes to each of the 13 interviews in a wave of open coding. Each interview was coded by a pair of researchers and then brought to the full team, including the three data collectors and two additional public health doctoral students who were trained in qualitative methods, which allowed rigorous consideration of interpretations and resolution of divergent coder perspectives.

We then conducted axial coding by comparing and contrasting the perspectives of administrators, within and across sites, on specific codes related to experiences with adolescents. For example, we examined the range of perspectives on what was coded as “preceptorship,” which included challenges to finding supervision opportunities for providers to practice LARC insertion with qualified physicians to be credentialed in this clinical skill with adolescents. In the final wave of selective coding, we condensed the codes in order to develop a narrative of overall experiences and barriers to the provision of contraceptive care with adolescents.

Results

Practice administrators uniformly perceived that demand for contraception, particularly LARC, had increased among adolescents across the state following implementation of the DelCAN initiative. Most adolescents seeking LARC wanted one of these devices because they had heard about them from friends or family. This word of mouth spread particularly quickly in schools and among friend groups. Some described seeing an increase in young women who wanted an IUD or implant before heading to college, opting for these devices so that they would not have to worry about contraception during their college years. As one nurse manager stated, “We always hear, ‘my friend has this, this is something that I want . . . I want the thing in my arm.’ That’s what they started calling it” (Figure 1).

Figure 1.

Quotation from a nurse manager explaining how adolescents began referring to the subdermal implant.

In some cases, adolescents chose a LARC method following frustration or failure using another contraceptive method. One administrator described, “They think that they can handle the pill, but then they’ll come back in frustration, ‘Uh, I missed two or three . . .’ and then we’ll talk about, well there are other options still.” In other cases, parents sought out LARC for their daughters. As one administrator stated: “The parents, they get the ease, they’re the ones driving people around and picking up refills . . . and they are the ones worried about the teen pregnancy more than the teen.” The long-term effectiveness, the privacy, and the ability to not have to think about contraception once a LARC is inserted were all cited as reasons that adolescent patients, and sometimes their parents, were interested in LARC methods. One administrator described adolescents’ interest this way: “teenage girls, yeah, definitely the Nexplanon. They didn’t have to think about it, they didn’t have to have it anywhere . . . no one had to know. It was boom, go on.”

Administrators observed that many adolescents preferred implants over IUDs. They attributed this to teens’ fear of, or discomfort with, the pelvic exam needed for IUD insertion. As one stated, “they’re young and they don’t want nothing going up there except for something they think is fun.”

Despite the interest in LARC among their adolescent patients, administrators consistently described numerous barriers to providing LARC for adolescents (Figure 2). These included confidentiality in patient visits and billing, preceptorship, and provider discomfort and assumptions about the need for contraception among adolescent patients.

Figure 2.

Barriers to providing long-acting reversible contraception for adolescents.

Confidentiality

Multiple primary care administrators reported that their practice did not have a policy about talking with adolescents alone in an exam room without parents, and therefore, providers did not have the chance to ask adolescents about their pregnancy intentions and interest in contraception. As one participant stated, “If you can’t talk to teens alone, then you’re not going to be able to prescribe birth control for them.” This concern about protecting adolescents’ confidentiality was especially problematic when it came to billing third-party payors for LARC devices and the visits needed to insert them:

We were concerned about people that had third party insurance, how that information was going to show up on . . . the EOB [Explanation of Benefits] that the parents would see. So the child was coming and then the Blue Cross would bill, and then the parents are, “well, wait a minute, when did you have this visit?” . . . [so if] some of them had insurance, then we couldn’t bill, being afraid that this was going to show up and then we would have a confidentiality breach.

This issue of confidentiality in billing is one that some practices used to deal with by simply not billing for visits for contraceptive care for adolescents. This unofficial policy could work when such visits were infrequent but became problematic when more adolescents began seeking care, and particularly LARCs, which are expensive. One administrator at a pediatric practice reported that this issue has led to new discussions in her practice about billing policies and confidentiality. She stated:

Now we’re talking about care that might be a couple thousand dollars per patient that you would write off . . . . We need to bill for some of these visits instead of writing them off . . . . What do we mean by confidential? Does that mean billing? Does that mean the parent finding out about the visit? There’s different steps.

At the time of our interviews, the DelCAN initiative was providing funding for LARC devices, but many administrators expressed concern about billing once that funding stream ended.

Preceptorship

Administrators uniformly reported that their providers enjoyed the training provided by Upstream, learned a great deal about contraceptive care, and left inspired to provide more comprehensive care to their adolescent patients. However, the didactic training session was not enough preparation to begin providing LARCs. Precepting is the process by which, after being trained to insert LARCs, clinicians perform several insertions under supervision in order to become credentialed to insert the devices on their own. Many administrators, particularly those at pediatric and general family practice sites, reported that having their clinicians go through this process was particularly challenging and time-consuming. In order to make efficient use of a precepting clinician’s time, a site needed to schedule multiple patients receiving LARC all in a block of several hours. For sites that had a low volume of patients seeking LARC, it was hard to consolidate them in this way, and this was made more complicated when patients would cancel or not show for their appointment. An administrator in a multisite primary care practice described this challenge at her site:

Precepting has been our largest challenge . . . . The only person available to sign people off has been Dr. X, and she has patients. So it’s very difficult to get her . . . . We’ve tried to do blocks here and have our primary care physicians come to her when she would have patients, so they would do the placement, she would credential them. But that did not work because basically we’d have somebody come and then the patients would cancel, and they would’ve spent half their day here with no patients or we’d have them sign up for a block and we couldn’t get patients to come for that block.

Others noted that adolescents are more likely to not show up for appointments and this would leave busy precepting clinicians with nothing to do. This very common challenge also created a significant lag time between when providers were trained to insert LARC and when they were actually able to offer this service to patients.

Provider discomfort

Administrators perceived, through staff discussions and provider behavior, that some providers, particularly pediatricians, were not comfortable with various aspects of providing contraceptive care to adolescents, including initiating conversations about sexuality and reproductive health. Furthermore, they reported that many providers on their staff lacked the training to provide contraceptive counseling and the technical skills to insert LARCs. While the training by Upstream offered providers the technical skills, administrators noted that providers were less likely to make use of these skills in a context of not feeling comfortable and/or being capable of providing contraceptive care more generally. One administrator in a pediatric setting described these challenges:

Our primary care physicians don’t get a lot of training on adolescent health and reproductive health in school and residency . . . . Also, pediatrics has kind of gotten away from a focus on adolescent care and a lot of pediatricians got into the field because they care about babies and less so adolescents . . . . We’ve definitely had a number of people generally feeling uncomfortable, unprepared for these discussions and feeling that the technical assistance and training helped them to be prepared to have the discussions. Also that the nature of the discussion made them generally uncomfortable because they’re just not used to talking about sex with teenagers.

Other administrators at pediatric practices described the lack of equipment, including gynecological exam tables, made it more challenging for pediatricians to provide IUDs specifically. For this reason, coupled with pediatricians’ lack of training and experience with pelvic exams, many pediatricians opted to provide implants but not IUDs for adolescent patients. Others in pediatric and family practice sites described discomfort with displaying reading materials about sex and contraception, out of concern that it would be inappropriate, or parents would find it inappropriate, for such materials to be seen by younger patients.

Providers’ discomfort with discussing sex and contraception with adolescents was, in some cases, compounded by assumptions made about which teens were having heterosexual sexual intercourse (Figure 3). Multiple administrators noted that the likelihood of a provider talking with a teen about contraception was determined by the provider’s assumptions about whether the teen was sexually active. Some described the need for contraception, and therefore the need for discussions about sex and contraception, as greater among urban rather than suburban teens. One described her practice this way: “So it’s not a suburban practice where it’s not talked about. It’s an urban practice, and our doctors want to see these kids grow up healthy, so they’re talking about it early.” Another observed, “I would say the more suburban and rural you are, the less likely you talk to your patients about it because your patients don’t do anything bad. But the urban and inner city practices do it.” One administrator also raised the issue of some providers having personal opinions about teens having sex and linked this to providers’ assumptions that “the type of teens in their care don’t have sex . . . like quote unquote we don’t have those kinds of patients.” Administrators generally deferred to provider preferences around care, but some described gently trying to bring more reluctant providers around to providing contraceptive care, particularly LARCs, to all adolescent patients.

Figure 3.

Clinic administrator reflection about biases regarding adolescents’ sexual activity.

Discussion

To our knowledge, this is the only study to use qualitative methods to explore practice-level barriers to adolescent contraceptive care. Because all providers in the practices from this sample were trained in contraceptive counseling and LARC insertions, this study in effect examined contraceptive care for adolescents when provider training was removed as a barrier. Our findings reveal that several substantial barriers to care still remain. Several of the administrators in our sample reported that they did not anticipate the extent of these challenges prior to their efforts to implement DelCAN. It is important to note that these barriers existed even in practices that were committed to the goal of providing comprehensive contraceptive access to their adolescent patients. They observed an increased demand for LARC in particular among their adolescent patients, and were actively working within their practices to find solutions. Specifically, barriers around confidentiality in person and through billing, preceptorship and credentialing of providers, and adjusting provider practices and comfort around discussing sex with teens limited practices’ capacity to implement this contraceptive access initiative as intended. Although this study also sought to identify facilitators of contraceptive care for adolescents, these were not offered in the interviews beyond appreciation of the training and support provided through the DelCAN initiative.

Provider values and biases about sexual behaviors among different groups of adolescents emerged organically in the interviews, without a direct prompt from the interviewers. While none of the providers and administrators explicitly discussed racial biases, or race-based assumptions about teen sexual behavior, many emphasized the differences between urban and suburban patients, that is, urban teens start having sex early, while suburban teens “don’t do anything bad.” It should be noted that in Delaware, the Black population is primarily located in the urban areas, while the suburbs are largely white. Such assumptions are consistent with previous research, including one study which found that, among poor adult women, providers were more likely to recommend IUDs to women of color than to white women. ³⁵ A qualitative study with young women found that they perceived providers as being more likely to promote LARCs and more reluctant to remove them with patients who were not racialized as white. ³⁶ Another qualitative study, conducted with providers in Delaware, also documented the more subtle forms of racial and socioeconomic biases held by contraceptive providers. ³⁷

This type of stereotyping, and the potential differences in practice that stem from it, may negatively affect both populations: indiscriminately encouraging adolescents of color to initiate contraception, while hindering white teens’ access to that same contraception. These provider biases are extensions of U.S. history of reproductive coercion based on race and serve as additional evidence of the urgency to use the reproductive justice framework when providing contraceptive care.

Providers and administrators were very cognizant of protecting adolescents’ confidentiality during patient visits and through billing, which hindered their ability to assess the need for, offer, and provide contraceptive care at every visit, as originally designed by the initiative. However, emerging evidence from a conservative state suggests that the vast majority of parents or guardians may subscribe to confidential portions of healthcare encounters for their children once the benefits of such visits are explained.^38,39 These studies, along with professional guidelines about best practices, ⁸ indicate that, while adolescent sexuality remains a fraught topic, providers’ anxieties about confidentiality in regards to their teenage patients are likely misplaced. Better communication between parents and providers may allow for the appropriate provision of high-quality care that includes sexual and reproductive health care for all adolescents.

This study had some important limitations. The data were collected from a single state, one in which access to contraceptive care for all people was an explicit policy priority. Additional barriers would likely be experienced in other communities without the policy, programmatic, and training support for providing contraception to adolescents. The data were also collected from respondents who were identified as champions of the initiative, and therefore had some investment in its success. This study did not collect data from nonadministrative providers, adolescent patients, or parents. Instead, we sought to understand barriers to providing contraceptive care, particularly LARCs, from the perspective of a primary care practice. Most of the administrators were also current or former providers, and all the practices were small enough that administrators were in frequent conversation with providers about their practices, so while additional research from the perspective solely of providers might offer some additional insights, the data collected here do provide practice-level information about provider practices.

Conclusion

Our findings speak to a need to move from technical training to culture change in order to more widely and comprehensively provide contraceptive care to adolescents in primary care settings. We are not alone in calling for contraceptive care to be integrated into training of pediatricians at every stage of their education.^22,40 However, our findings demonstrate that such training must go beyond education about contraceptive options and the clinical skills necessary for LARC insertion and removal, to include adolescent-friendly counseling skills that openly approach questions of pregnancy intention and sexual activity and respect adolescents’ autonomy, treating them as fully capable of educated decision-making around contraceptive care. Such training must also include an open examination and discussion of implicit biases about adolescent sexuality, particularly related to race and socioeconomic status, as providers seem to be making assumptions about adolescents’ sexual behaviors based on these characteristics. A culture change is also called for at the practice level in pediatric, family medicine, and other primary care practices through changes such as policies around providers meeting with all adolescents privately, having the necessary equipment and expertise on staff to conduct LARC insertions and removals, and supervising other clinicians in doing so. Having the capacity to offer same-day LARC insertions for adolescents, along with all other methods, may also increase access to the full range of available contraceptive options.

In sum, findings from this study offer important insights into how, in practical terms, adolescent health care providers can realize best practices in adolescent contraceptive care set forth by the American Academy of Pediatrics. The use of qualitative data adds a level of rich description not available through survey and other quantitative methods. Future qualitative research should explore questions about optimal contraceptive care for adolescents by adding the perspectives of adolescents themselves as well as parents and providers. Research on addressing barriers to the full spectrum of reproductive health care for adolescents must also be conducted in states that are not explicitly working to increase access to contraception. The need to answer such questions has only become more urgent following the Supreme Court Dobbs decision ensuing state laws which limit access to abortion care for all patients, including adolescents.