Why Don't More Minnesota Teens Use IUDs?

Over the past three or four years, the medical community has reached a consensus about the best method for sexually active teenage girls to avoid unplanned pregnancies.

Long-acting birth control devices -- IUDs and under-the-skin implants -- function for years without requiring any effort by women. Their effectivity rate, more than 99 percent, is surpassed only by sterility and celibacy. Teens who've used the devices prefer them to other contraceptives. And while the price of a single device is upwards of $800, their long-term cost is among the lowest of any birth control method.

In Minnesota, many sexual health educators and clinical staff have begun emphasizing long-acting birth control methods over other forms of contraception. The safe-sex talk at the 17 clinics partnering with Hennepin County's "Better Together Hennepin" now begins with long-acting birth control -- the new phenom -- and ends with the old news about condoms and the pill.

"In the past, we would talk about the most popular methods first," said Katherine Meerse, Better Together Hennepin's program manager. "Now we start with the most effective method, which is LARCs [long-acting reversible contraceptives]."

But even though LARCs have more than tripled in popularity nationally since 2002, health care professionals say many sexually active Minnesota teen girls have never heard of IUDs and implants -- and they won't necessarily learn more by talking with their doctors.

Most teens in the state get contraceptive advice from their pediatric or primary care physicians, who frequently have significant misperceptions about long-term birth control.

"A lot of well-intentioned, highly skilled family practice doctors may not have enough capacity or time to read the latest articles about how long-acting birth control is appropriate for teens," said Alissa Light, the executive director of Family Tree Clinic. "There is definitely a misconception, even still, that it should be reserved for people who have had kids before, but they are powerful for teens."

Things are worse in rural Minnesota, where teens are much less likely to get up-to-date reproductive care.

"In the Twin Cities, we have a large number of adolescent-specific clinics that provide access to birth control," said Judith Kahn, the executive director of Teenwise Minnesota. "In rural communities, very few."

The Decline In Teen Pregnancy

Teen pregnancy is now at an all-time low nationwide, with birth rates declining steadily since 1990, and the explanations as to why go beyond innovative sex education and the long-acting birth control boom.

Speculations on causes of the birth rate downturn run the gamut from the practical to the fantastical and include the popularity of the MTV show "16 and Pregnant," the easy Googleability of sex questions, a recession-inspired drop in teen libidos and a theory that correlates falling teen pregnancy rates with declining lead exposure.

But while increased sex education and greater IUD use don't appear to be fully responsible for the drops in teen birth rates, health professionals say they are the best bet to maintain the downward trajectory.

The incentives to do so are enormous.

More than 80 percent of adolescent pregnancies are unintentional, and beyond the vast personal costs, unplanned motherhood incurs a major public expense.

Hennepin County looked at 1,384 teen parents on the caseload of its Minnesota Family Investment Program in December 2008. The county's report calculated the total cost to the state, just for those 1,384 parents and their families, as adding up to more than $220 million.

The good news is that money spent on reducing teen pregnancy is a near unbeatable investment.

A study by the Guttmacher Institute has estimated that for every $1 invested in helping women avoid unplanned pregnancies, the Medicaid program saves $5.68 in related health expenses.

In Hennepin County, a $7.5 million sex education program helped cut the teen pregnancy rate by 50 percent over a five-year period.

A Colorado program received national headlines for a program that gave free long-acting birth control to low-income teens and led to a 40 percent drop in the birth rate over four years.

Developments And Drawbacks

Long-acting birth control methods have seen dramatic technological improvements in recent years. Merck's single-rod subdermal implant, introduced in 2006, is injected easily into the upper arm and has a failure rate of less than one tenth of one percent, while a new generation of hormonal IUDs, are smaller and more suitable for adolescents.

"The IUD we're talking about now is not your mother's IUD," Meerse said.

The American Academy of Pediatrics said last year that talking to patients about LARCs should be "among the highest priorities during clinical visits." And the American College of Obstetricians and Gynecologists has called them "top-tier contraceptives."

The mistakes that led to the disastrous rollout of the Dalkon Shield have been resolved, but long-acting birth control still has a number of side effects and other drawbacks.

IUDs are often accompanied by irregular bleeding, and implants placed too deeply below the skin require protracted "digging" to remove, said Dr. Helen Thomas, a resident at the University of Minnesota's family medicine department.

Academic literature is still somewhat thin, but women using LARCs may be less likely to use condoms than women taking oral contraceptives and thus more at risk for sexual infection.

"Once pregnancy is no longer part of the conversation, then what are you talking about when you suggest your partner use a condom?" Kahn said.

But sex educators say the deficiencies of long-acting birth control are minor when compared with the benefits and suggest they can be offset by better education.

"Teens who get LARCs from Family Tree receive a lot of information around sexually transmitted infections and condoms," Light said. "If anything, there's an increase in condom usage and a decrease in STDs for teens on LARCs here."

A 'Patchwork' System

The percentage of Minnesota teen girls on contraception who use long-acting birth control is somewhere between 5 percent and 9 percent, according to Health Department data. Nationally, about 4.5 percent of 15- to 19-year-old teens use LARCs.

What's frustrating about these relatively low figures is that many of the pieces are in place for wider use.

Sexual health clinics and state-sponsored programs have prioritized long-acting birth control and can usually use private grants or public funds to eliminate teens' out-of-pocket expenses.

Since 2006, Minnesota teens age 15 and older have been eligible for completely free, completely confidential long-acting birth control through the state's Family Planning Program. (The program is technically only for low-income women, but since parents' income is not considered in the application, just about every teenager can qualify.)

Yet Minnesota sex education professionals say the system remains confusing for teenagers, and many doctors are either unable or unwilling to help teens navigate their reproductive options and the convoluted paperwork involved.

Light described the network of contraceptive services available to teens as a "patchwork" rife with "over-complexity" that's "damn-near impossible for teens to maneuver."

"It's complicated to even get an appointment and get into a clinic," she said. "And then, depending on where a teen goes, they may enter a clinic that is really savvy with all the assistance programs and able to get them coverage, or they may enter a clinic without that level of savviness. And then layer on top of that how it is complicated for a teen to know if they have health insurance. Plus, there's bias within the healthcare system about who it's appropriate to give a LARC to. There's a perfect storm of barriers in so many ways."

The patchwork system, she said, means some groups have better access to long-acting birth control than others.

If you live in a rural area, if you're under 15, if you're an undocumented immigrant or if you're on your parents' insurance, then it may be more difficult to find a doctor specializing in teen health, to get a free IUD or to keep your medical care confidential.

"There aren't a lot of clinics that an adolescent who doesn't want to tell their parent can get to physically, or keep a sense of privacy," said Kahn, the executive director of Teenwise. "A lot of teens just don't know where to go."

What's needed, experts say, is more education and an easier path to access.

"Grants are amazing," Light said. "So are other simplified statewide initiatives to cut through all that red tape and say, 'We want to cover this for everybody.'"

By Zac Farber