Many states still teach abstinence in sex ed, but new data is compelling: free contraception and medically accurate information works

Doctors in St Louis have found a bold new way to reduce teen pregnancies: giving them medically accurate information and free contraception.

At a time when many states still teach abstinence-focused sex ed, the concept may seem radical. But, as the doctors report today in the New England Journal of the Medicine, providing wider-ranging options and eliminating costs led to fewer teen births and fewer abortions.

The driving force behind the heartening results was teens’ increased adoption of “long-acting, reversible contraceptives” (LARCs) – that is, intrauterine devices and hormonal implants.

Dr Gina Secura, lead author on the study and director of the Contraceptive Choice Project, called the 72% adoption rate of LARCs among study participants “compelling”. The national rate among women of the same age is close to 5%.

Because LARCs have much lower failure rates than the pill, condoms, or other reversible methods, teens in the Contraceptive Choice Project study had one-third fewer births than the national average – 19.4 and 29.4 per thousand women, respectively.

The full national rate includes both sexually experienced teens and those who have never had sex before, but nearly all the Choice Project participants were sexually active. So Dr Secura’s team compared their results to just the sexually experienced teen population, too. When they did, the gap between outcomes was even more impressive:



The findings build on previous work from the Contraceptive Choice Project, a four-year study that followed the contraceptive choices of thousands of St Louis–area women. The latest instalment focused specifically on those between the ages of 15 and 19, and included 1,404 participants.

The Choice Project study comes on the heels of new American Academy of Pediatrics guidelines, also published this week, that, for the first time, recommend LARCs be considered a “first-line” birth control option for adolescent patients. (The American Congress of Obstetricians and Gynecologists made similar recommendations in 2009.)

Bigger picture

America’s teen pregnancy rate has fallen significantly over the past 20 years, hitting the lowest level on record in 2012. Even so, more US teens get pregnant every year than in any other industrialised county. At least part of the problem can be attributed to poor contraceptive use. That’s why many experts are now looking to LARCs for help.

When doctors and educators talk about “long-acting, reversible contraceptives,” they are typically referring to two types of birth control: the small, T-shaped device known as the IUD; and the matchstick-sized hormonal implant. IUDs are inserted directly into the uterus by a gynecologist, and can last up to five or 10 years, depending on the type. Implants, which last up to three years, are typically inserted into the upper arm.

IUDs and implants often carry high upfront costs and are not always covered by insurance, which can make them prohibitively expensive for many women – especially teenagers.

Yet, these methods seem especially well-suited to teenage lifestyles.

LARCs’ big advantage is their “set and forget” nature, said Lawrence Finer, director of domestic research for the Guttmacher Institute.

“It’s easier to use them consistently than methods that require some action every day or every time one has sex, like the pill or condom,” Finer wrote in an email to the Guardian.

Teens are also less likely to discontinue LARCs than other forms of contraception and, despite high upfront costs, they are cheaper in the long run, added Dr Jennifer Unger, assistant professor in the Department of Obstetrics & Gynecology at the University of Washington. “When you really look at the whole package, it makes sense,” she said.

Despite such advantages, only 4.8% of teens reported using LARCs in 2009.

The much higher rate of LARC usage (72%) among Choice Project participants was attributed to teen-targeted, comprehensive contraception education by the study’s author, Dr Secura.



“Traditional counselling may start by asking the patient ‘What have you used in the past?’ ‘What are you interested in?’ or ‘Are you on the pill?’,” Secura said. “We started by talking about the most effective methods, down to the least effective.”

“We briefly talked about every single method in terms of effectiveness, and rounded it out at the end with a conversation about condoms because none of the [other] methods protect against STIs,” she said. The whole spiel took about 12 minutes on average.

Once teenagers made their choice, contraceptives were available on the spot.

The University of Washington’s Dr Unger called the Choice Project a “fantastic model to look up to”.

There is still, however, significant political resistance to long-acting contraception for teens. “Changing clinical practice takes time. When it’s something as politically and morally charged as talking about sex – especially sex and teens – it gets that much more complicated,” she said.