AMERICA’S teenage-pregnancy rate is seven times higher than Switzerland’s (see chart 1). About 50 in 1,000 American women aged 15-19 get pregnant each year, of whom 60% give birth. Teenage pregnancy has been falling in all states, as more young people use contraception. But only 7% of those use the most effective methods, which include hormonal implants (tiny rods inserted under the skin) and intrauterine devices (IUDs), according to data from publicly funded clinics in 2013 published by the Centres for Disease Control on April 10th. In many other countries, these long-acting contraceptives are far more popular (see chart 2)—though this is partly because older Americans are more likely to have themselves sterilised.

Four in ten unplanned pregnancies in America result from the slapdash use of contraception. Many of these could be averted by IUDs. Their failure rate is 0.2%, compared with 9% for the pill and 18% for condoms, the two most popular methods among teenagers. They work better because once they are inserted, you don’t have to think about them again. This means they are less fiddly than the pill, which a woman must remember to take every day, or the condom, which a man must put on when aroused and perhaps not thinking straight.

Implants and IUDs “change the default”, argues Isabel Sawhill in “Generation Unbound”. A woman who uses one is “virtually infertile until such time as she explicitly [chooses] to become a mother”. By contrast many women today, especially in poor families, drift into motherhood. In one survey 44% of young American women agreed that “It doesn’t matter whether you use birth control or not; when it is your time to get pregnant it will happen.”

Long-acting contraceptives cost more to begin with: $800-1,000 apiece. But they work out cheaper over time, since they last for three to ten years. They are covered by Medicaid, the public health scheme for the cash-strapped, but in some states the rules make it tricky for providers to get reimbursed. Since 2013 Obamacare has required private insurers to cover all FDA-approved contraceptives, with exemptions for old policies that have been grandfathered into the new system.

The main obstacle is not cost but knowledge. A survey last year by the National Campaign to Prevent Teen and Unplanned Pregnancy found that 77% of Americans aged 18-45 knew “little or nothing” about implants; 68% said the same about IUDs (one in four do not know where the IUD goes). Misperceptions about safety and efficacy are common, too. Teenagers rarely ask for coils or implants.

Even medical providers are often unaware of guidelines that recommend IUDs and implants as the “first-line” methods for teenagers—meaning that providers should mention them first, before the less effective options. In 2011 a survey found that, in nearly half of publicly funded clinics that provide contraceptives, staff worried that IUDs might not be suitable for teenagers.

Some of the mistrust has stemmed from the debacle of the Dalkon Shield, a flawed IUD that caused some infections. It was pulled from the market in the 1970s and its maker was bankrupted by hundreds of thousands of lawsuits. The bad rap that created for the IUD lingered, even as devices became very safe.

Both manufacturers and doctors are terrified of lawsuits in America. Contraceptives are especially likely to provoke them, since they are given to healthy people who, if they later fall ill, may call a lawyer. (This is also why obstetricians pay such sky-high malpractice-insurance rates—as much as $200,000 per doctor, per year in some parts of America.) Wary manufacturers of IUDs have been slow to push into the American market. But that is changing: there is now more advertising, new IUD brands are coming onto the market, and IUDs are becoming more popular.

Many providers are not trained to insert IUDs and implants. This is especially the case among paediatricians, the doctors whom many teenagers approach first, and primary-care providers, who look after women in public clinics.

Some states are promoting IUDs more vigorously than others. In Colorado in 2009 a private foundation started paying both for IUDs and implants in public clinics and for training the staff who provide them. Within two years teenage births fell by 26% and abortions by 34% (both were down in other age groups, too). Teenage births were six times more common among the poor when the programme began, so this led to a reduction of the number of young mothers claiming benefits for unplanned babies. The state saved over $6 for each dollar spent on the programme—excluding the gains to women who finished high school instead of dropping out to care for a child. The state Senate is now mulling a bill to extend the programme. Similar ones in Iowa and Missouri have also shown good results.

Helping teenagers who give birth once to avoid doing it again soon can pay off, too. In another Colorado programme, less than 3% of youngsters who opted for a free implant shortly after giving birth got pregnant again within a year (all of these had had the implant removed), compared with 20% of those who did not. After two years, the figures were 8% and 47%.