Adolescent Contraception What are the best choices?

Pregnancy in Adolescents Adolescent women aged 10-19 years account for: 11% of births worldwide 23% of overall burden of disease related to pregnancy and childbirth Risk of maternal death is 4 times higher among adolescents <16 years old compared to women in their 20s Up to 65% of women with obstetric fistula develop this problem as adolescents WHO Adolescent Pregnancy Fact Sheet, 2008.

Pregnancy in Adolescents Stillbirth Infant death in first week of life Infant death in first month of life Preterm birth Low birth weight Infant asphyxia More common among adolescent mothers WHO Adolescent Pregnancy Fact Sheet, 2008.

Rights-focused approach Recommend eliminating financial barriers to contraceptive use Recommend interventions to improve access to comprehensive contraceptive information and services for users and potential users with difficulties in accessing services (e.g., adolescents). Recommend provision of sexual and reproductive health services, including contraceptive information and services, for adolescents without mandatory parental and guardian authorization/notification. Unmet need high in vulnerable populations Adolescents are a vulnerable population WHO, Ensuring Human Rights in the provision of contraceptive information and services Guidance and recommendations, 2014

WHO Guidance In general, adolescents are eligible to use any method of contraception and must have access to a variety of contraceptive choices. Age alone does not constitute a medical reason for denying any method to adolescents. While some concerns have been expressed regarding the use of certain contraceptive methods in adolescents these concerns must be balanced against the advantages of avoiding pregnancy. WHO MEC 2009

WHO Guidance Consider: Counseling is very important Social and behavioral context (example: STI risk) Daily regimens more challenging than for adults Lower tolerance for side effects (= discontinuation) Sporadic patterns of sexual intercourse Need to conceal (married vs. unmarried) Counseling is very important

With Limited Clinical Judgement Category With Clinical Judgement With Limited Clinical Judgement 1 Use method for any circumstance Yes (use the method) 2 Generally use the method 3 Not recommended unless no other method available No (do not use) 4 Do not use Now, like I said before the WHO does not want to make these hard and fast rules but when clinical judgement is limited – the categories can be simplified into rules and into yes/no categories. Initiation (i) Continuation (c) 7

WHO MEC Recommendations Contraceptive Method MEC Category Combined hormonal methods 1 Injectable 2 (1) Progestin-only pill Implant IUD 2 Barrier Emergency Contraceptive Pills OK Injectable 2 is for menarche to <18 years

Safety Concerns – Bone Density DMPA has been associated with decreased bone mineral density (BMD) in adolescent users, but BMD returns to baseline within 12 months of stopping DMPA What about fracture risk? WHO There should be no restriction on the use of DMPA, including no restriction on duration of use, among women aged 18-45 years who are otherwise eligible to use the method Recommendations regarding DMPA use also pertain to the use of NET-EN WHO statement on hormonal contraception and bone health. Contraception 2006;73:443-444.

Other Considerations Weight gain in adolescents using DMPA? Obese adolescents may be more likely to gain weight Obese adolescents: DMPA is Category 2 NET-EN is Category 1 Use of combined methods in obese adolescents? Inconsistent reports of weight gain Inconsistent evidence of decreased efficacy Category 2

Other Considerations: IUD Condition MEC Category Nulliparity 2 Current PID 4 (I) 2 (C) Current purulent cervicitis, chlamydial infection, gonorrhoea Other STIs / Vaginitis Increased risk of STI 2/3 High risk of HIV Well-conducted studies show no increased risk of infertility in nullips Clarification: If a woman has a very high individual likelihood of exposure to gonorrhoea or chlamydial infection, the condition is Category 3. Evidence: Using an algorithm to classify STI risk status among IUD users, one study reported that 11% of high-STI-risk women experienced IUD-related complications compared with 5% of those not classified as high risk.(99)

Adolescents and IUDs Similar continuation rates 87% vs. 89% in large study (12 months) 2-3% discontinued due to adverse event Similar (LOW) complication rates Pregnancy risk? IUD type may matter ACOG supports LARC use! Study of claims data from 90,000 women with IUD. Increase in IUD use across all age groups 2002-09. Adolescents had increased odds of PP insertion compared to older women , and most adolscent iud inserted by OBGYN. Complaints of dysmenorrhea/irreg bldg more common in age 15-19, otherwise similar for most across age groups, and discontinuations similar after complications. (2-3% for LNg and 4-5% for copper). Overall discontinuation 11 vs 13%. Iud type may be more important than age – copper IUD more discontinuation & more some complications. Higher pregnancy rates in adolescents - 2-3% vs.1-2% . Berenson, et al, 2012; ACOG 2011

CHOICE project Who: 10,000 women age 14-45 who want to avoid pregnancy for at least 1 year What: Provision of no-cost contraception for 3 years When: 2007-2011 Why: to increase LARC awareness and utilization LARC = Long-acting Reversible Contraception (IUDs and implants)

CHOICE Findings: Adolescents 62% (658/1054) chose LARC method Factors that influenced choice of LARC: Prior unintended pregnancy Financial resources Not race or education level Mean age: 18.4y Mean age at 1st pregnancy: 17y Mestad, et al, Contraception 2011

1-year Contraceptive Continuation Rates Rosenstock, et al, OBG 2012

Continuation over 24 months 77% overall 41% overall Twenty-Four-Month Continuation of Reversible Contraception. ONeil-Callahan, Micaela; Peipert, Jeffrey; MD, PhD; Zhao, Qiuhong; Madden, Tessa; MD, MPH; Secura, Gina; PhD, MPH Obstetrics & Gynecology. 122(5):1083-1091, November 2013. DOI: 10.1097/AOG.0b013e3182a91f45 © 2013 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins, Inc.

Contraceptive Continuation Adolescent women are more likely than older women to discontinue a method while still in need More obstacles to consistent use Less likely to tolerate side effects Barriers to adolescents: Insufficient knowledge of modern methods Limited access to services Discouragement from health care providers Blanc AK et al. Int Perspectives on Sexual and Reproductive Health, 2009;35(2):63-71 Bearinger LH et al. Lancet, April 2007;369:1220-1231

Adolescents’ satisfaction with LARC Methods a prior analysis, CHOICE participants 14–19 years were more likely to discontinue non-LARC methods at 12 months compared with women aged 26 years and older and were less likely to be satisfied with non-LARC methods than women older than 25 years of age.7 In that same analysis, satisfaction rates for LARC methods among those aged 14–19 years were similar to those among women older than 25 years. IUD (N= 2,324) Implant (N=522) Rosenstock, et al, 2012 18

Adolescents’ Satisfaction with Contraceptive Methods Rosenstock, et al, 2012

Adolescents’ Satisfaction with Contraceptive Methods Rosenstock, et al, 2012

Contraceptive Failure: LARC vs. the rest LARC is 20 TIMES MORE EFFECTIVE than shorter acting methods at preventing pregnancy Cumulative % of women with contraceptive failure Winner B, et al, NEJM 2012 21

What about pregnancy rates? Births per 1,000 teens, ages 15-19 Peipert, et al., OBG 2012 22

Conclusions