By Tina Rosenberg, The New York Times
Some people worried that these shows would normalize teenage pregnancy. Instead, the shows reveal how grueling it truly is — the sleep deprivation, the losing struggle to complete high school, constant unromantic bickering with a boy who’s a kid and a father, the pull from friends who can still party with impunity.
These shows don’t persuade girls to abandon birth control. They are birth control. As one tweeter said:
Today, America’s birthrate for teenage mothers has hit a historic low — less than 40 percent of what it was at its modern peak in 1991, when it was 61.8 births per 1,000 girls 15 to 19 years old. In 2014, the rate was 24.2 per 1,000. (In the 1950s, when more women married in their teens, the rate was even higher than the 1991 figure.)
This is excellent news. Girls who get pregnant are less likely to finish their education, and their babies are at high risk for health problems, incarceration, academic troubles and, yes, teenage pregnancy — even after controlling for other factors.
No one really knows why these birthrates have dropped. It’s not because teenagers are having more abortions; those have dropped even more precipitously than births. The most important reason appears to be increased contraceptive use, perhaps as a result of comprehensive sex education and fear of H.I.V.
Still, however, the United States has a far higher rate of teenage pregnancies than most developed countries. Three-quarters of these pregnancies are unplanned, and 30 percent end in abortion, according to the Guttmacher Institute, a research organization committed to advancing reproductive rights.
Over the past seven years, that state has cut the rate of babies born to girls ages 15 to 19 by nearly half. The teenage abortion rate is down by the same amount. Repeat teenage births have dropped by 58 percent. Colorado has accomplished this with no increase in teenage sexual activity or in sexually transmitted infections. And the state has saved tens or perhaps hundreds of millions of dollars.
A main reason for Colorado’s success is a program to make long-acting reversible contraceptives (known as LARCs), such as hormonal implants or intrauterine devices, available cost-free to women and girls who want them.
These protect from unwanted pregnancy for years — in the case of some IUDs, 10 years. Because these methods are “set and forget,” they are the most reliable forms of birth control. Each year 1 percent of women on LARCs get pregnant, compared with 9 percent of women on oral contraceptives and 18 percent of those who rely on condoms.
When Colorado started the LARC program, only 2.5 percent of teenagers who came for family planning in clinics for low-income or uninsured people received LARCs. Last year that figure was 28.9 percent.
The push for LARCs came from the Susan Thompson Buffett Foundation, which offered Colorado a donation of $25 million to pay for a five-year program. Colorado accepted. When five years was up in 2015, Republicans in the State Legislature killed a bill that would have provided public funding for the program to continue. A coalition of private funders chipped in to keep it going at a low level.
Now, the program is again on solid ground, because the legislature reversed itself this year. Colorado now spends at a rate only half of what the Buffett Foundation did, but it’s enough, because Obamacare insurers and an expanded Medicaid program now pay for much of it. (These programs are supposed to cover birth control completely, but some women and components of the program, such as training for health care workers, aren’t covered.)
Since Medicaid would have paid for a vast majority of the unwanted births, reducing them provides immediate savings in tax revenues. Much larger are the long-term savings produced by a better life for both mother and child. One immediate benefit is that fewer children are born into poverty: Colorado has experienced a 25 percent drop in enrollment in the government’s nutrition program for low-income women and children.
The successes of the LARC program, now seven years old, have been widely reported. The American Congress of Obstetricians and Gynecologists recommends LARCs strongly, even for never-pregnant adolescents. The American Academy of Pediatrics calls them the “first-line contraceptive choice” for teenagers who don’t choose abstinence. Yet other states are getting off to a slow start in replicating the program.
The Association of State and Territorial Health Officials is trying to speed the process. The organization runs a working group that brings together officials from states seeking to provide LARCs to women who have just given birth. In 2014 the working group included officials from six states, and last year seven more states joined.
The challenges illustrate how difficult it is to spread new medical practices. Larry Wolk, executive director and chief medical officer of the Colorado Department of Public Health and Environment, has on occasion worn an IUD as a pin, so he can show people how small and light it is. Lots of people remember the Dalkon Shield of the 1970s and the injury and infertility it caused. The new IUDs are different. “This isn’t your mother’s IUD,” Wolk likes to say.
But just because something is safe doesn’t mean people know it’s safe. “We’re seeing there’s a lot of education needed,” said Lisa Waddell, the community health and prevention chief program officer at the health officials’ association. Many young women haven’t heard of LARCs, and some who have believe they are not reversible (they are, usually instantly), or are painful to use (insertion of an IUD is painful, but it can’t be felt afterward). Waddell says the best remedy is word of mouth from women who are happy with their birth control.
Health workers must use care when talking about LARCs, as with other forms of birth control. America has a sorry history of coercing young minority women into sterilization or birth control. Some state legislators have talked about making birth control a requirement for welfare, for example. That comes from a thoughtful article in The Nation by Dani McClain; it discusses why past coercion has made some women wary of LARCs, and the importance of information without pressure.
Any explanation, of course, requires a visit, and this can be a challenge. “The biggest barrier is access to care,” said Amy Crockett, a maternal-fetal medicine specialist at the Greenville Health System in South Carolina and clinical lead for the Birth Outcomes Initiative, a state government program. She said that LARCs could sometimes be a two-appointment procedure. “With a prescription for birth control pills, patients can go out and fill it. With a LARC, if we don’t have one in the office that day, the patient has to come back.”
This is one reason many states focus on women who have just given birth — it can be the only time women see a health care provider when they aren’t pregnant. (On the other hand, it’s by definition too late.)
But while many state governments wanted hospitals to insert LARCs, state Medicaid systems initially discouraged the procedure with their disbursement system. Hospitals were paid a bundled amount for a birth. They weren’t about to insert an $800 IUD if Medicaid wasn’t going to pay them extra.
In 2012, South Carolina became the first state to have its Medicaid reimburse for LARCs in a separate payment. Blue Cross and Blue Shield, the dominant insurer, quickly followed. Now many states’ Medicaid programs pay for LARCs this way.
This policy change was necessary but far from sufficient. At last year’s state health officials meeting, for example, program officials in Montana reported that the state’s Medicaid added a separate payment for LARC on January 1. Yet 10 months later, only four women had received LARCs immediately after giving birth, because providers hadn’t been told that they could get paid. “We currently do not have a method to contact our members with new information,” the officials said.
Melanie Giese, who leads South Carolina’s Birth Outcomes Initiative, said that a quarter of the state’s birthing hospitals are providing LARCs postpartum. She said that involving everyone from the beginning was crucial to success. “Pharmacy, the chief financial officer, labor and delivery, claims — everybody who’s going to touch the patient or the device. You can’t do it piecemeal.”
No matter how groundbreaking the idea, it can be felled by the mundane details of implementation. “LARCs have a lot of logistical issues that aren’t present with other forms of birth control,” said Crockett. “There are a lot of issues with billing, the time it takes to do the insertion, and with stocking the devices. I’m very committed to making LARC available, and even I’m struggling with these issues in my hospital. I learned it really takes leadership.”