Expanding Access to Contraception for Adolescents—Reproductive Justice and the Emergency Department

In a recent secondary analysis of a multicenter trial of strategies for sexually transmitted infection screening, Canter et al. assessed sexual activity, use of contraception, and pregnancy risk among a sample of adolescent ED patients assigned female at birth.¹ Of the 5136 adolescents in their sample, 37% had engaged in vaginal-penile sexual activity. Of these, nearly one in three (representing 11% of the entire sample) had not used contraception at their most recent sexual encounter. These findings are alarming, but not surprising: in a 2019 multicenter analysis of adolescent ED patients, 16.5% reported having had sex without contraceptives at least once in the preceding year, and in the 2021 YRBS, 30% of U.S. high school students had ever had sex, fewer than half of whom had used effective contraception the last time they had sex.² In their investigation, Canter et al. calculated a pregnancy risk index (the rate of expected annual pregnancies per 100 adolescents) of 7.9 across all adolescents in their sample; prior ED studies have demonstrated that, for sexually active adolescents, that number may be as high as 18.³

In 2021 in the United States, 77,588 adolescents 18 and younger gave birth.⁴ These statistics contain substantial inequity. Structural racism and historical reproductive oppression have resulted in adolescents from marginalized racial and ethnic backgrounds disproportionately experiencing pregnancy and parenting.^4,5 Importantly, adolescents from such marginalized backgrounds are increasingly more likely to live in states with limited options for reproductive autonomy. In this context, providing adolescents with high-quality reproductive healthcare remains an important priority for child health and health equity, and must be considered outside of traditional primary care settings. For many adolescents, the emergency department (ED) serves as their only point of healthcare access. In acknowledgement of this reality, many EDs have integrated initiatives to address critical public health crises. Canter et al. add to evidence suggesting that the ED has a role in providing adolescents access to high-quality reproductive healthcare.

In their analysis, Canter et al. draw attention to an under-used tool for preventing unintended adolescent pregnancy that is readily accessible to ED providers. Oral emergency contraception is effective and easily administered in the ED to adolescents who do not desire pregnancy and who present within 5 days of unprotected vaginal-penile intercourse. Emergency contraception administration to adolescent ED patients is not novel or unknown to ED clinicians: it is routinely given to those who present for care after sexual assault. For adolescents with barriers to, or ambivalence around, regular contraceptive use, emergency contraception can be prescribed for future use. Adolescent ED patients can also be counseled on accessing single-dose progestin-based pills over the counter without the need for a prescription. Importantly, adolescent ED patients are accepting of having the option to receive emergency contraception in the ED.⁶ Yet in Canter et al.’s investigation, only 6 of the 108 adolescents potentially eligible for emergency contraception had this prescribed, highlighting a clear gap with substantial potential to impact adolescent health.

The adolescent ED visit can also serve as an important setting for adolescents to access non-emergency contraception. A foundational body of evidence has established that interventions enhancing contraception education and access in adolescent ED patients are feasible and acceptable to clinicians, adolescents, and their parents.^7–10 The most rigorously developed of these have centered adolescent perspectives and incorporated essential tenants of patient-centered communication, including shared decision making and motivational interviewing.^7–9

This intentional use of adolescent-centered communicative approaches is a critical part of ensuring that these ED-based interventions are grounded in reproductive justice. As Canter et al. highlight, there remain striking racial inequities in adolescent contraceptive use, with meaningfully lower rates of contraceptive use among Black and Hispanic, compared to White, adolescents. However, these inequities must be viewed within the perspective of historical practices that, depending on the context, forced either sterilization or child-bearing upon individuals from marginalized racial and ethnic backgrounds. Reproductive justice is also a foundational consideration for adolescents with physical disability or developmental delay, who, due to chronic medical conditions, may have increased use of the ED. Adolescents disabilities may be particularly susceptible to both unintended pregnancies, as well as coercive contraceptive provision. As ED-based contraceptive initiatives may play an important role in reproductive health equity, adolescent-centered communicative approaches are a necessary strategy to avoid coercion and respect bodily autonomy.⁵

When considering health equity and reproductive justice, the extensive work done to support the ED as a setting to expand reproductive health access for adolescents has a notable limitation: adolescents who use languages other than English have been excluded from these efforts. The systematic exclusion of patients who use languages other than English from research has meaningful and often negative implications for patient health. In this case, patient-centered communication is of fundamental importance in partnering with parents for the provision of confidential care and in supporting adolescent self-efficacy and reproductive autonomy. As such, the exclusion of patients based on language, a central component of communication, presents an important gap in our ability to enhance equity in contraceptive access.

With Cantor et al.’s work highlighting the continued high and inequitable risk for pregnancy in adolescent ED patients, now is the time to expand what has been learned from the existing, well-designed single-center pilot trials and pursue multicenter hybrid effectiveness-implementation research initiatives. But as this work progresses, it is essential that reproductive justice, through adolescent-centered approaches and inclusive recruitment practices, are a central focus.