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. Author manuscript; available in PMC: 2014 May 29.
Published in final edited form as: Obstet Gynecol. 2012 Dec;120(6):1298–1305. doi: 10.1097/aog.0b013e31827499bd

Continuation of Reversible Contraception in Teenagers and Young Women

Jessica R Rosenstock 1, Jeffrey F Peipert 1, Tessa Madden 1, Qiuhong Zhao 1, Gina M Secura 1
PMCID: PMC4037699  NIHMSID: NIHMS570176  PMID: 23168753

Abstract

Objective

To examine the effect of age on continuation rates of reversible contraceptive methods among teenagers and young women aged 14–19 years and women aged 20–25 years, compared to women older than 25 years of age.

Methods

We analyzed data from 7,472 participants enrolled in the Contraceptive CHOICE Project, a prospective cohort study of women offered no-cost contraception. Our primary objective was to compare 12-month continuation rates between teenagers and women aged 14–19, 20–25, and 26 years and older. We collected data about method continuation from telephone surveys and chart review. We used Kaplan-Meier survival curves to estimate continuation and Cox proportional hazard models to examine the risk of contraceptive method discontinuation.

Results

Twelve-month continuation of long-acting reversible contraceptive (LARC) methods was over 75% for all age groups. Teenagers and young women aged 14–19 years using LARC methods had slightly lower continuation rates (81%) than older women (85–86%), but this did not reach statistical or clinical significance. Compared to women older than 25 years of age, teenagers and women aged 14–19 years had lower continuation rates for non-LARC methods (44% v. 53%; HRadj1.32, 95% CI 1.02–1.73). The teenagers and young women aged 14–19 years were less likely to be satisfied with non-LARC methods (42% v. 51%; RRadj 0.80, 95% CI 0.65–0.98), but not LARC methods (75% v. 83%; RR 0.94, 95% CI 0.88–1.01) when compared to women over 25 years of age; however, the differences were small.

Conclusion

Teenagers and young women have high rates of LARC method continuation.

INTRODUCTION

Teenage pregnancy accounts for over 750,000 pregnancies each year, of which 82% are unintended (1). A large percentage of unplanned pregnancies also occur among women aged 20 to 24 years at 64% (1). Despite the growing acceptance of long-acting reversible contraceptive (LARC) methods, the most common forms of contraception used by teenagers are the male condom, withdrawal, and the oral contraceptive pill (OCP) (2). Prior research indicates that teenagers are more likely to experience method failure with OCPs than women over 30 years of age, and are also less likely to adhere to a daily pill regimen (3–5).

Because of high rates of unintended pregnancy and low use of the most effective methods of contraception, teenagers and young women represent an important group who may benefit from LARC methods. The intrauterine device (IUD) and subdermal etonogestrel (ENG) implant have been shown to be extremely effective in preventing unwanted pregnancy with pregnancy rates of 0.05–0.8% in the first year of use (6). The typical- and perfect-use failure rates are almost identical for LARC methods, in comparison to OCPs and the male condom (6). Despite their high level of effectiveness, LARC methods are used by only a small percentage of women in the United States, and by an even smaller percentage of teenagers and young adults. One study found that only 1.7% of teenagers and women aged 15–24 years had ever used an IUD (7); another reported 4.5% of teenagers and women aged 15–19, and 8.3% of women aged 20–24 years currently use LARC methods (8).

Many experts recommend that LARC methods should be first-line contraceptive options for all women, including teenagers (9–11). Multiple studies have shown LARC methods to be acceptable and safe in young women (10–16), but there are no large-scale studies examining the effect of age on continuation rates. The purpose of this analysis was to examine the effect of age on contraceptive continuation rates in teenagers and young women enrolled in the Contraceptive CHOICE Project. Our hypothesis was that continuation rates among LARC users would not be affected by age, while young age would be associated with higher discontinuation in those using non-LARC methods (i.e. OCP, patch, ring, and depot medroxyprogesterone acetate (DMPA)).

MATERIALS AND METHODS

The Contraceptive CHOICE Project is a prospective cohort study of 9,256 female participants in the St. Louis region. A more detailed description of the methodology of the CHOICE Project has been previously described (17). Prior to initiation of recruitment, the CHOICE protocol was approved by the Washington University in St. Louis School of Medicine Human Research Protection Office. We briefly describe the project and analyses relevant to the present study below.

The primary objectives of CHOICE are to: 1) remove all financial barriers to contraceptive methods; 2) promote the use of the most effective methods of contraception (IUDs and implants); and 3) reduce unintended pregnancies in the St. Louis region. The study sample is a convenience sample of participants recruited from university-affiliated clinics, facilities providing abortion services, community clinics, and through word-of-mouth. Inclusion criteria for CHOICE are: 1) age 14–45 years; 2) no desire for pregnancy in the next year; 3) willing to switch or initiate a new contraceptive method; 4) sexually active with a male partner in the past 6 months or anticipate sexual activity in the next 6 months; and 5) reside in St. Louis city or county or seek clinical services in designated recruitment sites in the St. Louis region. To be included in this analysis, participants had to initiate their baseline chosen contraceptive method within 3 months of enrollment and reach the time point for their 12-month follow-up survey. Only the participant’s initial contraceptive method was included in this analysis.

All participants were read a script that emphasized that IUDs and implants are the most effective reversible contraceptive methods at the time of screening for study eligibility (17). Participants then underwent contraceptive counseling that included information about all FDA-approved reversible methods. The majority of this counseling (74%) was performed by research assistants who were trained contraceptive counselors at the university-based recruitment site. The remainder was performed by clinic staff and/or healthcare providers at the clinical facility providing the counseling (17). Each participant was offered no-cost reversible contraception for 2–3 years (depending on the date of enrollment). Sexually transmitted infection (STI) testing was performed after a face-to-face, standardized baseline survey. All participants were counseled about the risk of STIs and encouraged to use condoms if they were at risk. Participants were then followed with telephone interviews at 3 and 6 months, and every 6 months for the duration of follow-up.

During each follow-up telephone survey, the participant was asked, “are you still using the method?” If yes, she was asked, “did you ever stop using the method?” A “continuer” was a participant who reported using her baseline method at the 3-, 6-, and 12-month surveys without a temporary stop of 1 month or longer. A “discontinuer” was a participant who was not using her baseline method at any of the survey time points, or reported stopping her method for 1 month or longer. When participants missed a survey or completed the survey without answering the method use question, we used additional data sources. Among LARC users we used our contraceptive method allocation and removal log to confirm method use. Participants who were captured as having their IUD or implant removed in the removal log were considered “discontinuers.” For participants who experienced an expulsion of an IUD, replacement was offered. If the IUD was replaced within 1 month, this was considered a “continuer” whereas if the participant elected an alternative form of contraception after expulsion, she was considered a “discontinuer.” For those who used DMPA, OCPs, patch, or the ring, we used the method allocation log and pharmacy refill records to verify their method use. Participants who were lost to follow-up were censored at their last completed survey date.

We stratified participants by age group (14– 19, 20–25, and 26 years and older). Continuation rates were then assessed by age within each method group: LARC (IUD and implant) and non-LARC (OCPs, DMPA, patch, or ring) users. Demographic characteristics of the study participants were described using frequencies, percentages, means, and standard deviations where appropriate. We compared baseline characteristics using χ2 or Fisher exact tests when appropriate for categorical variables, and Student’s t-test for normally distributed continuous variables. Normality was assessed by evaluating the histogram of continuous variables. We used Kaplan-Meier survival curves to estimate continuation rates, and hazard ratios were estimated using Cox proportional hazard models.

We also compared user satisfaction at 12 months. There were 3 levels of satisfaction: “very satisfied,” “somewhat satisfied,” and “not satisfied.” All discontinuers were considered “not satisfied.” We grouped “very satisfied” and “somewhat satisfied” together and compared them to “not satisfied” to determine satisfaction at 12 months. We also performed univariable and multivariable Poisson regression with robust error variance to assess factors associated with satisfaction. Poisson regression with robust error variance allows for a conservative estimate of the relative risk when the outcome of interest occurs more than 10% of the time, as was the case with user satisfaction (18). Confounding was defined as a greater than 10% relative change in the association between continuation or satisfaction and age groups with or without the covariate of interest in the model. All the confounding factors were included in the adjusted multivariable model (education, gravidity, history of STI). Analyses were performed using STATA 11. The significance level alpha was set at 0.05.

RESULTS

Among 9,256 participants enrolled in CHOICE Project between August 2007 and September 2011, 7,472 met the inclusion criteria and are included in this analysis. Table 1 presents baseline characteristics of the analytic sample by age group. Participants who were 14–19 years old were more likely to be African American, report trouble paying for basic expenses, and less likely to be uninsured than participants in the older groups. Participants in the youngest age group were also more likely to be nulliparous and less likely to have experienced an unintended pregnancy or an STI.

Table 1.

Baseline Characteristics of Analysis Group by Age

14–19
(n=1099)		 20–25
(n=3417)		 26+ (n=2956)
Mean SD Mean SD Mean SD P
Age 17.7 1.4 22.6 1.7 31.0 4.5 <0.001
n % n % n %
Race <0.001
Black 672 61.1 1545 45.2 1483 50.2
White 341 31.0 1581 46.3 1266 42.8
Others 86 7.8 291 8.5 206 7.0
Education <0.001
  High school or less 786 71.5 1013 29.7 772 26.1
  Some college 311 28.3 1614 47.3 1231 41.7
  College or graduate degree 2 0.2 788 23.1 952 32.2
BMI <0.001
Underweight 47 4.3 118 3.5 52 1.8
Normal Weight 571 52.0 1442 42.2 922 31.2
Overweight 249 22.7 865 25.3 806 27.3
Obese 232 21.1 992 29.0 1176 39.8
Receiving public assistance <0.001
No 796 72.5 2159 63.2 1798 60.9
Yes 302 27.5 1255 36.8 1156 39.1
Trouble paying for basic expenses <0.001
No 824 75.2 2048 60.0 1639 55.5
Yes 272 24.8 1366 40.0 1312 44.5
Insurance <0.001
None 315 29.6 1450 42.5 1340 45.5
Private 463 43.5 1452 42.6 1299 44.1
Public 287 26.9 506 14.8 309 10.5
Gravidity <0.001
0 540 49.1 1244 36.4 458 15.5
1 395 35.9 807 23.6 401 13.6
2 127 11.6 634 18.6 587 19.9
3 or more 37 3.4 732 21.4 1510 51.1
Parity <0.001
0 848 77.2 1914 56.0 770 26.0
1 212 19.3 914 26.7 702 23.7
2 34 3.1 435 12.7 832 28.1
3 or more 5 0.5 154 4.5 652 22.1
Unintended pregnancies <0.001
0 568 51.8 1372 40.2 761 25.8
1 389 35.5 946 27.7 671 22.7
2 114 10.4 579 17.0 565 19.1
3+ 26 2.4 514 15.1 954 32.3
History of abortion <0.001
No 886 80.6 2296 67.2 1600 54.1
Yes 213 19.4 1121 32.8 1356 45.9
History of STI <0.001
No 820 74.6 2103 61.6 1588 53.7
Yes 279 25.4 1312 38.4 1367 46.3
Any current STI 0.40
No 952 92.2 3063 92.7 2661 93.3
Yes 81 7.8 240 7.3 190 6.7
Baseline chosen method <0.001
LNG-IUS 330 30.0 1527 44.7 1508 51.0
Copper IUD 55 5.0 313 9.2 516 17.5
Implant 378 34.4 532 15.6 304 10.3
OCPs 146 13.3 385 11.3 209 7.1
Ring 57 5.2 344 10.1 172 5.8
DMPA 112 10.2 244 7.1 201 6.8
Patch 21 1.9 72 2.1 46 1.6
Natural family planning
Diaphragm
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SD, standard deviation; BMI, body mass index; STI, sexually transmitted infection; LNG-IUD, levonorgestrel intrauterine system; IUD, intrauterine device; OCP, oral contraceptive pill; DMPA, depot medroxyprogesterone acetate;.

The 12-month LARC continuation rates were greater than 75%, and higher than non-LARC methods for all age groups as shown in Table 2. LARC continuation ranged from 81% in 14–19 year-olds to 86% in women older than 25 years. The levonorgestrel intrauterine system (LNG-IUS) had the highest 12-month continuation rate (86–87%) in both the 20–25 year and 26 years and older age groups. Participants age 26 and older reported LARC continuation rates over 84% (LNG-IUS 86%, copper IUD 86%, and implant 84%;). Non-LARC method continuation was 44% for 14–19 year-olds and 53% in the oldest group. Teenagers and young women (14–19 years) who used the ring reported the lowest 12-month continuation rate (31%), whereas women aged 20–25 and 26 and older reported the lowest continuation with the contraceptive patch (40 and 41%, respectively).

Table 2.

Continuation Rates at 12 Months by Contraceptive Method, Stratified by Age and Hazard Ratio of Risk of Discontinuation

Method Age n Continuation
Rate (%)		 Crude Hazard Ratio
[95% CI]		 Adjusted Hazard
Ratio [95% CI]*
LNG-IUS 14–19 330 80.6 1.44[1.08–1.92] 1.25[0.83–1.88]
20–25 1527 86.8 0.97[0.79–1.18] 0.95[0.76–1.17]
26 or older 1508 86.4 Ref Ref
Copper IUD 14–19 55 75.6 1.93[1.07–3.50] 1.24[0.54–2.85]
20–25 313 82.5 1.33[0.93–1.90] 1.25[0.85–1.85]
26 or older 516 85.9 Ref Ref
Implant 14–19 378 82.2 1.15[0.78–1.69] 1.12[0.59–2.11]
20–25 532 80.1 1.28[0.90–1.83] 1.27[0.87–1.87]
26 or older 304 84.4 Ref Ref
DMPA 14–19 112 47.3 1.17[0.84–1.63] 1.63[0.99–2.64]
20–25 244 57.1 0.91[0.69–1.21] 1.01[0.74–1.40]
26 or older 201 53.4 Ref Ref
OCPs 14–19 146 46.7 1.21[0.89–1.64] 1.21[0.78–1.87]
20–25 385 51.6 1.04[0.81–1.34] 1.14[0.86–1.51]
26 or older 209 53.9 Ref Ref
Patch 14–19 21 40.9 1.00[0.49–2.01] 0.71[0.26–1.98]
20–25 72 39.7 1.00[0.61–1.62] 0.90[0.53–1.51]
26 or older 46 40.7 Ref Ref
Ring 14–19 57 31.0 1.69[1.14–2.50] 1.71[1.01–2.89]
20–25 344 52.2 1.05[0.80–1.38] 1.06[0.78–1.45]
26 or older 172 53.1 Ref Ref
LARC 14–19 763 81.0 1.38[1.12–1.69] 1.22[0.89–1.68]
20–25 2372 84.7 1.10[0.94–1.28] 1.07[0.91–1.27]
26 or older 2328 86.0 Ref Ref
Non-LARC 14–19 336 44.0 1.25[1.04–1.50] 1.32[1.02–1.73]
20–25 1045 52.3 1.01[0.88–1.17] 1.07[0.91–1.27]
26 or older 628 52.6 Ref Ref
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CI, confidence interval; LNG-IUS, levonorgestrel intrauterine system; IUD, intrauterine device; DMPA, depot medroxyprogesterone acetate; OCPs, oral contraceptive pills; LARC, long-acting reversible contraceptive.

*

Adjusted for age, gravidity, and history of a sexually transmitted infection.

Table 3 provides satisfaction rates at 12 months by contraceptive method stratified by age. Loss to follow-up at 12 months was 6%. Satisfaction rates were higher for LARC users regardless of age (75% for age 14–19, 82% for age 20–25, and 83% for age 26 years and older), compared to non-LARC users (42% for age 14–19, 49% for age 20–25 and 51% for age 26 years and older). Teenagers and young women aged 14–19 reported the highest rates of being “not satisfied” with the ring (69%), patch (65%), DMPA (57%), and OCPs (54%). Participants aged 14–19 years were less likely to be satisfied overall with non-LARC methods (RRadj 0.80, 95% CI 0.65–98), but this difference was not seen with LARC methods (RRadj 0.94, 95% CI 0.88–1.01). The differences observed in satisfaction were small and may not be clinically significant.

Table 3.

Satisfaction at 12 Months by Contraceptive Method, Stratified by Age

Method Age Very
Satisfied		 Somewhat
Satisfied		 Not Satisfied Crude
Relative
Risk [95%
CI]		 Adjusted
Relative Risk
[95% CI]*
LNG-IUS 14–19 193(65.7) 34(11.6) 67(22.8) 0.92[0.86–0.99] 0.96[0.88–1.05]
20–25 931(68.3) 212(15.6) 220(16.1) 1.00[0.97–1.04] 1.00[0.97–1.04]
26 954(68.1) 201(14.6) 226(16.4) Ref Ref
Copper IUD 14–19 28(56.0) 8(16.0) 14(28.0) 0.88[0.73–1.05] 0.99[0.82–1.19]
20–25 176(63.3) 42(15.1) 60(21.6) 0.95[0.89–1.03] 0.97[0.90–1.05]
26 or older 298(64.9) 79(17.2) 82(17.9) Ref Ref
Implant 14–19 175(54.0) 65(20.1) 84(25.9) 0.93[0.85–1.01] 0.88[0.76–1.01]
20–25 253(52.6) 119(24.7) 109(22.7) 0.97[0.90–1.05] 0.94[0.87–1.02]
26 or older 154(56.4) 64(23.4) 55(20.2) Ref Ref
DMPA 14–19 38(37.3) 6(5.9) 58(56.9) 0.87[0.67–1.13] 0.70[0.47–1.06]
20–25 95(42.0) 26(11.5) 105(46.5) 1.08[0.89–1.30] 1.00[0.80–1.24]
26 or older 71(38.0) 22(11.8) 94(50.3) Ref Ref
OCPs 14–19 48(33.1) 19(13.1) 78(53.8) 0.88[0.71–1.10] 0.87[0.66–1.15]
20–25 145(39.7) 33(9.0) 187(51.2) 0.93[0.78–1.10] 0.87[0.72–1.05]
26 or older 72(36.4) 32(16.2) 94(47.5) Ref Ref
Patch 14–19 6(30.0) 1(5.0) 13(65.0) 0.85[0.42–1.69] 1.18[0.43–3.23]
20–25 19(26.8) 6(8.5) 46(64.8) 0.85[0.53–1.36] 1.02[0.61–1.72]
26 or older 16(34.8) 3(6.5) 27(58.7) Ref Ref
Ring 14–19 16(29.1) 1(1.8) 38(69.1) 0.57[0.37–0.86] 0.57[0.32–1.01]
20–25 141(41.6) 30(8.9) 168(49.6) 0.93[0.78–1.10] 0.92[0.76–1.12]
26 or older 85(50.3) 7(4.1) 77(45.6) Ref Ref
LARC 14–19 396(59.3) 107(16.0) 165(24.7) 0.91[0.87–0.95] 0.94[0.88–1.01]
20–25 1360(64.1) 373(17.6) 389(18.3) 0.99[0.96–1.01] 0.99[0.96–1.02]
26+ 1406(66.5) 344(16.3) 363(17.2) Ref Ref
Non-LARC 14–19 108(33.5) 27(8.4) 187(58.1) 0.82[0.70–0.95] 0.80[0.65–0.98]
20–25 400(40.0) 95(9.5) 506(50.6) 0.96[0.87–1.06] 0.92[0.82–1.03]
26+ 244(40.7) 64(10.7) 292(48.7) Ref Ref
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*

Adjusted for education, gravidity, and history of sexually transmitted infections.

CI, confidence interval; LNG-IUS, levonorgestrel intrauterine system; IUD, intrauterine device; DMPA, depot medroxyprogesterone acetate; OCPs, oral contraceptive pills; LARC, long-acting reversible contraceptive.

Data are n(%) unless otherwise specified.

DISCUSSION

Among participants in the Contraceptive CHOICE Project, we found that teenagers and young women aged 14–19 years had lower continuation rates of non-LARC methods when compared with older women. We found little difference in the continuation rates of LARC methods by age group; over 75% of participants of all ages were still using their LARC method at 12 months.

We noted slightly lower continuation rates among adolescents using the copper IUD when compared with older women (76% versus 86%). However, this difference was not statistically significant. We had limited power to detect differences by age group in copper IUD users due to the small number of participants aged 14–19 years using the copper IUD (n=55).

The youngest age group expressed slightly less satisfaction with all contraceptive methods compared to older women. Participants aged 14–19 years using OCPs, the patch, ring, or DMPA had the lowest satisfaction rates with more than half being “not satisfied.” Dissatisfaction was especially true for the patch (65%) and the ring (69%). In 2008, Creinin et al performed a randomized controlled trial comparing 3-month continuation rates of the patch compared with the ring (19). They found that 3-month continuation of the ring was higher than the patch (95% vs. 88%, p=0.03). However, when asked if participants intended to continue use of their assigned method after study completion, only 71% and 26% reported intent to continue the ring and patch, respectively.

The finding that participants aged 14–19 years are less likely to continue non-LARC methods is consistent with previous studies. Raine et al. conducted a 12-month longitudinal cohort study of 1,387 adolescent girls and women aged 15 to 24 years using OCPs, patch, ring, and DMPA for contraception (20). Continuation was independently associated with method type and younger age (lower continuation in younger participants). Continuation was lowest for the patch and DMPA. LARC methods were not included in this report.

Little evidence is available regarding continuation and satisfaction with IUDs in teenagers and young women (11), and data are especially sparse with regard to the copper IUD. Rasheed et al conducted a prospective cohort study of 281 women 13–19 years of age and 571 older women (age 20–30 years) at a family planning clinic who underwent placement of the copper IUD (21). This study included only primiparous women who had an IUD placed 6 to 8 weeks post-delivery, and had a fairly high rate of loss to follow-up (21% completed follow up at 6 months). At one month post-insertion, they noted that women 13–19 years of age had higher rates of pain, bleeding, displacement, expulsion, and removal than older women. At 6 months, women 13–19 years of age had equivalent rates of removal compared with older women. Godfrey et al conducted a small pilot study randomizing women aged 14–18 years to the LNG-IUS or the copper IUD (14). They found 6-month continuation rates of 75% for the LNG-IUS and 45% for the copper IUD. This study was limited by its small sample size (n=23). Additional studies evaluating the copper IUD in young women are needed.

Overall, 12-month continuation rates for the ENG implant range between 75 and 91% (22–24). A study comparing continuation and satisfaction between women using either the LNG-IUS or the ENG implant found similar 6-month continuation rates at 89% and 83%, respectively (25). However, satisfaction was lower among implant users (74% and 58%, respectively, p=0.002). This study did not stratify their population by age or specifically evaluate teenagers. In fact, there are few studies evaluating continuation of the ENG subdermal implant in adolescents. A prospective observational study of 171 females aged 13–24 years who received immediate postpartum implants found that 86% were still using the implant at 12-months (26). Repeat pregnancy rates at 12 months were significantly lower among implant users at 3%, compared to 19% among users of other contraceptive methods. The generalizability of these results is limited by the exclusively postpartum adolescent population. In a previous CHOICE analysis, we found that teenagers (age 14–17 years) were more likely to favor the implant over the IUD, compared to women between 18–20 years of age (12). These findings suggest that adolescents may prefer the implant for long-acting and highly effective contraception.

The strengths of our study include its large sample size, prospective design, low rate of loss to follow-up at 12 months (6%), and evaluation of all forms of reversible contraception. Limitations of our study include our requirement that participants start a new contraceptive method, utilization of a convenience sample, and recruitment limited to the St. Louis region which may limit the generalizability of our findings. Another potential limitation of our study is that continuation was self-reported and therefore subject to reporting bias. In addition, methods were provided at no cost which could have resulted in higher continuation of refillable methods (OCPs, patch, ring) and DMPA. However, our 12-month continuation rates for these methods are comparable to other reports (20, 27–30).

Teenagers and young women represent a population at especially high risk for sexually transmitted infections. Barrier methods are the best way to prevent STIs, and clinicians should continue to encourage condom use for STI prevention. An ideal approach in counseling teenagers and young women should emphasize dual method use, utilizing reliable contraception for pregnancy prevention and condom use to prevent STIs.

Given the high rates of continuation and satisfaction of LARC methods among teenagers and young women, long-acting reversible contraception should be offered to women of all ages as first-line contraceptive methods in order to best serve females who want to prevent unintended pregnancy.

Acknowledgments

Supported in part by The Susan Thompson Buffett Foundation and award number K23HD070979 from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NICHD or NIH.

Footnotes

Financial Disclosure: Dr. Madden has been a speaker for Bayer Pharmaceuticals in the past 3 years. The other authors did not report any potential conflicts of interest.

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