Northridge and Coupey Respond

We agree with the title of the response to our short Editor’s Choice column that we wrote to introduce the July 2015 issue of AJPH.^1,2 Realizing reproductive health equity for adolescents certainly requires more than long-acting reversible contraception (LARC). In fact, our editorial states, “Highly effective, evidence-based contraception is one vital component of this social justice agenda.”¹ However, the authors appear to have misconstrued our argument, and we welcome this opportunity to clarify our position on LARC for adolescents. As health care providers, our aim is to facilitate the fulfillment of the reproductive goals of our adolescent patients. The authors’ later points about prioritizing the bottom line along with racial and class bias are clearly directed to the larger society.

The American Academy of Pediatrics states that, “given their efficacy, safety, and ease of use, LARC methods should be considered first-line contraceptive choices for adolescents.”³ This by no means implies the indiscriminate promotion of LARC methods as best for all adolescents. Rather, the American Academy of Pediatrics recommends that LARC methods should be included when offering a range of effective contraceptive options to adolescents so that each adolescent can make an informed choice. Currently, most adolescents seeking contraception in the United States are not given the choice of LARCs because many health care providers, including pediatricians and gynecologists, are unaware that these methods are suitable for adolescents. Recent studies and our own clinical experience confirm that, when offered as a choice, many adolescents choose LARC methods⁴ such as the levonorgestrel intrauterine system (Mirena), the copper intrauterine device (Paragard), and the etonogestrel single-rod implant (Nexplanon). Far from offering LARCs only to poor and disadvantaged adolescents, we offer these highly effective methods to all of our adolescent patients. Indeed, many adolescents heading for college will chose an intrauterine device that is effective for at least five years to prevent pregnancy throughout their four-year college career. Furthermore, the “R” in LARC stands for “reversible,” and these methods are not to be confused with sterilization. Rather, they are highly effective contraceptives with immediate return to fertility upon removal.

Our experiences are confirmed by scientific evidence. For example the CHOICE study offered more than 1400 adolescents aged 14 to 19 years the full range of contraceptive options without barriers of access and cost and 72% of the adolescents chose a LARC method.⁴ Those who chose a LARC method were more likely to be satisfied with their method and to continue using it at 12 months, compared with those who chose oral contraceptive pills.⁵ We are in agreement with the position of one of the authors of the response² that quality and patient-centered family planning services are an important aspect of eliminating health disparities.⁶ Our point is that quality, patient-centered family planning counseling for adolescents should include information about the high effectiveness, safety, and continuation rates of LARC methods for their age group. A qualitative study from our institution found that adolescents who chose LARC methods based their decision on the perceived ease of use of the method, as well as the method’s high effectiveness and long duration of protection.⁷

In our Editor’s Choice column,¹ we sought to inform health care providers and public health practitioners of the most effective contraceptive methods with the highest satisfaction and continuation rates in adolescents. While the editorial in response to our column² mentions that young women experienced difficulties in having Norplant removed in previous decades, Norplant is no longer available worldwide, and the current implant available in the United States has no such issues. Indeed, bias against the most effective contraceptive methods available for young people based on historical versions of the intrauterine device and implant is one of the largest barriers we, as physicians serving adolescents on the front lines, face in providing the highest quality, patient-centered care for our patients.

Finally, the authors do not address our point that up to 17% of female adolescents face reproductive coercion from their partners and are at increased risk for unintended pregnancy.⁸ LARC methods, which are less susceptible to partner interference, are of particular importance to such at-risk adolescents. Based upon their high effectiveness, satisfaction, and continuation rates in this age group, intrauterine devices and implants are recommended as safe and appropriate contraceptive options for adolescents, not only by the American Academy of Pediatrics,³ but also by the American Congress of Obstetricians and Gynecologists and the American Academy of Family Physicians. Our overarching purpose is to unite adolescent health care providers with public health practitioners and use the best scientific evidence toward helping to realize reproductive health equity for all adolescent girls and young women.

For additional sources, see the appendix (available as a supplement to the online version of this article at http://www.ajph.org).