New York City Physicians’ Views of Providing Long-Acting Reversible Contraception to Adolescents

Susan E. Rubin; Katie Davis; M. Diane McKee

doi:10.1370/afm.1450

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Training our Family Doctors
Diana N. Carvajal

Published on: 10 April 2013
Physician Re-education
Linda Prine

Published on: 25 March 2013

Published on: (10 April 2013)
Page navigation anchor for Training our Family Doctors
Training our Family Doctors
Diana N. Carvajal, Assistant Professor of Family Medicine
In their recent paper entitled New York City Physicians' Views of Providing Long-Acting Reversible Contraception [LARC] to Adolescents, Rubin, et al present important and informative data about adolescent LARC counseling and provision practices among primary care physicians (PCPs) in New York City. Adolescent pregnancy rates in the U.S. continue to be high among industrialized nations(1). However, over the past decade,...
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In their recent paper entitled New York City Physicians' Views of Providing Long-Acting Reversible Contraception [LARC] to Adolescents, Rubin, et al present important and informative data about adolescent LARC counseling and provision practices among primary care physicians (PCPs) in New York City. Adolescent pregnancy rates in the U.S. continue to be high among industrialized nations(1). However, over the past decade, New York City's (NYC) adolescent pregnancy rate has consistently exceeded the national rate(2). Inconsistent contraceptive use among adolescents is often attributed to a lack of adherence to the prescribed contraceptive method -which is very often due to forgetfulness(3-5)(e.g., forgetting to take a daily pill, use a weekly patch, use a monthly ring, or even get an injection every 3 months). Yet, LARCS do not present this barrier and are recommended for use in adolescents(6-7). Why then, aren't all or most PCPs counseling and/or providing LARCs for their adolescent patients?
Well... Rubin, et al found that one of the main enablers (might also be viewed as a barrier) associated with adolescent counseling and/or provision of LARCs is provider training. Yet, provider training is likely a more easily modifiable factor compared to other barriers such as a lack of access to LARCs in the clinical setting or a lack of a supportive clinical environment -which would seem to be more difficult and time consuming to fix than focusing on the enhancement of provider training. When considering interventions for the improvement of counseling/provision of LARCs for adolescents, we might do well to focus our teaching efforts on increasing evidenced-based LARC training during residency.
Interestingly, the study's authors also found that family physicians in NYC already counsel/provide intrauterine contraception (IUC) at very similar rates and had comparable residency training as their ObGyn colleagues. However, in contrast to ObGyns, family doctors often have an advantage in that we are able to provide distinctive continuity from childhood to adolescence through early adulthood and beyond. We therefore have the advantage of being able to build strong, trusting, and lasting relationships with our patients -which makes us uniquely positioned to counsel and provide LARCs to our adolescent patients.
As family physicians, we should less often have to refer our patients for procedures (such as IUC insertion) that we are quite capable of performing and teaching to our residents. If, as a specialty, we focus on improving provider training of LARC insertion among adolescents (especially during residency), we have the potential to improve consistent contraceptive use among teens and possibly impact adolescent pregnancy rates. Given the current drive of residency curricula to focus on evidenced-based practice, family medicine training should really try to focus on enhancing teaching of adolescent LARC counseling and provision.
REFERENCES
1. Singh S, Darroch JE. Adolescent pregnancy and childbearing: levels and trends in developed countries. Family Planning Perspectives. 2000;32(1):14-23.
2. http://www.nyc.gov/html/doh/downloads/pdf/ms/ms-nyctp-2000-09.pdf. Accessed April 8, 2013.
3. Brown S, Guthrie K. Why don't teenagers use contraception? A qualitative interview study. Eur J Contracept Reprod Health Care. 2010 Jun;15(3):197-204.
4. Greenwald MN, Gold MA. Do they, don't they, or why haven't they? Contraceptive use patterns among inner-city sexually active female adolescents. J Pediatr Adolesc Gynecol. 2000 May;13(2):91-2.
5. Serfaty D. Oral contraceptive compliance during adolescence. Ann N Y Acad Sci. 1997; 816:422-31.
6. American College of Obstetricians and Gynecologists. Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 121. July 2011.
7. Centers for Disease Control and Precention U.S. medical eligibility criteria for contraceptive use. 2010. MMWR Early Release. 2010; 59:88.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (25 March 2013)
Page navigation anchor for Physician Re-education
Physician Re-education
Linda Prine, Physician
The study by Rubin et al on New York City Physicians' Views of Providing Long Acting Contraception to Adolescents contributes to our knowledge about why the epidemic of teen pregnancy continues in the US. Adolescents in the US and in Europe have similar patterns of sexual activity, yet the US teens have a much higher pregnancy rate. Adolescents in Europe have much higher use of the most effective (the "forgettable" for...
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The study by Rubin et al on New York City Physicians' Views of Providing Long Acting Contraception to Adolescents contributes to our knowledge about why the epidemic of teen pregnancy continues in the US. Adolescents in the US and in Europe have similar patterns of sexual activity, yet the US teens have a much higher pregnancy rate. Adolescents in Europe have much higher use of the most effective (the "forgettable" forms, as Rubin calls them) forms of contraception. (1)
I was an invited speaker for a NYC Department of Health Bronx Teens Clinic Leaders meeting last week, and the topic was "Quick Start of LARC". In the discussion, many of the attendees brought up barriers to IUD insertions being done on the initial visit when the teen comes in for birth control, and none of them are inserting implants at all, as Rubin also found. As the Affordable Care Act continues to roll out, one hopes that the cost barriers and administrative barriers (prior approvals) will diminish. Equally important, however, as the Rubin study shows, physician re-education needs to be addressed.
(1) Santelli J, Sandfort T and Orr M, Transnational comparisons of adolescent contraceptive use: what can we learn from these comparisons? Archives of Pediatrics & Adolescent Medicine, 2008, 162(1):92-94.
Linda Prine MD, Associate Clinical Professor Family Medicine, Institute for Family Health, Beth Israel and Harlem Family Medicine Residencies, New York, NY 10003
Competing interests: None declared
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Competing Interests: None declared.