Youth and long-acting, reversible contraception: Confronting the myths with truth

Photo Credit: Leanne Gray/FHI 360

Youth and contraception: two words that when used together excite visceral responses throughout the world. The response is even more fraught when we consider long-acting, reversible contraceptives (LARCs) for youth. Both intrauterine devices (IUDs) and implants are LARCs, and the challenges for young people who wish to use them — lack of access, myths and misconceptions, provider bias and community stigma — are pervasive. We have to understand more about these challenges in order to overcome them.

In late May 2015, FHI 360 and partners — U.S. Agency for International Development, PSI, MSI and Pathfinder International’s Evidence to Action project — sponsored a symposium, called “For Youth, a Healthy Option With LARCs” in Washington, DC. The meeting convened more than 100 experts from around the world, including program advisors and implementers, researchers, health providers, donors and advocates, as well as young people themselves. The meeting’s goal was to encourage participants to share experiences, tackle tough questions and advocate for wider access to LARCs for young women.

Although LARC use by youth is a hot topic, it is not a new concept. Landmark evidence from the Contraceptive CHOICE project (CHOICE) in the United States paved the way for serious discussion about youth and LARCs. CHOICE participants were women between the ages of 14 and 45 who were sexually active, who did not want to become pregnant in the next year, and who were not using a contraceptive method or were willing to switch to a new, reversible contraceptive method. The project eliminated cost barriers and, in doing so, provided true contraceptive choice. Each woman was counseled about her contraceptive options, in the order of most effective to least effective method (tiered counseling). According to the tiers of effectiveness, based on the World Health Organization publication Family Planning: A Global Handbook for Providers, IUDs and implants are in tier 1 — the most effective methods.

When participants were offered all methods at no cost and in order of effectiveness, 75 percent chose to use a LARC method. Over time, compared to the general U.S. population of the same age, CHOICE participants had a 43 percent reduction in unintended pregnancies and a 47 percent reduction in abortions. Results were even more impressive among teenage participants: Compared to the U.S. population of girls ages 15 to 19 years, adolescent participants using LARCs experienced 64 percent fewer pregnancies and 65 percent fewer abortions. Adolescent participants experienced no more side effects or other complications from LARCs than did older women. So for youth, CHOICE showed that LARCs are both extremely safe and the most effective method of contraception. Results from LARCs projects in Madagascar and Mali have been equally encouraging.

Despite this and other evidence about LARC effectiveness and safety for young women, myths and misconceptions about the methods persist. Many parents and providers believe that greater access to more effective contraception will encourage more young people to have sex. Yet, many studies have found this sexual disinhibition doesn’t happen. Other fears are based on the belief that LARCs will cause infertility. No basis exists for this myth. Those who discontinue LARCs to become pregnant have similar or better intended pregnancy rates than those discontinuing other methods.

The best way to confront myths and fears about LARCs is to share the facts: LARCs make sense for young women and adolescents. Youth often want to delay pregnancy for a longer time period than do older women, and many LARCs are effective for more than three years. Because they are long-acting, LARCs help young women avoid monthly trips to refill supplies or quarterly visits to health care providers. This is especially important for young people, who may lack transportation or have access only to clinics whose hours conflict with school and jobs. Additionally, LARCs can reduce menstrual periods over time, which makes managing menstrual hygiene an easier task.

How can we help young women to make well-informed contraceptive choices when so many myths persist and when LARCs are not presented as an appropriate method for youth? Providers need training in client-centered, youth-friendly services, and they should offer nonjudgmental counseling regardless of their clients’ age and marital status. Providers should be educated about LARC effectiveness and trained in safe insertion and removal. Client-centered counseling, client autonomy and factual information about all methods combine to provide the rights-based, informed choice that young people deserve.

Look for upcoming guidance on youth and LARCs in a report and joint consensus statement from FHI 360, MSI, PSI and Pathfinder’s Evidence to Action.