The costs of unintended pregnancy to the individual and to society are substantial. Teen childbearing cost Arkansas taxpayers at least $129 million in 2013 for about 4,155 teen births. Nationally, teen childbearing costs taxpayers at least $9.4 billion each year.

Women with unintended pregnancies are less likely to seek prenatal care in the first trimester, and more likely to use alcohol and tobacco, therefore putting themselves at higher risk of poor pregnancy outcomes. They are also more likely to suffer physical abuse during pregnancy and the year prior to conception.

Teen pregnancy is associated with greater perinatal risks. Teen mothers are more likely to develop anemia, hypertension problems, deliver preterm and low birth-weight babies, suffer a higher rate of infant mortality and are more likely to contract sexually transmitted diseases. These problems can affect their child’s health for a lifetime, including more behavioral problems and chronic conditions throughout life. Some of these problems can be treated but many cannot be overcome.

Arkansas has the highest teen birthrate in the nation – 76 births per 1,000 girls ages 18-19 (in 2014); 40 births per 1,000 girls ages 15-19. This compares to the nationwide rate of 24 births per 1,000 girls ages 15-19. Most of these births are unintended pregnancies and represent lost opportunities for teen parents and their children. Over the last decade, the teen birth rate has declined nationwide, but far less so in Arkansas, according to a Dec. 2015 report from the National Center for Health Statistics.

LARC works best

Unintended pregnancy is lowest in women who use long-acting reversible contraception (LARC) methods. LARC methods provide the most reliable form of contraception, with a failure rate of less than 1 percent. The failure rate of pills, patches or rings in a typical use population is 9 percent; 20 percent for women under age 21.

The continuation rate for LARC is higher than other methods, including among women ages 14 to 19. LARC methods only require attention once every three to 10 years. Return to fertility is rapid upon discontinuation of LARC methods.

Barriers to using LARC

Only 10 percent of patients use LARC methods; the adoption rate is even lower in adolescents. Barriers to use include women’s knowledge of and attitudes towards LARC, provider practice patterns and high initial cost.

Removing these barriers increases LARC use. In a study of 10,000 women who were offered thorough education regarding contraception options, more than 75 percent chose a LARC method.

The American College of Obstetricians and Gynecologists says LARC methods are the safest and most effective form of reversible contraception and recommends they be included in contraceptive counseling. LARC methods are also endorsed by the American Academy of Pediatrics and the American Association of Family Physicians. LARC methods should be encouraged for all appropriate candidates including nulliparous women, adolescents, women seeking contraception immediately after miscarriage or abortion, immediately postpartum, emergency contraception (copper IUD) and for most women with coexisting medical problems.

LARC myths

IUDs do not cause abortions, emphasizes Wilbur C. Hitt, Jr., MD, FACOG, and associate professor, department of obstetrics and gynecology at the University of Arkansas for Medical Sciences. “The mechanism of action for the copper IUD is the inflammatory reaction in the uterus that is toxic to sperm. The levonorgestrel IUD works by increasing cervical mucous and suppressing the endometrium,” Hitt wrote in a Journal of the Arkansas Medical Society article in February.

Hitt wrote in the same article that “IUDs do not increase the rate of pelvic inflammatory disease (PID). There is a potential elevated risk of PID immediately following IUD insertion. This is why it is important to screen for gonorrhea and chlamydia infections at the time of IUD insertion. Treatment of gonorrhea or chlamydia detected at time of IUD insertion without removal of the device is highly effective. Requiring a patient to wait for a negative cervical culture puts an undue burden on the patient.”

LARC methods do not cause ectopic pregnancy. Hitt says that, “because the number of IUD failures is so small, the overall risk of ectopic pregnancy in IUD users is much lower than that of the general population. The risk of ectopic pregnancy in users of the etonogestrel implant is similar to the risk in the general population.”

Best practices for LARC:

  • Same-day insertion when requested, if pregnancy can be ruled out
  • Offer LARC methods at time of delivery, abortion or surgically treated miscarriage
  • Screen for sexually transmitted infections (STIs) at time of IUD insertion, with treatment of positive results while leaving the IUD in place
  • Offer copper IUD as the most effective emergency contraception method
  • Strongly encourage use of condoms in LARC users who are at risk for STIs

Types of LARC

The three types of LARC methods are:

  • Hormonal IUDs – There are currently three hormonal IUDs available in the United States that all release The Mirena® IUD is effective for five years; Skyla® and Liletta® IUDs are effective for three years.
  • Non-hormonal IUD – The only one currently available in the United States is the ParaGard® IUD that contains a small amount of copper. It is effective for 10 years.
  • Hormonal implant – Nexplanon® is the only one available in the United States. It is a 4 cm x 2 mm hormone-containing (etonogestrel) rod that is placed subdermally. It is effective for three years. Attendance at a Clinical Training Program is required before health care providers can purchase the implant.

LARC methods are covered by Arkansas Medicaid and Health Insurance Marketplace plans must cover all contraceptive methods and counseling, as prescribed, without charging a copayment or co-insurance even if the patient has not met her deductible. Some religious employers do not cover any form of contraception.

Arkansas Medicaid is focusing on increased education and awareness of unplanned pregnancies for women ages 15-44. AFMC’s Medicaid Quality Improvement team, with direction from Medicaid, has developed educational tools and materials for colleges, universities and federally qualified health centers to use in efforts to raise awareness about LARC methods and reduce unplanned pregnancies.

Teen pregnancy and poverty

Most teens who give birth face a lifetime of poverty for themselves and their children. Sixty-three percent of teen mothers receive public benefits within the first year after childbirth. Teen pregnancy is a key contributor to high school dropout rates. Only about half of teen mothers earn a high school education by age 22, compared to 90 percent of women who have not given birth as a teen. Only 2 percent of teen mothers finish college by age 30. Children of teen mothers are often less prepared for kindergarten, have lower school achievement and are more likely to drop-out of school and never return.

Teen births often continue the cycle of teen births. More than a third of teen parents had teen parents themselves.  The highest percentage of second births occurs among women aged 18-19. Arkansas also ranks high in the percentage (more than 20%) of repeat teen births.  Repeat teen births produce infants that are often small or born premature, leading to more health problems for the infant.

The National Campaign to Prevent Teen and Unplanned Pregnancy cautions that even the most effective abstinence programs have modest results. Timely and accurate information about contraception is the only reliable method to reduce teen pregnancy.

There’s more information about strategies to use with your patients.

Free downloadable tools about LARC are available  are available

For more information about implant-insertion training, contact Michelle Murtha with AFMC at 501-212-8770 or mmurtha@afmc.org.