Editor's Note: This blog post is part of an effort to use PolicyLab research and expertise to help other researchers, policymakers, program developers, and institutions understand the downstream effects of limiting youth access to comprehensive reproductive health care. For more, read a post on how access to comprehensive reproductive health services is an adolescent health issue and view a recording of our virtual conversation on centering youth voices in supporting access to comprehensive sexual and reproductive health services. We'll update this editor's note with additional resources as they become available.
Adolescents in 2022 are faced with an ever-increasing number of challenges. In addition to coming of age during the COVID-19 pandemic and facing a growing mental health crisis, they must cope with the reality of the U.S. Supreme Court overturning Roe v. Wade, which had affirmed a constitutionally protected right to abortion.
Comprehensive reproductive health care includes both access to contraception and abortion, and we must do our best to make these rights accessible to our patients. On the heels of a U.S. Supreme Court decision that has led to increased state-based restrictions on access to abortion services, it is of the utmost importance that we maximize adolescents’ ability to prevent undesired pregnancy. Therefore, we must work to make free, confidential, same-day contraception available when it is desired. This is especially important given that youth are disproportionally affected by abortion restrictions.
In this piece, I will explore barriers and facilitators to adolescent contraceptive care today and how we can ensure that access to these services is maintained even as state protections for abortion care are uncertain and quickly changing.
Adolescent access to contraception has helped decrease our country’s teen pregnancy rate. One study found that in 2014, the teen pregnancy rate would have been 73% higher without publicly funded contraceptive services. Today, according to the most recent Youth Risk Behavior Surveillance Survey (YRBS), 30% of sexually active teens used a prescription contraceptive method prior to last intercourse. Of the many safe and effective options, most teens in the survey were using oral contraceptive pills.
The use of long-acting reversible contraception (LARC) has been increasing among this population. LARC includes contraceptive implants and intrauterine devices, both of which have the highest rates of pregnancy prevention. In 2019, 5.4% of high school self-identified females used a LARC compared to 1.8% in 2013.
It is safe for youth to choose any method of contraception, including a LARC, and have it started that same day in most cases. Given difficulties with transportation, confidentiality, and school absences, same-day services offer many benefits to adolescents. However, significant barriers to same-day services persist, the most significant of which include issues with confidentiality and cost.
While we encourage adolescents to discuss all health care issues with their guardians, and many adolescents do discuss decisions related to contraception with their guardians, lack of confidentiality prohibits some adolescents from obtaining contraception. In fact, about 1 in 5 teens report they would not seek reproductive health services if there is risk of their parents finding out.
Currently, only 23 states and the District of Columbia explicitly allow all minors to consent to contraceptive services. A large proportion of minors are covered as dependents under a guardian’s insurance, and only 14 states protect the confidentiality of dependents under insurance. Even with confidentiality protections in place in some states, access to free, confidential contraception has been compromised over the last few years. Despite mandates for contraceptive coverage in the Affordable Care Act, studies show that insurance does not always cover contraceptive options adequately.
Rule changes to the Title X program also affected access to contraception for adolescents. Title X is a federal program that provides funding to clinics for the delivery of reproductive health care, though this funding cannot be used for abortion services. In Title X clinics, contraception can be provided confidentially and free. These clinics are a vital source of reproductive health care for people without insurance or those who do not wish to use their insurance in order to protect confidentiality, particularly adolescents.
In March 2020, the federal government implemented new rules to govern Title X-funded clinics, including prohibiting abortion referrals, requiring financial and physical separation of abortion services from Title X clinics, discontinuing the requirement to provide comprehensive pregnancy options counseling, and allowing clinics to limit contraceptive options offered due to reasons of conscience. Practically speaking, this meant that if a patient visited a Title X clinic, was found to be pregnant and desired an abortion, a provider was prohibited from directly telling the patient where to go for this service.
As a result of these rule changes, 39% of Title X clinics opted to stop receiving this federal funding. A recent PolicyLab study showed that these changes were associated with almost 1 million youth ages 15-17 years losing access to these vital services, such as contraception and testing for sexually transmitted infections. These rules were still in place when the COVID-19 pandemic started, and the pandemic only further inhibited contraceptive access. As hospitals and clinics halted all but “essential” services during the initial COVID-19 outbreak, many were confronted with the question of whether contraceptives should be considered essential, and some were forced to temporarily shut down.
While the Biden administration reversed the 2019 Title X rule changes in 2021, future changes to the program may again put adolescents’ health at risk.
Educating all adolescents
Improving comprehensive sexual education in schools and stopping the spread of contraception myths will help adolescents better understand their contraceptive options. This education is crucial for everyone, regardless of gender. PolicyLab recently released an issue brief sharing evidence-based recommendations for informing decisions on core components of health education, including topics of sexual/reproductive health.
Educating primary care providers
One way to increase access to contraception is to encourage primary care settings to offer immediate access to as many contraceptive options as possible. Many providers, particularly pediatricians, do not feel comfortable prescribing contraception in their practice. IUD and implant procedure training during residency has been shown to correlate with provision of these methods. Even becoming more familiar with counseling can be helpful; one study showed that patients were 2.7 times more likely to be interested in the IUD after discussing it with a health care provider. Training primary care providers, including pediatricians, about contraception provision and counseling would increase access by allowing adolescents to learn about or obtain contraception in a variety of settings.
As education and counseling increase, it is important that health care providers working in this realm respect Reproductive Justice, the idea that people have bodily autonomy in making their reproductive health decisions. Younger people and people of color are historically more affected by policies that decrease access to reproductive health care. In order to decrease these health inequities, contraceptive access is imperative for those who desire it. As we improve contraceptive access, we must be mindful about pregnancy desires of individual patients and intentionally avoid coercion of any kind.
Expanding location of services
All primary care clinics and medical homes that provide health care for adolescents should foster developmentally appropriate discussions about sexual decision making, access to contraception, and referral to needed reproductive health care services that are not available on-site. School-based clinics may provide easy access for students to obtain reproductive health care. Pharmacies may also increase access to contraceptive options, and the case for over-the-counter contraception is currently being considered. The American College of Obstetricians and Gynecologists supports over-the-counter contraception without age restrictions. Additionally, websites and apps are becoming more popular places to obtain contraception. As long as the quality of care is not compromised by expanding access to contraception, broadening the locations that provide these services may be key to expanding access.
Ensuring easy access to emergency contraception
Emergency contraception is a safe, effective way to prevent pregnancy that is different from abortion pills because it prevents a pregnancy from occurring. It is most effective when taken less than 72 hours after unprotected sex, so quick access is key to the success of this method. Teenagers should be educated about emergency contraception regardless of their gender so they know how to obtain this time-sensitive method. Legislation can greatly affect accessibility of emergency contraception; only 20 states require hospital emergency rooms to provide it to sexual assault victims, and 6 states allow pharmacists to refuse to dispense contraception, including emergency contraception. Increasing over-the-counter access to this medication will help prevent unintended pregnancy in teens.
Given that public funding for contraception has been correlated with decreased teen pregnancy rates, we must continue to provide this vital funding, including for Title X clinics. Furthermore, states without confidentiality laws currently in place should pass legislation to protect this right for adolescents.
The reality in a nation that does not guarantee access to abortion is that some people will be forced to carry undesired pregnancies to term, and this issue will disproportionately affect adolescents. It is vitally important to protect access to abortion services as part of a comprehensive policy on reproductive health care services. At the same time, increasing access to contraception can help to prevent some unintended pregnancies. Increasing contraceptive access will be most successful if services can be provided without the need for patients to worry about confidentiality and cost.
Reproductive health care is a human right. Our patients deserve the opportunity to choose if and when they want to become parents. Increasing access to contraception for adolescents is crucial in today’s post-Roe world.