Increasing Support and Supply to Address Barriers to LARC Access Among Adolescents Who Utilize Pediatric Primary Care

Purpose/Objectives: In the United States between 2002 and 2019, long-acting reversible contraceptive (LARC) use increased 8-fold among people aged 15 to 19. However, LARC use remains lower among adolescents than any other reproductive age group despite increasing availability and insurance coverage. Barriers to LARC uptake among adolescents include misinformation or lack of information and method access difficulties. Increasing access to contraceptive counseling and LARCs in the pediatric setting is one way to reduce adolescent barriers to LARC, however, time constraints and competing visit priorities can create further barriers to access. Here we describe results of a pilot program to improve access to contraceptive information and LARC provision in a pediatric primary care practice.

Design/Methods: In 2017 in an urban academic pediatric practice, an Obstetrics/Gynecology complex family planning fellow began a monthly contraceptive implant clinical session for any interested adolescent patient. Patients were referred by clinicians and implants were available on-site. 21 months later, a full time contraceptive counselor was added to supplement contraceptive counseling during pediatric well visits and support contraceptive appointment coordination. We conducted a retrospective EMR review of all adolescent encounters at baseline before the intervention (January-December 2016), then all encounters after on-site contraceptive implant provision began (January 2017-September 2018), then encounters after contraceptive counselor addition (October 2018-October 2019) for a total of 33 intervention months. Our primary outcome was uptake of two clinic-administered contraceptive methods (hormonal injections and implants) before and after program initiation. Secondary outcomes were STI (chlamydia, gonorrhea, trichomonas) and pregnancy tests completed before and during the intervention.

Results: There were 4,868 encounters with adolescents aged 12-21 years between January 2016 and October 2109. Over the first 21 months of implant availability (January 2017-September 2018), number of implant insertions and STI testing increased. Most patients who received implants were using no contraceptive at baseline. Addition of the contraceptive counselor coincided with increases in STI/pregnancy testing and administration of both contraceptive method types followed by overall decline during last 6 months of pilot period (July-December 2019) (Figure 1). From start of on-site implant provision to end of pilot period, insertions increased and remained stable. Over the study period, STI testing increased significantly and remained above baseline while pregnancy testing increased but remained lower than STI testing. Injections decreased slowly through pilot period to lower than baseline by pilot end.

Conclusion/Discussion: While preference for LARC varies among adolescents, providing on-site LARC provision can address access barriers in a primary care pediatric practice. A contraceptive counselor may provide opportunities to promote other aspects of sexual health and may reduce contraceptive access barriers through appointment coordination. Future work may focus on sustainability and reproducibility of services.