Expanding Contraception Access for Teenagers: Contraception Counseling in the Pediatric Emergency Department

Background: Efforts to increase contraceptive use among adolescents are urgently needed. One approach is to use clinical settings that do not routinely provide contraception services, such as the emergency department (ED), especially given that many adolescents use the ED as their only source of health care. We sought to assess intention to initiate contraception among adolescent females immediately after receiving ED-based contraceptive counseling, and to assess counseling feasibility, contraception initiation, and participants' attitudes around counseling and contraception.

Methods: Prospective cohort study in two urban pediatric EDs with a nested in-depth interview study. Using webinar modules and in-person sessions, advanced practice providers (APPs) were trained to deliver brief contraception counseling. Through a patient-centered approach APPs discussed contraception type, same-day initiation and follow-up needs. Patients aged 15-18 years with any chief complaint were included if they were not currently pregnant and identified as high-risk for pregnancy. At the index visit we assessed demographics, feasibility of the counseling session (by both participant and APP) and intention to initiate contraception (5-point Likert scales); we assessed contraception initiation (assessed via medical record review and participant phone interview at 8 weeks post-index visit), and analyzed interview data using a modified grounded theory approach.

Results: We trained 27 APPs and enrolled 99 adolescents; mean age was 16.8 years, and 18% were White, 57% Black, 15% Hispanic. The majority (73%) reported prior sexual activity. Counseling lasted a mean of 12 minutes. Over half (62%) reported intention to initiate contraception. APPs reported counseling was easy to deliver (90%) and they had sufficient time to provide the counseling (85%). Most adolescents (90%) reported satisfaction with the counseling session. 5% received Depo-provera during the index visit; of the 22% who completed a follow-up visit, most (81%) reported starting contraception since the ED visit. We analyzed 28 in-depth interviews, and the following themes emerged: 1. the counseling was viewed very positively, in particular due to comfort with the provider and the wide range of options presented in a non-judgmental manner, with many stating this was the most detailed information they had ever received; 2. there are many negative misconceptions about contraception side effects that affect decision-making; 3: decision-making is impacted by prior contraception experiences and the experiences of peers, most often leading to fears and concerns around specific methods.

Conclusion: A brief contraception counseling session was feasible during a pediatric ED visit, and the majority of those counseled expressed intention to initiate contraception, with some completing a follow-up visit and actual contraception initiation. In-depth interviews further supported the acceptability of the counseling, with an emphasis on the importance of detailed information about a range of options in a non-judgmental fashion. The ED can be used effectively to reach teens who may not receive contraception information elsewhere.