Providing Adolescent Contraception in the Emergency Room (PACER)

Adolescent pregnancy is a crippling problem. Despite declines in adolescent birth rates, adolescent pregnancies cost taxpayers a staggering $9.4 billion in 2010. New Mexico has one of the highest rates of adolescent pregnancy in the country.(1) In New Mexico, nearly 1 in 5 adolescent females are not using any form of contraception.(2) Long-acting reversible forms of contraception, including the subdermal contraceptive implant known as Nexplanon, are increasingly popular among adolescents. Nonetheless, despite an increase from 0.3% in 2000 to 4.5% in 2013, few adolescents using any contraception are using a long-acting reversible form.(1) The American College of Obstetricians and Gynecologists issued a policy statement in late 2012 recommending long-acting, reversible forms of contraception as first line contraception for adolescents.(3) Long-acting, reversible forms of contraception are highly effective at preventing pregnancy and have rates of continuation among adolescents comparable to older women.(4) Prior studies of adolescents have demonstrated that cost, access, and education are the primary barriers to initiation of long-acting reversible forms of contraception and that, if these barriers are removed, acceptance rates approach 75%.(5,6) However, adolescents at highest risk of pregnancy have few opportunities to obtain highly-effective contraception.

The contribution of the proposed research is to demonstrate the feasibility of providing comprehensive counseling about contraception for adolescents in a novel outreach setting, a pediatric emergency department. This contribution will be significant because, if this counseling intervention increases initiation of contraception through a pediatric emergency department, unintended pregnancies among vulnerable adolescents may decrease. The term vulnerable will be used throughout this application to refer to adolescent girls who seek care for non-emergent complaints in emergency departments, are likely to be publicly insured or uninsured, engage in risky behaviors, have co-morbid psychiatric disorders, or have high-risk social characteristics such as interpersonal violence, substance abuse, or poverty.(7-9) Vulnerable adolescents are at high risk of unintended pregnancy, yet are difficult to reach through outpatient care settings. Initiation of contraception at the time of pediatric emergency department encounter could reduce unintended pregnancy, reduce adverse outcomes to the woman and her child associated with adolescent pregnancy, and reduce the financial costs borne by society.

Currently, most contraception for adolescents is initiated through an outpatient encounter. In New Mexico, adolescent girls aged 13 to 18 who present to an outpatient clinic for contraception can be prescribed contraception or have a contraceptive device placed during the clinic visit without parental consent under state law.(10) This approach has enjoyed considerable success, with a 15-fold increase in the use of intrauterine or subdermal contraceptive implants by adolescents seeking contraception over the past decade.(1) The Contraceptive CHOICE study has demonstrated that adolescents have high acceptance of long-acting, reversible forms of contraception.(5) Typically, providers of highly-effective contraception are gynecologists, advanced practice physicians, and family practice physicians. This has resulted in a scarcity of providers who can offer the long-acting, reversible contraception to adolescents that is recommended by the American College of Obstetricians and Gynecologists.(3,11) Additionally, not all adolescents are able to access clinic-based, outpatient medical care by a gynecologist or family practitioner. Adolescents who experience poverty, coercive sexual relationships, co-morbid psychiatric disorders, and abuse are especially vulnerable to pregnancy.(12) These risk factors for adolescent pregnancy mirror the characteristics of adolescents who utilize emergency departments for medical care.(7-9,13) A prior survey of female adolescents and adults seeking care in an emergency department felt it was acceptable to have contraceptive provision in the emergency department. (14)

It is not known whether pediatric emergency medical providers can successfully initiate contraception for adolescents in a pediatric emergency department. Adolescent girls who present to the UNM Pediatric Emergency Department (PED) currently receive some contraceptive and sexual health care, but the care delivered varies based on the provider.

As a continuing education initiative at UNM, Dr. Nancy Sokkary, Adolescent Gynecologist, has been providing educational sessions on current best contraceptive practices for adolescents to pediatricians. Included in this education has been an FDA-approved procedural training in the insertion of the subdermal contraceptive implant, Nexplanon. Pediatric residents and attending physicians have begun to offer Nexplanon in the inpatient setting and in pediatric clinics. As PED attending and fellow physicians, all of whom are board-certified pediatricians, undergo this education, we anticipate increased knowledge on the part of PED providers on current contraceptive recommendations. This proposed research capitalizes on an opportunity to expand comprehensive counseling on contraception in the PED.