Are Pediatricians Hesitant About IUDs for Adolescents?

Overall, clinicians in North Carolina inserted more intrauterine devices (IUDs) in adolescents on Medicaid after a 2014 American Academy of Pediatrics (AAP) policy statement, but insertions by pediatricians lagged behind, a cross-sectional study found.

Among all healthcare practitioners (HCPs), average monthly IUD initiations rose from 4.1 before the policy statement to 10.5 after (P<0.001), Bianca Allison, MD, MPH, of the University of North Carolina School of Medicine in Chapel Hill, and colleagues reported in a JAMA Pediatrics research letter.

Mean monthly subdermal implants, however, fell from an average of 15.0 per month to 7.7 (P<0.001) among all HCPs, they reported.

And among pediatricians specifically, mean monthly subdermal implant initiations fell from 1.7 to 0.2 (P<0.001), and there was no difference in monthly IUD initiations before versus after the policy, they found.

“Given no change in IUD initiation and decreased implant initiation among pediatricians, more work is needed to increase pediatrician training and comfort with placement of [long-acting reversible contraception] LARCs while supporting reproductive autonomy, particularly among racial, ethnic, and economic minority patients, who have historically experienced systemic and interpersonal reproductive coercion,” the researchers wrote.

Melissa Goldin Evans, PhD, MSPH, of Tulane University in New Orleans, who was not involved in the paper, told MedPage Today that historically, LARCs have been underutilized in adolescent populations in part because of provider and patient misperceptions about safety — but policy statements such as the AAP’s can correct the narrative.

“This study demonstrates the importance of pediatricians’ role as adolescent reproductive healthcare providers,” Goldin Evans said. “Pediatricians should receive training in LARC insertions so they do not need to refer their patients to another healthcare provider thereby creating a potential barrier for LARC access.”

In 2014, AAP issued a policy statement recommending LARCs for adolescents, stating that because of “the efficacy, safety, and ease of use, LARC methods should be considered first-line contraceptive choices for adolescents.”

Previously, the American College of Obstetrics and Gynecology (ACOG) had issued similar guidelines in 2012. Then in 2020, AAP updated their LARC policy statement to emphasize an adolescent-centered approach to contraceptive counseling.

To get a better understanding of how the AAP policy statement impacted practice, Allison and colleagues assessed North Carolina Medicaid claims data from January 1, 2013 through the end of 2018 of 13- to 19-year-old females with continuous Medicaid enrollment. They identified IUDs and implants from billing codes and conducted interrupted time series analyses at LARC initiation, by pediatricians and other healthcare providers.

During that time, North Carolinian HCPs inserted 44,803 implants and 23,991 IUDs in this population. Pediatricians only placed 5% of all LARCs, while ob/gyns placed the most at 55% and other HCPs placed 40%.

Allison and co-authors noted that since most LARCs were inserted by ob/gyns, the 2012 ACOG guidance may have had more influence on practice. “Few pediatricians were likely trained to place IUDs, resulting in referrals to ob/gyns,” they wrote.

Reasons for diminished use of subdermal implants may include wider “on-site” availability of other contraceptives, preferences for non-implanted contraception, or greater HCP comfort with other types of contraception, including IUDs, the authors said.

Also, the “trend observed may reflect changes in adolescent preferences for IUDs or HCP comfort and availability,” they wrote.

Limitations of the research included inaccurate coding that could impact the LARC data, as well as inconsistent or unclear billing for counseling and referrals for LARC that may have changed after AAP’s policy statement, the researchers said.

Still, they concluded that future research should “assess trends in LARC initiation alongside research assessing HCP perceptions of and training in LARC initiation, LARC referral initiation and completion, and adolescent preferences and experiences.”

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