IUD use increased after AAP recommendation

Key takeaways:

• IUD use among adolescents increased following an AAP recommendation in 2014.
• Over half of the IUDs and implants were placed by OB/GYNs, whereas 5% were placed by pediatricians.

There was a significant increase in the use of long-acting reversible contraception among adolescents after the AAP recommended it almost a decade ago, according to findings published in JAMA Pediatrics.

In late 2014, the AAP encouraged pediatricians to counsel patients about contraceptive services, including educating them about the use of long-acting reversible contraception (LARC) methods such as subdermal implants and intrauterine devices (IUDs). The AAP reaffirmed its policy statement in 2021.

“Long-acting reversible contraception ... is highly efficacious,” Bianca A. Allison, MD, MPH, an assistant professor in the department of pediatrics within division of general pediatrics and adolescent medicine at the University of North Carolina School of Medicine, told Healio. “Uptake has been increasing but certainly lags behind other forms of contraception that young people are using.”

Allison and colleagues conducted a cross-sectional study using data from North Carolina’s Medicaid claims database from Jan. 1, 2013, to Dec. 31, 2018, involving females aged 13 to 19 years .

They identified the initiation of 44,803 implants and 23,991 IUDs — 55% placed by OB/GYNs, 5% by pediatricians, and 40% by other health care providers.

“Once we were able to identify those who actually use IUDs and implants using billing codes, we did an interrupted time series analysis to better understand LARC initiation,” Allison said. “We also looked specifically at pediatricians because the policy statement was issued by the AAP, so we thought maybe there would be some direct impact that we could evaluate.”

For all providers, mean monthly IUD insertions increased from 4.1 (95% CI, 3.1-5.1) before the AAP statement to 10.5 (95% CI, 9.6-11.4) afterward. In contrast, implant insertions decreased from 15 (95% CI, 13-17) prestatement to 7.7 (95% CI, 6.5-9) afterward. Among pediatricians specifically, mean monthly implant initiations decreased from 1.7 (95% CI, 1.4-2) to 0.2 (95% CI, 0-0.4), with no difference in monthly IUD initiations (0.1 [95% CI, 0-0.3] to 0.2 [95% CI, 0.1-0.2].

According to Allison and colleagues, the decrease in implant use may be explained by the availability of other options and health care providers’ comfort in discussing them. As for the low initiation of IUDs by pediatricians, the researchers said many pediatricians are not trained to place them and instead refer patients to OB/GYNs. They noted that a 2012 American College of Obstetrics and Gynecology recommendation supporting LARC “may have contributed to more placements.”

“We also know that there were changes for Medicaid reimbursement in our state in 2016 for postpartum LARC, in particular IUD placement, so that may also possibly explain some changes in like reimbursement from Medicaid around like implementation and use of LARCs in the hospital setting,” Allison said. “I would encourage providers to think critically about the ways they're having conversations about contraception.”

References:

Allison BA, et al. JAMA Pediatr. 2023;doi:10.1001/jamapediatrics.2023.5932.

Braverman PK, et al. Pediatrics. 2014;doi:10.1542/peds.2014-2299.

AAP. Pediatrics. 2021;doi:10.1542/peds.2021-052583.