Chernick, Lauren S.

Fischer, Kayleigh

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Washington University School of Medicine Digital Commons@Becker Open Access Publications 2020 Contraception provision in the emergency department: Are we ready to overcome the obstacles? Kayleigh Fischer Lauren S. Chernick Follow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubs EditorialsContraception Provision in the Emergency Department:Are We Ready to Overcome the Obstacles?Kayleigh Fischer, MD1 and Lauren S. Chernick, MD, MSc2Despite recent declines in birth rates, adolescent fe-males aged 15–19 years in the United States have oneof the highest pregnancy rates among industrialized nations,with the majority of these pregnancies unintended.1 Ado-lescent unintended pregnancy has negative medical, finan-cial, social, and emotional consequences for the pregnantadolescent, the child, the medical field, and society as awhole.2,3 Adolescent mothers have increased high schooldropout rates, with only 50% achieving high school diplomasby 22 years, leading to lower lifetime income potential andperpetuating socioeconomic disadvantages.4–6 The childrenof adolescent parents have higher risk of preterm birth, higherrisk of health issues, lower school achievements, higher highschool dropout rates, and higher likelihood of incarcera-tion.7,8 Strategies are needed to decrease unintended teenpregnancy in novel places caring for high-risk teens.The reduction of adolescent pregnancy remains a top pri-ority of both the Center for Disease Control and Preventionand U.S. Department of Health and Human Services.6,9 They,along with multiple national academies, including TheAmerican Academy of Pediatrics and the American Collegeof Obstetrics and Gynecology, have recognized the need forincreased contraceptive care, which is the mainstay of preg-nancy prevention.10–12 Medical providers are encouraged tooffer contraception to all adolescents and reduce barriers toallow increased access to effective hormonal contraception.In addition, studies involving choice of hormonal contra-ception reveal that long-acting reversible contraceptive(LARC) methods such as the implant or intrauterine device,which are highly effective and easy to use, are a preferredmethod of contraception for women aged 14–45 years.13These options should be explored with teens of all ages.Our location where adolescent do seek medical care is inthe emergency department (ED). More than 18 million ado-lescents use EDs every year with many being underinsuredand having no primary care physician.14,15 Previous studieshave demonstrated that adolescent females who use theED participate in high-risk behaviors, in particularly riskysexual behaviors.16–18 Effective birth control use is infre-quent, with single center studies showing up to one in fiveadolescent females expected to become pregnant in thesubsequent year.17 Condom use is inconsistent, increasingthe risk of sexually transmitted infections.19 Furthermore, ina national study, sex without contraceptives among teensaged 13–17 years was associated with other high-risk be-haviors, such as binge drinking, depression, and conductdisorder.20 Given the number of high-risk adolescents seen inpediatric EDs, it forces us to wonder if the ED should be apoint of access to hormonal contraception.In this issue of The Journal of Women’s Health, Gutmanet al. explore the reproductive health practices of the ado-lescent population in the pediatric ED and their desire forcontraceptive counseling and initiation in this setting.21 Theysurveyed a convenient sample of 381 females aged 16–21years in one urban pediatric ED. The authors found that 39%of participants were using contraception, with more than half(57.2%) satisfied with it. Two thirds were interested inlearning more about hormonal contraception with one-third(37.5%) interested in a LARC method. More than one quarter(28%) had a history of a prior pregnancy.The results of this study are consistent with previouslypublished literature that the adolescent population in thepediatric ED have inadequate rates of contraception use butare interested in learning and initiating new methods. Manyadolescent females who present to the pediatric ED are in-terested in initiation of contraception during their ED visit,particularly a LARC method.17,22,23 Notably, this study addsto the literature in that it highlights how many of thosefemales using contraceptives are not satisfied with it. Onereason for this might be that Gutman’s population was olderthan those populations in other studies, with a mean age of19 years instead of 16.22,23 However, given that dissatisfac-tion with contraception can lead to discontinuation, thisfurther emphasizes the risk of pregnancy among the EDfemale population.The gap in care for this high-risk population exposes apotentially novel access point for initiating contraception,which in turn could lower rates of adolescent unintendedpregnancy. However, should EDs be offering contraceptivecare? First, provider comfort with discussing contraceptiveoptions varies widely; this threatens the standardization ofthese practices. For example, although the placement of aLARC method such as an implant is quick, which may makeit an ideal method for the ED, LARC methods require train-ing for placement and a maintenance of that training. Second,billing and insurance is a major hurdle to the provision ofcontraception in the ED, especially LARC methods, as manyrequire preauthorization. Third, both parental and provider1Department of Pediatrics, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri.2Department of Emergency Medicine, Columbia University Medical Center, New York, New York.JOURNAL OF WOMEN’S HEALTHVolume 29, Number 5, 2020ª Mary Ann Liebert, Inc.DOI: 10.1089/jwh.2020.8294603Downloaded by Washington Univ from www.liebertpub.com at 09/10/20. For personal use only. acceptance of offering contraception in the ED is an area thatneeds further exploration, as political, social, and ethicalbarriers may exist. Fifth, there is currently scant literatureon the implementation process of contraceptive screeningand provision or on the feasibility of offering LARC methodsin the ED setting other than case studies.24,25Yet, despite these barriers, the benefits to providing con-traceptives are undeniable. Preventive care already occurs inthe ED setting, with certain pediatric EDs implementingother public health, including screening for suicide and do-mestic violence. Medical directors are receptive to pregnancyprevention interventions.26 If we can design novel ways toweave contraceptive provision in to the ED workflow, suchas using technology or outside assistance such as health ed-ucators, we may be closer to finding the middle ground inwhich our female patients are receiving the evidence-basedpatient-centered reproductive counseling they not only needbut also deserve.References1. Mosher WD, Jones J, Abma JC. Intended and unintendedbirths in the United States: 1982–2010. Natl Health StatReport 2012:1–28.2. United Nations Population Fund. Adolescent pregnancy: Areview of the evidence. 2013. Available at: www.unfpa.org/publications/adolescent-pregnancy Accessed December 1,2016.3. Romero L, Pazol K, Warner L, et al. Reduced disparities inbirth rates among teens aged 15–19 years—United States,2006–2007 and 2013–2014. MMWR Morb Mortal WklyRep 2016;65:409–414.4. Oringanje C, Meremikwu MM, Eko H, Esu E, MeremikwuA, Ehiri JE. Interventions for preventing unintended preg-nancies among adolescents. Cochrane Database Syst Rev2016;2:CD005215.5. Rich-Edwards J. Teen pregnancy is not a public healthcrisis in the United States. It is time we made it one. Int JEpidemiol 2002;31:555–556.6. Centers for Disease Control and Prevention. ReproductiveHealth: Teen Pregnancy. Available at: https://www.cdc.gov/teenpregnancy/about/index.htm Accessed September 1,2016.7. Elfenbein DS, Felice ME. Adolescent pregnancy. PediatrClin North Am 2003;50:781–800, viii.8. Koniak-Griffin D, Turner-Pluta C. Health risks and psy-chosocial outcomes of early childbearing: A review of theliterature. J Perinat Neonat Nurs 2001;15:1–17.9. Center for Disease Control and Prevention. Contraception:How effective are birth control methods? 2016. Availableat: https://www.cdc.gov/reproductivehealth/contraceptionAccessed January 1, 2017.10. American College of Obstetricians and Gynecologists.Guidelines for adolescent health care. 2011. Available at:www.acog.org/About-ACOG/ACOG-Departments/Adolescent-Health-Care Accessed December 1, 2016.11. American Congress of Obstetricians and Gynecologists.Statement on Teen Pregnancy and Contraception. 2015.Available at: www.acog.org/About-ACOG/News-Room/Statements/2015/ACOG-Statement-on-Teen-Pregnancy-and-Contraception Accessed December 1, 2016.12. Committee on Adolescence. Contraception for adolescents.Pediatrics 2014;134:e1244–e1256.13. Birgisson NE, Zhao Q, Secura GM, Madden T, Peipert JF.Preventing unintended pregnancy: The ContraceptiveCHOICE Project in Review. J Womens Health (Larchmt)2015;24:349–353.14. Schappert SM, Rechtsteiner EA. Ambulatory medical careutilization estimates for 2006. Natl Health Stat Report2008:1–29.15. Wilson KM, Klein JD. Adolescents who use the emergencydepartment as their usual source of care. Arch PediatrAdolesc Med 2000;154:361–365.16. Ahmad FA, Jeffe DB, Plax K, et al. Characteristics of youthagreeing to electronic sexually transmitted infection riskassessment in the emergency department. Emerg Med J2018;35:46–51.17. Chernick L, Kharbanda EO, Santelli J, Dayan P. Identifyingadolescent females at high risk of pregnancy in a pediatricemergency department. J Adolesc Health 2012;51:171–178.18. Chernick LS, Chun TH, Richards R, et al. Sex withoutcontraceptives in a Multicenter Study of AdolescentEmergency Department Patients. Acad Emerg Med 2019.DOI:10.1111/acem.1386719. Walton MA, Resko S, Whiteside L, Chermack ST, Zim-merman M, Cunningham RM. Sexual risk behaviors amongteens at an urban emergency department: Relationship withviolent behaviors and substance use. J Adolesc Health2011;48:303–305.20. King CA, Brent D, Grupp-Phelan J, et al. Five profiles ofadolescents at elevated risk for suicide attempts: Differ-ences in mental health service use. J Am Acad ChildAdolesc Psychiatry 2019. pii: S0890-8567(19)32222-1.21. Gutman CK, Dorfman D, Meese H, et al. Identifying agolden opportunity: Adolescent interest in contraceptiveinitiation in a pediatric emergency department. J Women’sHealth 2020;29:620–624.22. Hoehn EF, Hoefgen H, Chernick LS, et al. A pediatricemergency department intervention to increase contracep-tion initiation among adolescents. Acad Emerg Med 2019;26:761–769.23. Miller MK, Randell KA, Barral R, Sherman AK, Miller E.Factors associated with Interest in same-day contraceptioninitiation among females in the pediatric emergency de-partment. J Adolesc Health 2016;58:154–159.24. Potter J, Koyama A, Coles MS. Addressing the challengesof clinician training for long-acting reversible contracep-tion. JAMA Pediatr 2015;169:103–104.25. Koyama A, Dorfman DH, Forcier MM. Long-acting re-versible contraception in the pediatric emergency depart-ment: Clinical implications and common challenges.Pediatr Emerg Care 2015;31:286–292; quiz 293–295.26. Ahmad FA, Jeffe DB, Carpenter CR, et al. Emergencydepartment directors are willing to expand reproductivehealth services for adolescents. J Pediatr Adolesc Gynecol2019;32:170–174.Address correspondence to:Lauren S. Chernick, MD, MScDepartment of Emergency MedicineColumbia University Medical Center3959 Broadway, CHN 1-116New York, NY 10032E-mail: lc2243@columbia.edu604 EDITORIALDownloaded by Washington Univ from www.liebertpub.com at 09/10/20. For personal use only. 

Contraception provision in the emergency department: Are we ready to overcome the obstacles?

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Contraception provision in the emergency department: Are we ready to overcome the obstacles?

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