Initiation of Long-Acting Reversible Contraception in Hospitalized Adolescents in the United States

This study is a secondary data analysis of the Kids’ Inpatient Database, Healthcare Cost and Utilization Project (HCUP), and Agency for Healthcare Research and Quality.⁹  The data set contains deidentified encounter-level information for inpatient medical and psychiatric admissions across 46 states in the United States and is collected every 3 years. In this study, we analyzed the 2016 data (N = 4200 hospitals).

Hospital encounters for girls 10 to 20 years old were eligible for inclusion. The primary outcome was initiation of LARC while hospitalized (ie, presence of International Statistical Classification of Diseases and Related Health Problems, 10th Revision [ICD-10] procedure codes for either IUDs or subdermal etonogestrel implants). Girls with ICD-10 diagnosis codes for active pregnancy but without a postpregnancy code (ie, for birth, delivery, or therapeutic, elective or spontaneous abortion) were excluded. Covariables included age (defined as young adolescents aged 10–13 years, middle adolescents aged 14–17 years, or older adolescents aged 18–20 years), race or ethnicity (white, Black, Hispanic, and “other” [Asian American or Pacific Islander, American Indian, or “other”]), insurance type (Medicaid, private, and “other” [Medicare, self-pay, no charge, or “other”]), postpregnancy status (yes or no), region of hospital location (Northeast, Midwest, South, or West), hospital type (rural or urban, teaching or nonteaching), hospital size (small, medium, or large), and hospital status (children’s or nonchildren’s hospital).

Bivariable statistics were calculated by using survey-weighted analysis¹⁰  with χ² test for homogeneity to examine the distribution of patient-level and hospital-level characteristics across LARC initiation. A design-based, fully adjusted logistic regression model¹¹  using Wald tests analyzed which patient- or hospital-level factors were associated with LARC initiation. Covariates included age, race or ethnicity, payer, postpartum status, region of hospital location, hospital type, hospital size, and hospital status. When studying the odds of implant versus IUD initiation, effect measure modification by hospital region was identified, requiring further stratification of the adjusted logistic regression model by region. Statistical analysis was completed by using Stata SE 16 (Stata Corp, College Station, TX) and SAS 9.4 for Windows (SAS Institute, Inc, Cary, NC).

This study was reviewed and determined by the University of North Carolina Institutional Review Board to be exempt (19-1890).

Overall, LARC initiation occurred in 0.4% (3706 of 874 193) of eligible hospital admissions. Eligible adolescents were older and more frequently white, covered by Medicaid, and had non-postpregnancy diagnoses (Table 1). The top 20 nonpostpartum diagnoses associated with LARC placement can be found in Supplemental Table 4. The majority of eligible admissions was from hospitals in the South, urban teaching hospitals, larger hospitals, and nonchildren’s hospitals. Significant differences in LARC initiation based on patient age, insurance type, race or ethnicity, and postpregnancy status, as well as hospital type and children’s hospital status, were found (all P < .01).

Several patient factors had significantly higher odds of LARC initiation (Table 2): middle adolescents compared with older adolescents; public insurance compared with private insurance; racial and ethnic minorities compared with white adolescents; and postpregnancy adolescents compared with non-postpregnancy adolescents (all P ≤ .001). Rural or urban nonteaching hospitals had significantly lower odds of LARC initiation compared with urban teaching hospitals, and small or medium sized hospitals had lower odds compared with large hospitals (all P < .01).

Factors associated with implant versus IUD initiation, specifically postpregnancy status and hospital size, varied regionally (Table 3). Smaller hospital size and postpregnancy status increased the odds of implant initiation (after adjusting for age, insurance, race, and hospital type), especially for small hospitals in the Northeast and West and medium hospitals in the West (all P < .05). Postpregnancy adolescents in the Midwest, South, and West also had increased odds of implant initiation (P < .05).

In this study, we found that LARC initiation occurred in <1% of adolescent hospitalizations and 90% of LARC placement occurred in adolescents with postpregnancy primary diagnoses. Additionally, middle adolescents (aged 14–17 years), Black and Hispanic adolescents, and adolescents who receive public insurance had higher odds of LARC initiation.

Middle adolescents in particular were more likely to initiate LARC. Although our data cannot elucidate reasons for this, it is possible that more pregnancies at this age were unintended¹²  or that providers were more proactive in initiating immediate postpregnancy LARC in this age group compared with older adolescents to prevent repeat pregnancies.¹³  Additionally, this study suggests several barriers to accessing inpatient contraceptive services for nonpregnant adolescents. The low rates of LARC initiation in adolescents hospitalized for medical diagnoses other than pregnancy could represent important missed opportunities for LARC initiation, especially given low rates of contraception provision in adolescents prescribed teratogenic medications in outpatient settings¹⁴  and the high rates of readmission for adolescents with chronic diseases.¹⁵  Although we were unable to examine this specifically, these findings may suggest that nonobstetric inpatient providers may be less aware of the contraceptive needs of this patient population, may be less comfortable providing LARC to adolescent patients, or may be less aware of the protections offered by minor consent laws and confidentiality related to sexual and reproductive health.

Whereas white adolescents made up the majority of eligible hospital admissions, nonwhite adolescents more frequently initiated LARC after adjusting for age, insurance type, and postpregnancy status. There may be a number of reasons for this difference, including that physicians hoping to reduce unplanned pregnancies in populations with the highest rates may be more mindful to offer LARC methods to those patients.¹⁶  Although exploration of physician factors was not possible through the data set used for our study, it is possible that physicians may be disproportionately offering LARC on the basis of biases that stem from the historical, systemic, and structural undervaluation of minority women’s reproductive autonomy.¹⁷  Additionally, patient factors may impact acceptance of LARC: nonwhite adolescents may be accepting offered LARC because of poor access outside of the hospital¹⁸  or feeling disproportionately pressured to accept LARC from their providers compared with white adolescents.¹⁹  Future research is needed to study the differences in contraceptive counseling methods by providers among different racial and ethnic minorities and how LARC initiation is impacted by receipt of preferred counseling methods among racial and ethnic minorities. Furthermore, prospective studies are needed on providers’ use and patients’ perceptions of patient-centered approaches to contraceptive counseling that maximize patient autonomy and promote respect for each individual’s choices about childbearing and contraception use.^20–22 

Postpregnancy status and smaller hospital size had higher odds of implant initiation compared with IUD initiation, and this association differed by region. Implants may be more likely to be placed because the procedure is less invasive and they are more widely accepted than IUDs by adolescents.²³  These findings may also be due to regional variations in provider training and comfort with LARC,²⁴  differences in state-level reimbursement of immediate postpregnancy LARC,²⁵  or preference for implant due to concern for possible expulsion of postpregnancy IUD (notably, the American College of Obstetricians and Gynecologists²⁶  encourages immediate postpregnancy IUD placement for those at greatest risk of not having recommended follow-up). More than 60% of inpatient pediatricians think initiation of LARC in the inpatient setting is appropriate, although they cite insufficient training, insufficient exposure to maintain skills, lack of time, and concerns about follow-up as potential barriers.²⁷  Addressing LARC, and especially IUD, capacity in rural, nonteaching, and smaller hospitals, such as increasing access to training and continuing education opportunities, may be particularly important in improving LARC access.

This study had several limitations. First, we could not measure if adolescents had preexisting LARC or other contraception, and, as such, we may have seen a lower proportion of LARC placement if contraception was previously initiated outpatient. Second, incomplete or inaccurate coding may have resulted in some LARCs not being captured and therefore not included in our analysis. Third, because of the limitations of the data available, we could not measure why LARC may have been placed (eg, for treatment of abnormal uterine bleeding versus for pregnancy prevention) or frequency of LARC in adolescents with associated high-risk diagnoses (eg, mental health or substance use), although this is an important area for future inquiry. Fourth, we could not assess why LARC may not have been placed for an eligible and interested adolescent (eg, if there was provider discomfort in placement of LARC or if a provider intended to initiate LARC but had issues with insurance reimbursement). Relatedly, we were unable to assess which provider specialties were or were not initiating LARCs. Finally, we were unable to conduct state-level analysis because of data use restrictions and so were unable to evaluate if differences in LARC initiation varied by state-determined public insurance reimbursement or parental consent laws.

The results of this study have important implications for both health care providers and policymakers. Hospitalization can be an important opportunity to initiate LARC for adolescents, but inconsistent insurance reimbursement²⁵  may limit LARC placement. Universal coverage of LARC by all insurance companies without cost-sharing,^28,29  unbundling postpartum LARC from other maternity care,²⁵  consistent Medicaid reimbursement of immediate postpregnancy LARC,³⁰  and reimbursement for contraceptive counseling³¹  may increase LARC access. Especially in rural and nonteaching hospital settings, provider discomfort²⁷  and a lack of hospital-based programs³²  may decrease access, which may require policy changes, such as increasing provider education and institutional protocols for LARC initiation²⁶  and reducing logistic and administrative barriers to increase supply.²⁵  Future research is needed to clarify the causes of the low rates of inpatient LARC initiation and to identify and close gaps in the number of adolescents desiring and initiating LARC in inpatient settings.

We acknowledge the HCUP Data Partners that contribute to HCUP: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.