Reforms stemming from the Affordable Care Act (ACA) are set to lower birth control costs for many women. For instance, new HHS guidelines require insurance plans to cover FDA-approved contraception without cost-sharing. The ACA also expands Medicaid eligibility and offers ways to simplify enrollment so that more low-income Americans can receive needed coverage, which includes family planning services and supplies.

Ideally, reducing costs should give women more freedom to choose the birth control method that is best for them, including methods with higher upfront prices. For example, intrauterine devices (IUDs) are considered one of the most effective methods, but they are also one of the most expensive.

The IUD is becoming more popular (it was even featured in a recent issue of Wired magazine), but only 5.5 percent of women in the United States are currently using one.[1] While one reason for this low rate may be high upfront costs, research shows there are other barriers, particularly for teens. For example, some providers may follow outdated guidelines that recommended against offering IUDs to unmarried women who have not yet had children. However, with additional research and improvements made to a new generation of IUDs, the American College of Obstetricians and Gynecologists (ACOG) now supports the IUD for adolescents and women who have not had children.[2]

In fact, IUDs may be particularly suited for teen mothers, many of whom experience repeat pregnancies during their teen years. Teens raising one child already face increased risks of poverty, unemployment, and delayed educational attainment; subsequent births may exacerbate these struggles.[3] Rates of repeat teen births are lower today than in the 1990s, but they are still higher for African American and Hispanic girls compared to Whites.[4]

The University of Chicago’s Section of Family Planning wanted to know about the obstacles adolescent mothers face when choosing the IUD as their birth control method. As part of a larger NIH-funded study, we interviewed 40 African-American, first-time adolescent mothers, 20 of whom said they were interested in using an IUD. Eight of these young women ended up getting an IUD within six months of giving birth, leaving 12 teens who did not get one. Most used condoms or withdrawal as a back-up method, but struggled with these and other methods like the pill or the vaginal ring. Three of the teens who did not get an IUD became pregnant within 12 months of giving birth.

Obstacles to Obtaining IUDs

Some of the biggest barriers for the teens included service-level obstacles (such as insurance, clinic access, provider inexperience), influence from their partners, and fears about side effects influenced by friends and family members.

Misinformation from Providers
One teen was incorrectly told by a provider that she had to be 18 or have parental consent while another was told that “only certain doctors” will provide IUDs. A third teen was informed that her doctor could not provide an IUD because his clinic was connected with a Catholic hospital. For another teen, it was hard to work out a time to get in for an appointment: “I missed my appointment . . .last month, . . . I couldn’t do it ‘cause I couldn’t afford to miss any more days out of school.”

Fears of Side Effects and Procedures
Many general misconceptions about IUD side effects continue to exist.  Even though IUDs have an excellent safety record[5], several participants had fears about complications and side effects that strongly affected their decision. The prevalence of misinformation among the study participants was concerning, suggesting that teens are in need of clearer counseling from providers.

One 16-year-old said, “Well they gave me a packet . . . and I read the side effects and I was like ohhh . . . I don’t know if I want to get this. It can fall out and get all these infections.” Another teen reported, “Cause [my doctor] said it was going to rip. I don’t want nothing to rip inside of me. So I got scared. . . I’m still thinking about getting it, but that scared me.”

A number of teens expressed fears about infections or infertility that they had heard from friends and family members. One young woman who had heard of a relative who couldn’t have kids after having an IUD said: “the doctor was saying… it’s different now, but, you know, if something [could] happen like that, I don’t even want to try it.”

General fears about the insertion procedure were also influential: “I don’t know what they do, they might stick me with something and I’m scared of needles and stuff like that.”

Resistance from Partners
A few participants faced resistance from their partners, with one teen reporting that her partner didn’t “want anything inside” her for five years and feared the presence of the IUD during sex. One partner wanted another baby and resisted a long-acting method: “He say he want another baby. But I’m, I’m not ready. I don’t want one . . . he got mad at me because I wanted to get on the 5-year thing.”

Support for Obtaining an IUD

The teens who obtained IUDs talked about the support they received from clinics, providers, family, friends and partners.

Support from Providers
Provider support and help in planning for the IUD during the pregnancy was a strong factor. As one participant reported, “When [I was] pregnant . . . I found out about a 5-year IUD and that’s when I started wanting it. As soon as I went to [my next prenatal visit] they asked me, ‘what did I want?’, and I told them and they ordered it then.”

Another teen said, “…they had it ready for my 6-week check up . . . I was 6 months pregnant, they had asked me. . . ‘did I plan on using the birth control method?,’ and the doctor had ordered it for me.”

Support from Family and Friends
Encouragement from family and peers was also valuable. One teen had a sister who liked her IUD while another talked to other people who had positive experiences with the method. This same teen noted that her partner encouraged her to consider birth control and agreed with her that the IUD was a good option.

At the same time, a strong sense of reproductive autonomy also influenced IUD choice, with one young woman reporting, “Cause he want to have a baby, another one, at least 3, and me . . . no. But it don’t matter, it’s me, it’s my body . . . that’s my decision.”

Careful Comparison
Some teens made their decision after comparing their options, with one commenting, “I don’t think the other methods would be good for me and this is something that I don’t have to worry about. So with the IUD I can just insert it and then I can go about my life.”

Another teen recognized that the IUD would offer consistent protection: “I missed my shot in February because I didn’t go to the doctor, I forgot I had an appointment and I didn’t go . . . and then I got on the IUD.”

As a result of health care reform, more women will be able to choose the best birth control method for them, not just the most affordable. Our study, which is set to be published in an upcoming issue of the American Journal of Obstetrics & Gynecology, suggests that health care providers can play a big role in supporting women’s birth control choices. Providers should be encouraged to stay up-to-date with information and research evidence on the full range of contraceptive methods.

Given the influence of family and peers, providers might start by asking young women what they have heard about different methods in order to address fears and provide comprehensive information. Where appropriate, including partners in birth control counseling may also prove helpful.

In these ways, they can counsel women – such as teens at high risk for repeat pregnancy – in choosing a safe and effective method.