Some of my teenage patients think that they can't get pregnant if they have sex standing up. Or that they can't get pregnant in a swimming pool. And that they're protected the first day they start the contraceptive pill.
What is more surprising is that teenagers aren't the only ones who have misconceptions (no pun intended) about birth control. Many women - and even their nurses and physicians (or other clinicians) - are not up to date on the latest evidence.
Our nation's unintended pregnancy rate is a red flag, telling us that women need help not only accessing birth control but selecting methods that will work well for them and understanding appropriate use.1
Fifty percent of pregnancies in the U.S. are unintended, and more than two thirds of those among unmarried women aged 20-29 are unintended.2-3
Nurses can play an important role in this effort, providing education about consistent and effective use.
Understanding Contraception Options
To use birth control reliably, women first must know their options, so that they can pick the method that will be most effective and efficient for them.
Birth control methods have changed in the past few years, and so have guidelines for eligibility.
Two of the biggest changes in protocol concern use of the birth control pill and intrauterine device, not to mention the development of new hormonal methods like the ring, the patch, and the implant.
To help a patient select the right method, the Reproductive Health Access Project provides excellent fact sheets on birth control choices. It's a free download in multiple languages and simplifies contraceptive education at: http://www.reproductiveaccess.org/fact_sheets/bc_choices.htm.
Don't Hold Birth Control Hostage
Birth control must be easily accessible for it to be used reliably, but there are many common practices that create unnecessary barriers for women.
The idea that women need to have a pelvic exam and Pap smear before receiving, or renewing, a prescription for oral contraception is practically engraved in stone in many clinicians' offices.
As the gatekeepers of these practices, nurses are often charged with enforcing this requirement. But we know now that there is no connection between cervical cancer and hormonal contraception.4
Some medical practices use the birth-control prescription as a carrot to ensure that women have regular office visits.
However, if a woman can't make it to her appointment for any reason, including circumstances beyond her control, she could run out of birth control and become pregnant.
Although it is important for women to attend follow-up appointments, we should not tie the number of refills to the next appointment.5
Quick Start: The Fastest Way to Protection
Quick start means initiating the pill, patch, ring, or injection on the day of an office visit.
For most patients, there's no need to wait until the next period - it's easier to start right away. Quick start helps avoid unintended pregnancies that occur while patients are waiting to start a new method.
In the adolescent clinic where I work, many teens choose the progestin injection (also known as Depo Provera). Depo is an adolescent-friendly form of birth control, because young women can receive the injection at a clinic and do not have to go to a pharmacy. One shot lasts for 3 months.
I caution girls, however, that, if their parents are not supportive of their choice to use birth control, they may not be able entirely to keep this choice to themselves.
Depo can cause heavy periods as well as skipped periods. Another popular choice for teens is the Nuvaring. It can be purchased at a pharmacy and needs to be changed once a month. Nuvaring's high cost is a barrier for many teens and women.
Long-Acting Reversible Contraception
Due to the consultative role nurses play in the clinic setting, it is crucial that they fully understand the pluses and minus of the IUD and implant.
The IUD is a safe method and use is on the rise in the U.S. but still lags far behind Europe. Once thought appropriate only for women who'd given birth, the World Health Organization and Centers for Disease Control and Prevention guidelines now confirm that the IUD is safe in women and teens who have never had a baby.
There are two kinds of IUD: the copper IUD (non-hormonal) and the progestin IUD (hormonal).
The IUD and implant are excellent choices for young women who are sexually active and whose lives are not sufficiently stable to use the pill consistently.
For example, a girl who travels between two parents' homes or is likely to forget to take or to lose her pills is a good candidate.
However, any teenager using an IUD or implant must understand that these methods, like the pill/patch/ring, don't protect them from sexually transmitted diseases, and condoms remain essential for that purpose.
Many clinicians worry that IUDs cause ectopic pregnancy. It's true that the rare pregnancies that occur with an IUD in place may be ectopic; but the overall rate of pregnancy is so low with IUDs, that they actually serve to protect women from ectopic pregnancy.
Most insurance carriers and Medicaid cover IUDs, but uninsured patients may find IUDs' up-front cost prohibitive.
The cost of an IUD can range from about $200 in a federally funded health center to more than $1,000 in other settings. Although IUDs cost more initially, they last for 7-12 years, depending upon the type, so they are often less expensive in the long run than other birth control methods.
Birth Control after Childbirth
Many women request contraception at the time that they give birth, and postpartum nurses are often their go-to resources for advice in this area.
Although many women believe that they can't get pregnant while breastfeeding, they certainly can.
Many women use the "mini" (progestin-only) pill or the IUD while breastfeeding, and switch to the regular pill or other hormonal contraception once they are finished breastfeeding.
For an IUD to be placed, women need a post-partum check-up (unless the IUD is placed in the first few minutes after birth).
Possibly the most misunderstood form or contraception is the emergency form - called EC, or the "morning-after pill."
It is even more important now that healthcare providers understand EC, since the U.S. Department of Health and Human Services recently began requiring that this medication be held behind the pharmacy counter and that women under age 17 provide a prescription for it. Emergency contraception can be used up to five days after sex to prevent implantation of the embryo.
It is not the same as medication abortion, which is a pill-induced abortion that can be used within the first 8 weeks of pregnancy.
Prescribing Birth Control to Teens
For teens who are seeking birth control, the issue of confidentiality can be a major barrier.
Yet, it is legal in many states to provide teens with birth control medication or devices without parental consent. Visit the Guttmacher Institute website, http://www.guttmacher.org/statecenter/spibs/spib_MACS.pdf for state-by-state information on minors' access to contraceptive services.
Moreover, patients who don't have health insurance do not have to pay the high price of brand-name oral contraceptives. Most of the major brands are available in generic form from chain pharmacies for as little as $9 a pack.
The Reproductive Health Access Project offers a list of pharmacies that offer low-cost birth control pills: http://www.reproductiveaccess.org/contraception/lowcost_pills.htm
Protection Against Disease: Condoms
Sexually active teens and women may not realize that they must protect themselves from sexually transmitted diseases as well as from pregnancy.
I constantly emphasize with my patients that birth control is for pregnancy prevention and condoms are for disease prevention. Both are essential because the risk of pregnancy with condoms is relatively high.
In New York City, where I live, girls ages 15 to 19 have the highest rate of chlamydia, whereas men ages 20-24 have the highest rates of infection-a function of young women having older partners.
Women in trusting, monogamous relationships sometimes make the decision to stop using condoms. But in a new relationship, or one in which either partner is having sex with multiple partners, condoms should be non-negotiable.
If I could give all nurses one bit of advice, it would be this: Make sure that your patients know all of their birth control options! For some patients, the best method is the one they hadn't considered.
References for this article can be accessed here.
Mary Joan L. Murphy is a pediatric nurse practitioner in New York, NY.