Teen-pregnancy rates have declined considerably in the United States over the last couple decades—from 61.8 births per 1,000 15-to-19-year-olds in 1991 to 26.5 per 1,000 in 2013. That’s an all-time-low, according to the Centers for Disease Control and Prevention, and is partly thanks to increased use of contraception.

But teenagers’ preferred methods are still condoms and the Pill—relatively few are using what is now considered the gold standard of birth control: long-acting reversible contraception (LARC) methods like intrauterine devices (IUDs) and implants. According to new CDC data, in 2013, 7.1 percent of 15-to-19-year-olds seeking contraception at Title X family-planning clinics chose LARC methods, with more of them going for implants than IUDs. This is up from 0.4 percent in 2005—a 15-fold increase—but still pretty low, considering IUDs and implants are widely considered to be the best birth control available.


Percentage of Female Teens Aged 15-to-19 Using LARC

CDC

In 2011, the American College of Obstetricians and Gynecologists declared LARC methods to be “the most effective forms of reversible contraception available and… safe for use by almost all reproductive-age women.” In 2014, the American Academy of Pediatrics recommended IUDs and implants for adolescents, newly declaring IUDs safe for adolescents who have never given birth.

Those past concerns might stem from the Dalkon Shield debacle of the 1970s, when multiple users of that IUD reported experiencing serious medical problems—inflammation, infection, and even infertility. That shadow loomed large in U.S. consciousness for a while, Quartz reported last year: "Many patients—and even physicians—are still under the impression that all IUDs put women at risk for infertility, ectopic pregnancy, and perforation of the uterus," author Rachel Feltman wrote.

"Currently available IUDs are safe and effective for women, including teens," Tara Jatlaoui, an OB-GYN and guest researcher in the CDC’s Division of Reproductive Health, said in an email. "While many IUDs of the past were also safe, the Dalkon Shield tainted the IUD's reputation and was pulled from the market in the 1970s due to serious complications with its use after a few short years. Current IUDs do not have the same design or insertion procedure as the Dalkon Shield, which contributed to an unacceptable number of complications with its use."

“IUDs are very different than they were in the 1970s,” says Lisa Romero, the lead author on the new report and a health scientist in CDC’s Division of Reproductive Health. “[Parents] may think about ‘the IUD I knew back when.’” She says she encourages parents to get educated, as well as teens. As well as providers. Education all around, actually, seems to be in order.

With the AAP and ACOG recommendations still being relatively new, IUDs and implants may not yet have saturated the public consciousness the way condoms and birth-control pills have.

“A lot of times teens go into a clinic and say ‘I want to get on the birth-control pill,’ because they’re not aware they can use a long-acting reversible method,” Romero says. If they did know they could, most of them would choose one. When the CHOICE project, conducted by Washington University in St. Louis, offered free contraception and counseling to 1,404 teens, 75 percent of them chose a LARC. And 86 percent of the LARC adopters were still using their method of choice a year later.

“Continuation rates are very high,” Romero affirms—probably because once the IUD or implant is inserted, that’s it. You don’t have to do anything else until it’s time to take it out three to 10 years later. But even when teens are fully informed, they may have concerns. Getting an IUD inserted is more invasive than just swallowing a pill, after all.

“They may be concerned about having a foreign object in one’s body, or about possible painful insertion or removal,” Romero says. “They may say ‘I’ve heard you bleed a lot at the beginning,’ or ‘I’m concerned you might be able to see or feel the implant in my arm.’”

The physician’s role in all this is as an informant—to let patients know what to expect and address misconceptions (you can’t feel or see an implant in your arm, for example, Romero says). Many adolescents still see pediatricians, though, and as Kaiser Health News reported earlier this year, pediatricians aren’t always sufficiently trained in inserting IUDs. And they may not be comfortable offering IUDs and implants as options to young women, since it’s likely that for most of the time they’ve been in practice, this wasn’t the official recommendation.

The U.S. in general seems to be lagging behind other countries when it comes to using LARC birth control, at least according to a 2007 report by the Guttmacher Institute, which found a much smaller percentage of U.S. women used IUDs than women in European countries.


IUD Use By Country

Guttmacher Institute

Romero sees a similar disparity among youth. “When you look at European studies, they’re not facing the same barriers that we are,” she says. “I just think that they have overall different cultural attitudes and beliefs toward adolescent sexuality. And I’ll leave it at that.”

Within the U.S., adoption is spotty. In the CDC report, states varied widely in how many teens were using LARCs—Colorado was the highest at 26 percent, and Mississippi was the lowest at 0.7 percent.

Overall, though, the trend is on the upswing. The CDC recommends a “client-centered approach for contraceptive counseling” in its report, in which providers help patients figure out what works best for them. But it also recommends that “the most effective methods be discussed first”—those being LARCs. If they’re at the front of the line, the thinking goes, soon they’ll be front of mind for women looking for birth control, and those bar charts will continue to climb.