AMERICAN JOURNAL OF PUBLIC HEALTH
EDITOR’S CHOICE
EDITOR-IN-CHIEF ASSISTANT EDITOR DEPUTY EDITOR FEATURE EDITOR IMAGE EDITOR ASSOCIATE EDITORS
Realizing Reproductive Health Equity for Adolescents and Young Adults Reproductive health equity is essential to optimizing quality of life for adolescents and young adults. Highly effective, evidence-based contraception is one vital component of this social justice agenda. An unplanned pregnancy and birth may alter the life course of an adolescent mother and her partner, hindering their opportunities to complete high school, graduate from college, secure meaningful employment with a living wage, and raise their children in a nurturing home within a safe community. Moreover, direct medical costs and increased public assistance expenditures from adolescent pregnancy and childbirth are estimated at $10 billion annually in the United States alone. As adolescent medicine specialists providing comprehensive contraceptive services to adolescent and young adult women in Bronx, New York, we help prevent many unintended pregnancies. Despite our efforts, some of our patients become pregnant before they are ready to be parents. We are currently investigating the role of reproductive coercion by male partners in the disproportionately high rates of adolescent pregnancy in the Bronx when compared with other communities. Reproductive coercion consists of (1) contraceptive sabotage or active interference with contraceptive methods, such as disposing of birth control pills or manipulating condoms, or (2) pregnancy pressure, such as threats to promote a pregnancy or block the female partner from seeking access to contraception. In the United States, nearly 600 000 girls younger than 20 years become pregnant each year. The majority of these pregnancies are unintended. The resulting burden of abortions and ill-timed births rests overwhelmingly on the poor and racial/ethnic minorities. Nonetheless, according to data from the National Survey of Family Growth, US pregnancy rates among girls aged 15 to 19 years have decreased over the past two decades. Increased use of condoms, birth control pills, and injection methods as well as two or more methods such as pills and condoms has been shown to be the main driver of this decrease. Yet further improvement is within reach. The American Academy of Pediatrics recommends long-acting reversible contraceptives (LARC), such as implants or intrauterine devices (IUDs), as a first-line option for adolescents and young adults. While LARC methods are highly effective as well as both safe and acceptable to adolescents and young adults, their use in this age group remains low. Yet LARCs
1284 | Editor's Choice
are associated with higher continuation rates than shorter-acting methods such as birth control pills, especially for adolescents and young adults. In a large cohort study where barriers to contraception including access and cost were removed, the majority of girls aged 14 to 17 years chose a LARC method. More importantly, pregnancy, birth, and abortion rates in this cohort were below corresponding US national rates. As readers of AJPH are aware, the Affordable Care Act (ACA) has expanded health care coverage to certain vulnerable populations, including adolescents and young adults. Many preventive health services are required elements of the new insurance exchange plans, including contraceptives, at no additional cost. Therefore, by eliminating cost barriers to contraception for adolescents and young adults, the ACA may usefully abet increased use of LARCs, which have high up-front but low overall cost, and ultimately even further decreases in unintended pregnancy and birth rates in this age group. LARC methods may be especially effective in decreasing unintended pregnancy rates among adolescent women who experience reproductive coercion, given that IUDs and implants are less susceptible to partner interference. If the past is any guide, even with cost barriers removed, there will no doubt be knowledge gaps, access issues, and confidentiality hurdles to realizing reproductive health equity for adolescents and young adults. Thus, we must reframe the debate around the latest scientific evidence, and the lived experiences of adolescents and young adults. All young people deserve every opportunity we can afford them as a society to pursue healthy and meaningful lives. j
Jennifer L. Northridge, MD Postdoctoral Fellow in Adolescent Medicine Susan M. Coupey, MD Chief, Adolescent Medicine and Professor of Pediatrics The Children’s Hospital at Montefiore The Pediatric Hospital for Albert Einstein College of Medicine Bronx, NY doi:10.2105/AJPH.2015.302701
Mary E. Northridge, PhD, MPH Ariel P. Greenblatt, DMD, MPH Farzana Kapadia, PhD Gabriel N. Stover, MPA Aleisha Kropf Hortensia Amaro, PhD Eric R. Buhi, PhD Paul C. Erwin, MD, DrPH Michael R. Greenberg, PhD Sofia Gruskin, JD, MIA Said Ibrahim, MD, MPH Robert J. Kim-Farley, MD, MPH Stewart J. Landers, JD, MCP Stella M. Yu, ScD, MPH ASSOCIATE EDITOR FOR STATISTICS AND EVALUATION Roger Vaughan, DrPH, MS INTERNATIONAL ASSOCIATE EDITORS Kenneth Rochel de Camargo Jr, MD, PhD (Rio de Janeiro, Brazil) Daniel Tarantola, MD (Ferney-Voltaire, France) DEPARTMENT EDITORS Roy Grant, MA Government, Law, and Public Health Practice Public Health Policy Briefs Elizabeth Fee, PhD, and Theodore M. Brown, PhD Images of Health Public Health Then and Now Voices From the Past Mark A. Rothstein, JD Public Health Ethics Kenneth R. McLeroy, PhD, and Deborah Holtzman, PhD, MSW Framing Health Matters EDITORIAL BOARD Jeffrey R. Wilson, PhD, MS (2015), Chair Chinua Akukwe, MD, MPH (2015) Jermane Bond, PHD (2017) Gwen Chodur (2015) Keith Elder, PhD, MPH (2016) Thomas Greenfield, PhD (2015) Dio Kavalieratos, PhD (2016) Denys T. Lau, PhD (2017) Maureen Lichtveld, MD, MPH (2015) Justin B. Moore, PhD (2016) Samuel L. Posner, PhD (2015) F. Douglas Scutchfield, MD (2017) Ruth Zambrana, PhD (2016) STAFF Georges C. Benjamin, MD Executive Director/Publisher Ashell Alston, Publications Director Brian Selzer, Deputy Publications Director Morgan Richardson, Production Coordinator Michael Henry, Associate Production Editor (Sr) Aisha Jamil, Associate Production Editor (Jr) Mazin Abdelgader, Graphic Designer Vivian Tinsley, Subscriptions Manager FREELANCE STAFF Kelly Burch, Greg Edmondson, John Lane, Gary Norton, Michelle Quirk, Alisa Riccardi, Trish Weisman, Eileen Wolfberg, Copyeditors Nestor Ashbery, Sarah Cook, Marci McGrath, Chris Smith, Proofreaders Vanessa Sifford, Graphic Designer
A list of sources for this column is available upon request.
American Journal of Public Health | July 2015, Vol 105, No. 7
EDITOR’S CHOICE
EDITOR-IN-CHIEF ASSISTANT EDITOR DEPUTY EDITOR FEATURE EDITOR IMAGE EDITOR ASSOCIATE EDITORS
Realizing Reproductive Health Equity for Adolescents and Young Adults Reproductive health equity is essential to optimizing quality of life for adolescents and young adults. Highly effective, evidence-based contraception is one vital component of this social justice agenda. An unplanned pregnancy and birth may alter the life course of an adolescent mother and her partner, hindering their opportunities to complete high school, graduate from college, secure meaningful employment with a living wage, and raise their children in a nurturing home within a safe community. Moreover, direct medical costs and increased public assistance expenditures from adolescent pregnancy and childbirth are estimated at $10 billion annually in the United States alone. As adolescent medicine specialists providing comprehensive contraceptive services to adolescent and young adult women in Bronx, New York, we help prevent many unintended pregnancies. Despite our efforts, some of our patients become pregnant before they are ready to be parents. We are currently investigating the role of reproductive coercion by male partners in the disproportionately high rates of adolescent pregnancy in the Bronx when compared with other communities. Reproductive coercion consists of (1) contraceptive sabotage or active interference with contraceptive methods, such as disposing of birth control pills or manipulating condoms, or (2) pregnancy pressure, such as threats to promote a pregnancy or block the female partner from seeking access to contraception. In the United States, nearly 600 000 girls younger than 20 years become pregnant each year. The majority of these pregnancies are unintended. The resulting burden of abortions and ill-timed births rests overwhelmingly on the poor and racial/ethnic minorities. Nonetheless, according to data from the National Survey of Family Growth, US pregnancy rates among girls aged 15 to 19 years have decreased over the past two decades. Increased use of condoms, birth control pills, and injection methods as well as two or more methods such as pills and condoms has been shown to be the main driver of this decrease. Yet further improvement is within reach. The American Academy of Pediatrics recommends long-acting reversible contraceptives (LARC), such as implants or intrauterine devices (IUDs), as a first-line option for adolescents and young adults. While LARC methods are highly effective as well as both safe and acceptable to adolescents and young adults, their use in this age group remains low. Yet LARCs
1284 | Editor's Choice
are associated with higher continuation rates than shorter-acting methods such as birth control pills, especially for adolescents and young adults. In a large cohort study where barriers to contraception including access and cost were removed, the majority of girls aged 14 to 17 years chose a LARC method. More importantly, pregnancy, birth, and abortion rates in this cohort were below corresponding US national rates. As readers of AJPH are aware, the Affordable Care Act (ACA) has expanded health care coverage to certain vulnerable populations, including adolescents and young adults. Many preventive health services are required elements of the new insurance exchange plans, including contraceptives, at no additional cost. Therefore, by eliminating cost barriers to contraception for adolescents and young adults, the ACA may usefully abet increased use of LARCs, which have high up-front but low overall cost, and ultimately even further decreases in unintended pregnancy and birth rates in this age group. LARC methods may be especially effective in decreasing unintended pregnancy rates among adolescent women who experience reproductive coercion, given that IUDs and implants are less susceptible to partner interference. If the past is any guide, even with cost barriers removed, there will no doubt be knowledge gaps, access issues, and confidentiality hurdles to realizing reproductive health equity for adolescents and young adults. Thus, we must reframe the debate around the latest scientific evidence, and the lived experiences of adolescents and young adults. All young people deserve every opportunity we can afford them as a society to pursue healthy and meaningful lives. j
Jennifer L. Northridge, MD Postdoctoral Fellow in Adolescent Medicine Susan M. Coupey, MD Chief, Adolescent Medicine and Professor of Pediatrics The Children’s Hospital at Montefiore The Pediatric Hospital for Albert Einstein College of Medicine Bronx, NY doi:10.2105/AJPH.2015.302701
Mary E. Northridge, PhD, MPH Ariel P. Greenblatt, DMD, MPH Farzana Kapadia, PhD Gabriel N. Stover, MPA Aleisha Kropf Hortensia Amaro, PhD Eric R. Buhi, PhD Paul C. Erwin, MD, DrPH Michael R. Greenberg, PhD Sofia Gruskin, JD, MIA Said Ibrahim, MD, MPH Robert J. Kim-Farley, MD, MPH Stewart J. Landers, JD, MCP Stella M. Yu, ScD, MPH ASSOCIATE EDITOR FOR STATISTICS AND EVALUATION Roger Vaughan, DrPH, MS INTERNATIONAL ASSOCIATE EDITORS Kenneth Rochel de Camargo Jr, MD, PhD (Rio de Janeiro, Brazil) Daniel Tarantola, MD (Ferney-Voltaire, France) DEPARTMENT EDITORS Roy Grant, MA Government, Law, and Public Health Practice Public Health Policy Briefs Elizabeth Fee, PhD, and Theodore M. Brown, PhD Images of Health Public Health Then and Now Voices From the Past Mark A. Rothstein, JD Public Health Ethics Kenneth R. McLeroy, PhD, and Deborah Holtzman, PhD, MSW Framing Health Matters EDITORIAL BOARD Jeffrey R. Wilson, PhD, MS (2015), Chair Chinua Akukwe, MD, MPH (2015) Jermane Bond, PHD (2017) Gwen Chodur (2015) Keith Elder, PhD, MPH (2016) Thomas Greenfield, PhD (2015) Dio Kavalieratos, PhD (2016) Denys T. Lau, PhD (2017) Maureen Lichtveld, MD, MPH (2015) Justin B. Moore, PhD (2016) Samuel L. Posner, PhD (2015) F. Douglas Scutchfield, MD (2017) Ruth Zambrana, PhD (2016) STAFF Georges C. Benjamin, MD Executive Director/Publisher Ashell Alston, Publications Director Brian Selzer, Deputy Publications Director Morgan Richardson, Production Coordinator Michael Henry, Associate Production Editor (Sr) Aisha Jamil, Associate Production Editor (Jr) Mazin Abdelgader, Graphic Designer Vivian Tinsley, Subscriptions Manager FREELANCE STAFF Kelly Burch, Greg Edmondson, John Lane, Gary Norton, Michelle Quirk, Alisa Riccardi, Trish Weisman, Eileen Wolfberg, Copyeditors Nestor Ashbery, Sarah Cook, Marci McGrath, Chris Smith, Proofreaders Vanessa Sifford, Graphic Designer
A list of sources for this column is available upon request.
American Journal of Public Health | July 2015, Vol 105, No. 7
