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May 7, 2020

Providing Contraception for Young People During a Pandemic Is Essential Health Care

Author Affiliations
  • 1Department of Pediatrics/Children’s Health Services Research, Indiana University School of Medicine, Indianapolis
  • 2Jane Fonda Center, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
  • 3Division of Adolescent Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Columbus
JAMA Pediatr. Published online May 7, 2020. doi:10.1001/jamapediatrics.2020.1884

Adolescent and young adult reproductive health care needs are not diminished during pandemics. Needs for family planning services may be heightened because of various environmental changes in response to the pandemic, including amount of parental supervision, daily structure, and usual ways of accessing contraception and condoms. Health care professionals (HCPs) caring for adolescent and young adult patients need to acknowledge that contraception is an essential need and adopt new approaches to providing this crucial care.

In response to the coronavirus disease 2019 (COVID-19) pandemic, HCPs are exploring ways to ensure delivery of essential health care services and minimize exposure risks to personnel and patients, including virtual care. Fortunately, both telephone and video platforms are well suited to providing contraceptive care. While an in-person encounter may be ideal, many reproductive health care services can be performed virtually, including contraception counseling, provision and maintenance of regular and emergency contraception, and sexual risk-reduction counseling. We propose the following approach for providing contraception to adolescents during COVID-19 that leverages virtual care and minimizes the need for in-person visits (Figure). This approach can be used by many HCPs and across telehealth and in-person settings.

Figure.  Algorithm for Providing Contraception for Young People During a Pandemic
Algorithm for Providing Contraception for Young People During a Pandemic

AYA indicates adolescents and young adults; BP, blood pressure; DMPA, depot medroxyprogesterone acetate; EC, emergency contraception; HCP, health care professional; IUD, intrauterine contraceptive device; LARC, long-acting reversible contraception; US MEC, US medical eligibility criteria for contraceptive use.

Safe provision of contraception relies largely on history and rarely requires a physical examination, pelvic or breast examinations, sexually transmitted infection, or cervical cancer screenings.1 Much of the information needed can be obtained from the patient history, including patient-reported or previously recorded blood pressure. The US Medical Eligibility Criteria for Contraceptive Use provides guidance on contraindications to contraceptives based on the patient history and is available in many forms, including a smartphone application.1

A challenge in conducting telehealth with adolescents is patient privacy; adolescents may not have a private space and HCPs may not be able to reliably assess whether an adolescent’s verbal communication is actually private. It is important to explore who is in the room and if the patient can speak freely. We recommend using clinical judgement to guide whether you can safely ask about sensitive content and how much you need to obtain. It is not necessary to obtain a complete sexual history to prescribe contraceptives. Consider using yes/no questions for sensitive topics, such as interest in contraception, sexual history, and pregnancy screening.

Fortunately, a healthy young person with no active or previous medical conditions who takes no medications or supplements can safely use any reversible contraceptive method. Using contraception is very safe and is safer than pregnancy. HCPs can ask questions to be reasonably certain a person is not pregnant. If there are no signs or symptoms of pregnancy and the patient meets additional criteria as identified in the US Medical Eligibility Criteria for Contraceptive Use (Figure), contraception, other than intrauterine contraception, can be administered immediately.1 Even in situations in which an HCP is not reasonably certain a person is not pregnant, the benefits of administering contraception that day (except intrauterine devices) generally outweigh the risks, as none of the contraceptive methods are known to be teratogenic or abortifacient.1 Health care professionals can encourage patients to take a home pregnancy test in these situations.

Contraception counseling can be performed virtually using shared decision-making to incorporate patients’ preferences and priorities. Clinicians may consider incorporating high-quality resources, including videos and images, such as those available at bedsider.org, before, during (screen-sharing), or after their virtual patient encounter.2 Pills, transdermal patch, and vaginal rings can be refilled or initiated on the day of the telehealth encounter and a 12-month supply should be provided.3 After initiation, use of a backup method for 7 days is recommended. Progestin-only contraceptive pills (norethindrone and drosperinone) are an option for those with a medical contraindication to estrogen.1

Depot medroxyprogesterone acetate is a progestin-only method available as a 150-mg intramuscular or 104-mg subcutaneous injection. Traditionally, it is administered every 3 months in a clinical setting. However, during pandemic times, HCPs can consider extending the dosing interval to 15 weeks and exploring creative approaches to intramuscular delivery (eg, curbside).1 Alternately, the subcutaneous form may be prescribed along with alcohol swabs for self-administration at home. Medication teaching can be provided verbally, by video, and/or via a patient information sheet, such as the one made by the Reproductive Health Access Project.4

For the patient who is interested in a long-acting reversible contraceptive method (ie, an intrauterine device or implant), a shorter-acting contraceptive should be offered to provide contraception while awaiting in-person placement. People currently using a long-acting reversible contraceptive method nearing the end of their US Food and Drug Administration–approved length of use can be reassured that these devices have contraceptive benefit beyond the approved window.5

Counseling patients about using emergency contraception pills (ie, levonorgestrel, 1.5 mg, and ulipristal acetate, 30 mg) and offering an advanced prescription may be particularly beneficial now to reduce patient cost and access barriers. Ulipristal acetate is more effective than levonorgestrel, particularly for those who have a body mass index (calculated as weight in kilograms divided by height in meters squared) above 30 or who had sex more than 72 hours ago. Patients who take ulipristal acetate for emergency contraception should wait 5 days to take a hormonal contraceptive and use condoms until their next menses. It is also important to encourage consistent condom use for sexually transmitted infection prevention, backup for birth control, and dual protection. For any contraceptive method prescribed, clinicians should review the options for obtaining the product (eg, purchasing or filling a prescription at a pharmacy and online/telephone ordering with home delivery). After a method is chosen, HCPs should inform patients to contact them if there are costs or insurance barriers during the pandemic.

In addition to these approaches, 11 states and the District of Columbia allow for pharmacist-prescribed contraception. Further, some private companies provide telehealth options for home delivery of contraceptives.6,7 However, we believe it is possible and imperative for HCPs to prioritize contraception access for young people throughout this pandemic and beyond as essential health care.

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Article Information

Corresponding Author: Tracey A. Wilkinson, MD, MPH, Indiana University School of Medicine, 410 W 10th St, Ste 2000, Indianapolis, IN 46202 (tracwilk@iu.edu).

Published Online: May 7, 2020. doi:10.1001/jamapediatrics.2020.1884

Conflict of Interest Disclosures: Dr Berlan is a consultant to Merck and Bayer and is a Nexplanon clinical trainer. No other disclosures were reported.

References
1.
Curtis  KM, Tepper  NK, Jatlaoui  TC,  et al. US Medical eligibility criteria for contraceptive use, 2016. Accessed April 4, 2020. https://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm
2.
Power to Decide. Birth control methods. Accessed April 4, 2020. http://www.bedsider.org/methods
3.
Quick Start Algorithm. Patient requests a new birth control method. Accessed April 6, 2020. https://www.reproductiveaccess.org/wp-content/uploads/2014/12/QuickstartAlgorithm.pdf.
4.
Depo-Provera Sub-Q. User guide. Accessed 2, 2020. https://www.reproductiveaccess.org/resource/depo-subq-user-guide/
5.
McNicholas  C, Swor  E, Wan  L, Peipert  JF.  Prolonged use of the etonogestrel implant and levonorgestrel intrauterine device: 2 years beyond Food and Drug Administration-approved duration.   Am J Obstet Gynecol. 2017;216(6):586.e1-586.e6. doi:10.1016/j.ajog.2017.01.036PubMedGoogle ScholarCrossref
6.
Williams  RL, Meredith  AH, Ott  MA.  Expanding adolescent access to hormonal contraception: an update on over-the-counter, pharmacist prescribing, and web-based telehealth approaches.   Curr Opin Obstet Gynecol. 2018;30(6):458-464. doi:10.1097/GCO.0000000000000497PubMedGoogle ScholarCrossref
7.
Free the Pill. Who prescribes the pill online? Accessed April 4, 2020. http://freethepill.org/online-pill-prescribing-resources/
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