Objective
We assessed barriers and facilitators to uptake of the intrauterine device (IUD) among primiparous African American adolescent mothers.
Study Design
Twenty participants who expressed IUD desire completed 4-5 qualitative interviews during the first postpartum year as part of a larger longitudinal study. Transcripts were analyzed for salient themes using a grounded theory approach to content analysis.
Results
Twelve participants did not obtain IUDs and instead used condoms, used no method, or intermittently used hormonal methods, resulting in 3 repeat pregnancies. Outdated IUD eligibility requirements, long wait times, lack of insurance coverage, and fear of IUD-related side effects precluded or delayed uptake. Facilitators to IUD uptake included strong recommendations from providers or family members, planning for IUD during pregnancy, and perceived reproductive autonomy.
Conclusion
Postpartum adolescents may reduce their risk of rapid repeat pregnancy by using IUDs. Providers and members of adolescents’ support networks can be instrumental in method adoption.
The United States has the highest adolescent birth rate in the developed world. Rapid repeat pregnancy (RRP), occurring within 24 months of the previous birth, is experienced by 20-66% of adolescent mothers, and increases the risk of poor maternal and fetal outcomes, unemployment, and poverty. National birth data indicate higher rates of RRP among African American adolescents (23%) compared to white adolescents (17%). Reducing the proportion of RRPs among women in the United States, including adolescents, is a Healthy People 2020 objective.
Interventions to reduce RRP among adolescents have featured home visiting, motivational counseling, mentoring, and monetary incentives. While some recent achievements have been noted, these programs have not demonstrated consistent success and some researchers have called for the promotion of long-acting contraception methods for at-risk adolescents. Indeed, studies have shown that adolescent mothers who initiate longer-acting, reversible contraceptive methods (ie, depot medroxyprogesterone acetate [DMPA] or progestin-only implants) immediately after delivery have a lower risk of RRP and higher method continuation rate at 12 months compared to those who adopt shorter-acting methods such as oral contraceptive pills or the contraceptive patch.
The intrauterine device (IUD) is an ideal postpartum method because it does not interfere with lactation, facilitates adequate birth spacing, and does not require repeat health care visits for contraceptive refills. A recent committee opinion by the American College of Obstetricians and Gynecologists recommends the IUD as a first-line choice for adolescents. Despite its potential benefits, the IUD remains underused in the United States by women of all age groups and research has demonstrated barriers for postpartum and adolescent populations. A retrospective study found that only 60% of postpartum women who requested an IUD obtained the device, waiting an average of 60.5 days postdelivery for insertion. Providers may limit IUD use among adolescents by citing concerns about infection, expulsion, and infertility.
The purpose of this research is to better understand barriers to IUD uptake by postpartum adolescents. Through longitudinal qualitative interviews, we identify factors that prevent, delay, or support uptake of the IUD among postpartum adolescents who expressed desire to obtain the IUD. We focus exclusively on African Americans to provide rich information on a subset of the adolescent postpartum population at high risk for RRP.
Materials and Methods
This analysis uses data from the Postpartum Adolescent Birth Control Study (Postpartum ABCs), a longitudinal study of first-time African American adolescent mothers. Participants were recruited through referral from physicians, social workers, labor and delivery nurses, housing programs, community-based programs, and schools in the Chicago, IL, area serving pregnant adolescents. Toward the end of the study we used snowball sampling to recruit participants to accelerate progress toward enrollment targets; 4 participants enrolled in the study through this mechanism. Eligible participants were 14-18 years old at childbirth, primiparous, African American, ≤9 weeks’ postpartum, and living in Chicago, IL. Following enrollment, we conducted qualitative, semistructured interviews at 4-9 weeks (baseline), 3 months, 6 months, 9 months, and 12 months postpartum. Eligibility criteria were relaxed for 4 participants who enrolled later in the postpartum period (ie, 11-13 weeks) and thus completed a combined baseline/3-month interview, for a total of 4 total interviews. Forty participants enrolled in the study and completed a baseline interview. Interview completion rates at each study visit were 100%, 90%, 85%, 85%, and 80%, respectively, with 31 (78%) participants completing all study visits. Participants received $20 for each completed interview. We obtained written informed consent from all participants and parental consent for those aged <18 years. The institutional review board at the University of Chicago approved the research protocol.
Female research staff conducted 45- to 90-minute interviews in a private space in the participants’ homes. All interviews were recorded and transcribed verbatim by study staff or a professional service. The interview guide was derived through formative research consisting of 2 focus groups with young African American women who had given birth as adolescents. Based on findings from these sessions, the longitudinal interviews explored the following topics: contraceptive use and attitudes; postpartum physical changes; relationship dynamics with parents, peers, and partners; educational and vocational goals; and neighborhood safety.
This analysis focuses on the section of the interview in which participants were asked about their use of contraception. From the larger study sample of 40 participants, we restricted the analysis cohort to participants who expressed both desire for and intention to obtain the IUD in at least 1 interview. Those missing >3 interviews (n = 2) were excluded from this analysis, given its focus on longitudinal outcomes. This resulted in 20 participants: 19 who completed all study visits and 1 who missed only her 3-month visit. We used a qualitative data analysis software program (ATLAS.ti 5.0; Scientific Software Development GmbH, Berlin, Germany) to code and assist in data analysis. Research staff developed an initial code dictionary of concepts pertaining to contraceptive use and postpartum well-being using the interview guide. At least 2 researchers coded each transcript, adding new codes for emerging concepts based on a grounded theory approach. Rare coding discrepancies were resolved through discussion. We then constructed matrices based on salient themes–those appearing in multiple interviews–to facilitate in-depth analysis and synthesis.
Results
The participants were 18 (n = 8), 17 (n = 6), 16 (n = 5), or 15 (n = 1) years old. Most (n = 12) identified as Baptist and as being “somewhat religious” (n = 15). Half reported that their mothers first became pregnant when they were aged ≤18 years.
Contraceptive and pregnancy outcomes of the 20 participants are in the Figure . Almost all participants expressed their IUD desire early in the postpartum period, at the baseline or 3-month interview. The 8 participants who successfully received an IUD obtained it within 6 weeks (n = 3), 3-4 months (n = 2), and 5-6 months (n = 3) postpartum. All were using the levonorgestrel-releasing intrauterine system. One participant had her IUD removed due to pain. Another participant had her device removed after downward displacement into the cervical canal. She obtained her second IUD a month later and used the vaginal ring in the interim. Twelve did not receive an IUD within the 12-month study period; 3 of these adolescents experienced a repeat pregnancy. Most used condoms or withdrawal in the interim and struggled with adherence to these and other methods, including oral contraceptive pills and the vaginal ring.
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