Colorado's policy leads to stunning drop in teen births

DENVER - She was 15 and adrift. Her mother long dead. Her father otherwise occupied - he did not seem to notice when one of the young men who hung out in his corner market playing Street Fighter took an interest in her. Or that the interest was mutual.

She could not say that this video game player was particularly good-looking, but he was 19, did not speak of women as conquests and when he flirted with her he used her childhood nickname, "China," instead of her given name of Arlin.

"I liked the way he said 'Chee-na,'" she says. "He used sweet words like beautiful. He said he liked my smile and my eyes."

She started sneaking out at night to see him, down the stairwell outside her room, into the alley, where he waited to take her to his house or a friend's house. She did not love him, but was curious. They hung out for three months before having sex and, she says, it happened maybe three or four times before she moved, leaving behind her video game Valentino for high school in Aurora, Colo. She had already started picturing graduation and life as someone her dad would be proud of, a detective, maybe.

"When the doctor said I was pregnant, I couldn't stop crying," she says. "I was just really scared, you know."

The video game player has never held the son she later bore.

In the weeks it took Arlin Rueda to move from panic to fear and back again, she decided a few things. First, she would not have an abortion. Second, she didn't think she could go through nine months of pregnancy without growing attached to the baby to be born, so adoption was out. Third, she did not want to become pregnant again.

So, the teenager made a choice, one that underscores a profound public policy shift in the family planning landscape in Colorado. After Rueda delivered her son, but before she left the hospital, she had a contraceptive implant placed in her upper left arm.

There are two key points in that last sentence. The first is that Rueda chose what is called long-acting reversible contraception. The second is when she chose to start that contraception. Right now national attention is on the first point. For good reason.

Between 2007 and 2012, Colorado saw the highest percentage drop in birthrates among teens 15 to 19 in the country, according to a report released recently by Centers for Disease Control and Prevention's National Center for Health Statistics.

During that time, its teen birthrates dropped 39 percent compared to 29 percent nationwide. Abortion rates in the state among teens fell 35 percent between 2009 and 2012 and are falling nationally, as well.

The CDC's report comes on the heels of Colorado's own study, which reported a 40 percent decline in births among teens 15 to 19 from 2009 to 2013. The stunning decline in teen birthrates is significant not just for its size, but for its explanation.

State public health officials are crediting a sustained, focused effort to offer low-income women free or low-cost long-acting reversible contraception, that is, intrauterine devices or implants.

The Colorado Family Planning Initiative, supported by a $23 million anonymous donation, provided more than 30,000 IUDs or implants to women served by the state's 68 family-planning clinics. The state's analysis suggests the initiative was responsible for three-quarters of the decline in the state's teen birthrates.

Public health officials there and elsewhere long have argued the use of long-acting reversible contraception can dramatically reduce the number of unintended pregnancies - which make up a majority of teen pregnancies.

Colorado's initiative built upon a somewhat similar effort in St. Louis, Mo., which educated about 7,500 sexually active women on various forms of contraception and then offered to pay for that contraception over the next three years.

Seventy percent of women in the Missouri study chose an IUD or implant. The conclusion: those who chose short-term methods such as the pill or the patch were 20 times more likely to have an unintended pregnancy than those who used an IUD or an implant.

Taxpayers saved an estimated $12 billion alone in 2010 from costs associated with government-funded health care, child welfare and higher incarceration rates of teen moms, the CDC says.

"If you have a drug that is 20 times more effective than other drugs, you will always start with that as your first option," says Greta Klingler, family planning supervisor for the Colorado Department of Public Health and Environment.

"What we did (in the Colorado Family Planning Initiative) is kind of flip the mindset, so rather than introducing all contraception as being on the same playing field, we said, 'Let's start with what is most effective.'"

Colorado is part of a larger national trend: teen birthrates have been falling steadily in the country for decades, save a few isolated spikes. Since 1991, the decline has been especially pronounced (63 percent) for African-American teens age 15 to 19, according to a survey and study of teen births from 1940 to 2013 released recently by the Centers for Disease Control and Prevention's National Center for Health Statistics.

But from 2007 to 2013, the birthrate among Hispanic teens fell the most - 44 percent. That would account for some of the dramatic declines seen in places with larger Latino populations such as Arizona, Colorado and California, says Stephanie Ventura, lead author of the National Vital Statistics report.

"The dynamic has changed so much for all groups, in all states. It's just really across the board," she says. "I think it's the biggest public health success story in recent years."

Among the reasons given for the falling rates: teens waiting longer to have intercourse, increased use of contraception and, the report posits, the recession likely played some role in holding down recent teen birthrates as it did among all other women under 40.

Buried amid the headlines in Colorado is more welcome news. The state also saw a 50 percent drop in repeat pregnancies among teens. With a second child, the already-high odds are ratcheted up that a low-income mother will not finish high school, remain trapped at the low-paying end of the economic ladder and reliant upon public assistance.

Rueda did not need statistics to understand all this. Her life was already hard. So, she kept her contraceptive implant until it expired three years later. But when she had it removed, she did not replace it. She was in a new relationship by then, her first real one, and living with her boyfriend and his parents.

"I just thought, 'I'll take care of myself with pills.' But, yeah, it didn't happen."

She became pregnant. She was scared, she says, but she also was with someone she loved and with a family that treated her like a daughter. She was not thinking ahead.

The difference between short-term and long-term birth control isn't just method. It's mindset.

"With an implant or an IUD, if someone wants it out, we take it out, but once it's in and they have to make an appointment to take it out, they really have to think, 'OK, do I want a baby now, really?'" says Stephanie Teal, the Colorado Department of Public Health and Environment's medical director of Family Planning.

"As opposed to the pill, you basically have to decide every single day, 'Do I want to be not pregnant?' And some days, you might want to be pregnant."

And that makes short-term birth control particularly ineffective for adolescents, says Stephen Scott, associate professor in obstetrics and gynecology at Colorado University's School of Medicine and director of the Colorado Adolescent Maternity Program (CAMP). CAMP provides not only medical care, but mental health, nutrition and a social worker to low-income mothers and their babies.

"They oftentimes are not thinking about the future," Scott says. "Cognitively they are still developing. They're in and out of relationships. They aren't necessarily motivated to be pregnant, but they aren't necessarily motivated not to become pregnant."

And this is the second part of the long-acting reversible contraception course Colorado has been charting: Timing. Several years ago, CAMP offered 396 of its pregnant adolescent mothers who wanted birth control a choice: They could have an implant inserted after they gave birth, but before they left the hospital.

Or, they could wait the typical six weeks and then start any form of contraception they wished. Not quite half - 171 - chose the immediate postpartum implant at the hospital. The remaining 225 chose the later start - some much later - though by year's end nearly all were on some form of birth control, including IUDs or implants.

Of the mothers who chose the immediate postpartum implant, only 2.6 percent became pregnant again within a year - and that's because they had their implants removed. Among those who chose the delayed start, 20 percent got pregnant again within the first year.

By the end of the second year, Teal says, 8 percent of moms who chose the postpartum implant were pregnant again. But among that second group? Forty-six percent were pregnant again.

Presented with those findings, the state last year expanded its Medicaid coverage to allow for reimbursement of immediate postpartum long-acting reversible contraception. South Carolina, New Mexico, California and New York have also approved a similar policy change, Teal says.

Rueda is a CAMP mother. After giving birth to her daughter, she again chose to have an implant inserted before she left the hospital.

"My daughter is beautiful, but I wanted to do something in life. Before I got pregnant, I thought, 'I need to be someone in life.' But I failed. I mean what I wanted to be, I don't know how it can be. It's just feels impossible."

Her relationship with the baby's father, a house painter, is rocky at the moment, but they're working on it.

"I can't imagine having a third child. Right now, I'm working. I'm going to school to get my GED, but I'm going to have to struggle to give my children a future."

She is now 20. She had her baby girl two months ago. The space between her children? Roughly the three-year life span of her implant.