Pregnant adolescents have a higher risk of poor maternal and fetal outcomes, particularly in the setting of concomitant maternal alcohol and other drug (AOD) use. Despite numerous programmes aimed at reducing overall teen pregnancy rates and the recognition of AOD use as a risk factor for unintended pregnancy in adolescents, interventions targeting this specific group have been sparse. In adult drug-using women, financial incentives for contraception have been provided but are ethically controversial. This article explores whether a trial could ethically employ monetary incentives in adolescents with AOD use to promote the use of long-acting reversible contraception (LARC), with special attention to the relevant distinctions between adults and adolescents. We conclude that a trial of incentives to promote LARC in this patient population is ethically permissible if the incentives are small, are tied to completion of an educational activity to minimise the quick fix temptation and potential for non-attendance to the risks and benefits of LARC and are provided only to the adolescent after an assessment of her reasoning to rule out coercion (eg, by guardians) as motivation. Information about treatment for AOD use and follow-up care in case of problems with the contraceptive or desire for removal should also be provided. Before implementing such a trial, qualitative research with input from providers, potential patients and their parents should be conducted to inform the programme's specific structure.
- Availability of Contraceptives to Minors
- Substance Abusers/Users of Controlled Substances
- Public Health Ethics
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- Availability of Contraceptives to Minors
- Substance Abusers/Users of Controlled Substances
- Public Health Ethics
Alcohol and other drug (AOD) use among pregnant adolescents is not a rare phenomenon, with an estimated rate of illicit drug use in pregnant women aged 15–17 of 14.6%, leading to 10 984–12 618 affected pregnancies annually in 2012 and 2013.1 ,2 The combination of pregnancy and substance abuse tends to have poor outcomes for both the fetus and the mother.3 Alcohol, for example, can result in fetal malformations while other drugs have been associated with depression and learning disabilities in the child.4 The challenges for adolescents with AOD use who become pregnant extend beyond pregnancy for those who choose to keep their children, as adolescent mothers with AOD use are more likely to experience poverty, anxiety, depression and low self-esteem, although a causal relationship between these associations has not been established.4–6 Even without the addition of AOD use, teen pregnancy carries higher maternal and fetal risks than adult pregnancies and incurs a conservatively estimated annual cost of $9.4 billion.7 ,8
While some adolescents seek to become mothers at an early age, the majority of adolescent pregnancies are unintended.9 Numerous interventions incorporating education, home visitations by nurses, parent training, contraceptive access, community engagement, motivational interviewing and skills training have attempted to reduce the incidence of teen pregnancy.7 ,10–13 While Stevens-Simon et al14 previously showed that paying adolescent mothers to avoid pregnancy and participate in a support group was not effective in preventing repeat adolescent pregnancies, monetary incentives have more recently been used to promote at-risk adolescents’ participation in case management and peer education sessions with higher rates of contraceptive use noted.15 Long-acting reversible contraceptives (LARC), which include implants and intrauterine devices, are effective in reducing teen pregnancy rates,7 ,16 endorsed by multiple professional societies and popular among adolescents when cost is not a factor.17 Teens with AOD use have been recognised as a population at greater risk of unintended pregnancy18 with more frequent use of reproductive health services,19 but the efficacy of pregnancy-prevention programmes in this group has not been examined. A recent meta-analysis suggests that females of reproductive age with AOD use have lower rates of contraceptive use and rely heavily on less effective methods.20 Interventions to reduce the rate of AOD-exposed pregnancies in adults have included motivational interviewing,21 education and psychological services,22 home visitations23 ,24 and financial incentives for the use of LARC through a programme called Project Prevention.25 While information about Project Prevention participants’ method of contraception has shown that their choices mirror those of women in the general population26 and economic simulations suggest its cost-efficiency,27 the efficacy of the programme has not been evaluated against alternative interventions such as contraceptive cost elimination.28
The provision of incentives to promote the use of contraception in adults through Project Prevention is not without ethical controversy and has led to a rich debate about the ethical concerns of incentivising contraception in specific populations.25 ,26 ,29–33 Yet the ethical permissibility of providing monetary incentives to promote contraceptive use among adolescents with AOD use raises unique issues that have not been previously addressed in the literature to our knowledge. The ethical literature on incentivised contraception in adults often relies on ideas of rights and autonomy that may not correspond to adolescents. Similarly, cost/benefit analyses of incentivising pregnancy avoidance and promoting use of LARC in the general adolescent population do not consider the additional risk of AOD use to the mother and fetus. It is therefore possible that financially incentivising contraception could prove more ethically permissible in adolescents than in adults, although its efficacy is unknown.
Thus, a study is needed to compare the efficacy of providing financial incentives for contraception against current strategies such as contraceptive cost elimination for adolescents with AOD use. This article uses existing ethical frameworks and principles (Blumenthal-Barby et al, An ethical framework for public health nudges: a case study of incentives as nudges for vaccination in rural India. In Nudging health: health law and behavioral economics. Johns Hopkins UP (forthcoming 2016)) to identify potential concerns about this proposed study, and concludes with recommendations outlining the circumstances under which such a study would be ethically justified. As AOD use is a risk factor for teen pregnancy,18 our discussion considers this broader category rather than the potentially restrictive diagnoses of substance abuse.
Should financial incentives for contraception be studied in AOD-using adolescents? Analysis by ethical domain
The anticipated benefits and harms of any intervention under investigation are of critical importance (table 1). The potential benefits of offering financial incentives to AOD-using adolescents to use LARC include a reduction in the incidence of prenatal drug exposure, lower rates of teen pregnancy and avoidance of the distress experienced by women who lose custody of their children due to an inability to care for them.27 Considering the difficulty providers have in effectively identifying adolescents who engage in AOD use and the success of programmes that globally increase access to LARC in reducing teen pregnancy rates, interventions that are not limited to AOD-using adolescents may be more effective than narrowly targeted efforts at decreasing prenatal drug exposure.16 ,17 Yet offering incentives to all adolescents would be more costly and may encourage unnecessary interventions for teens who are not sexually active.
The benefit of incentives may be limited if women discontinue their contraceptive method due to side effects;31 however, continuation rates are higher for LARC than non-LARC methods of contraception.38 Research in incentive psychology has suggested that incentives may reduce an individual's intrinsic motivation for a behaviour once the incentive is no longer offered, although data on incentives specifically in the context of health-related behaviours suggest that they do not demonstrate an undermining effect.39 It is therefore unlikely that providing financial incentives for the use of LARC would make adolescents less likely to use LARC in the future; in fact, evidence that prior LARC use is one predictor of current use40 suggests that personal experience with LARC may dispel adolescents’ unfounded or exaggerated fears and promote continued use.
Concerns about the potential harm of incentives stem largely from fears about their misuse. There is a risk that adolescent females might be more likely to use drugs if their ability to obtain a financial reward for using LARC depends on a history of AOD use or if the financial incentive enables their purchasing of substances. A study employing incentives should monitor adolescent AOD use in the communities where such incentives are used and compare it to other communities to evaluate for increases that may be related to the financial incentive. Yet the use of incentives to obtain drugs is unlikely to differ greatly between adolescents and adults, in whom small monetary incentives for research participation have not been shown to increase drug use and may be more motivating than vouchers for goods, which could also be exchanged for drugs.25 ,41 To avoid encouraging or ignoring adolescents’ AOD use, however, the study should provide appropriate treatment for their substance use. While psychological harm from stigmatisation is a concern in adults, it is less likely in adolescents since pregnancy is generally discouraged among their peers. Still, assessments of participants' attitudes toward being offered an incentive (as well as parental attitudes if the participants consented to their parents being contacted) would be a valuable component of the study.
Finally, some authors have questioned the potential benefit of incentive programmes by challenging assumptions about certain adult women's inability to be responsible parents. Qualitative data suggest that some adult women with a history of AOD use aspire to be good parents and attempt to decrease their drug use after childbirth.31 ,36 However, these challenges may not be valid in the adolescent population whose drug use often increases in the postpartum period and remains stable into adulthood.4 From an overall utility perspective of the potential consequences of a study on incentivised LARC among adolescents with AOD use, the anticipated benefit of determining whether this strategy could reduce teen pregnancy rates and in-utero drug exposure in a high risk group may outweigh the seemingly unlikely risks of incentive misuse and stigmatisation.
A common ethical concern when discussing incentives is whether an individual can make a truly autonomous choice if a single option is incentivised or whether such ‘nudges’ are coercive. The amount and kind of incentive used are ethically relevant when determining whether an incentive is potentially coercive,42 but the value that minimises cost and coercion while retaining efficacy has not been determined in adults and may differ for adolescents.25 While the ideal of an autonomous decision is relatively uncontested in adult women, the value and feasibility of a decision made free of external influence is less clear in adolescents, who may lack the maturity to make decisions in complete independence. Adolescents’ ability to appropriately weigh future costs of childbearing, both economically and with respect to their future opportunities, against immediate gains may be hindered by their developmental stage in which the ability to delay gratification and plan ahead are not fully developed.43 Adolescents also have higher rates of unintended pregnancy when using non-LARC methods compared with adults, which indicates a need for providers to take a more active role in advocating for the most effective contraceptive option.44 Although it may seem that older adolescents are likely to have a more developed sense of autonomy, the complexity of determining a minor's competence for making medical decisions is recognised in the literature and may include assessments of self-sufficiency, experiences, maturity and other case-specific considerations.45 Thus, age alone cannot determine the propriety of encouraging a particular treatment in adolescents. Incentives for LARC may enhance autonomy by increasing the number of options available as long as the amount is not large enough to be coercive, particularly because its reversibility recognises that the teen may want to have children in the future and empowers her to choose the appropriate time.25 Adolescents, particularly when engaged in AOD use, represent a vulnerable population subject to numerous social pressures for whom specific counselling regarding contraception and environmental modifications may be more appropriate than value-neutrality.4 ,30 ,32 ,43
Although a minority of adolescents purposefully become pregnant, their interest in reproduction is still likely to be limited given their greater risks and rate of unintended pregnancy compared with adults, and the cost to society of their reproduction is significant.46 There is no clear point at which economic cost trumps autonomy, as various ethical considerations must be weighed in coming to a conclusion about an intervention's appropriateness, but the initial cost of an incentive may be worthwhile if it effectively produces benefits in the lives of adolescents and is considered in relation to the cost of their unintended pregnancies. Furthermore, adolescents’ right to contraception is not always protected from infringements that practically negate it. In states that require parental consent for prescribed contraception,47 the barriers adolescents face in obtaining confidential contraception may not be lessened by an incentive programme. While efforts to educate parents about LARC could be beneficial in these states, offering incentives to the adolescent for a decision ultimately in the hands of the parent would not enhance the patient's autonomy and may subject her to undue coercion from her guardian.
In states where adolescents do not need parental consent to receive contraception, the cost associated with treatment such as gas or transit money to travel to the clinic could still prevent adolescents from seeking these services if they are financially dependent on their parents. For these adolescents, however, monetary incentives could facilitate their ability to exercise their right to contraception and may therefore enhance their autonomy. With respect to autonomy, the ethical considerations unique to adolescents with AOD use indicate that a study of incentives to use LARC in this population may be ethically justifiable provided the legal environment allows adolescents to participate in confidential contraceptive services.
A third consideration is justice, which has both procedural and distributive components. Procedural justice would require affected individuals to participate in the decision-making process regarding the use of incentives for contraception. For example, adolescents may be interviewed regarding their thoughts on being offered such incentives, including whether they expect it to address barriers they face in using LARC or if they have any concerns about the incentive. Providers involved in treating these patients should also be given the opportunity to express their concerns about the programme; engaging both patients and providers in this discussion would encourage procedural justice in the programme's creation (box 1) and may help identify disparities or other areas in need of change.
Sample exploratory questions for potential participants and providers in considering a trial of monetary incentives for LARC in adolescents with AOD use
Questions for adolescents and providers:
What are your initial thoughts about the programme?
What concerns do you have about the programme? Do you have any suggestions about how these could be addressed?
Questions for adolescents:
What effect do you think the programme would have on your relationship with your healthcare provider?
Would you be more comfortable participating if the programme was through your regular doctor's office, a school clinic or another location?
What kind of information would you want to know about the programme?
Do you think society should help you obtain contraception in this way, or do you think it's inappropriate?
How would you benefit from the programme?
What are some risks or harms you might experience if you participated in the programme?
What would you do with the incentive money?
If treatment for AOD use was offered, would you use it?
If the incentive was only offered if you used the LARC and participated in treatment for AOD use, would you still participate?
If you didn't like the idea of using LARC and wanted to use a method that wouldn't come with an incentive, would you feel comfortable telling your doctor you wanted a different method after discussing the incentive programme for LARC?
Do you use a method of contraception currently? If not, why? If you do not use LARC, what are your reasons?
Questions for providers:
What effect do you think the programme would have on your relationship with your patient?
What information would be appropriate to convey to your patient when discussing the programme?
Do you think society should help your patient obtain contraception in this way, or do you think it's inappropriate?
How would your patient benefit from the programme?
What are some risks or harms your patient might experience if she participated in the programme?
Do most of your adolescent patients with AOD use employ a method of contraception? What methods are most common?
What barriers to or concerns about LARC have your patients with AOD use expressed?
Whether an incentive creates new disparities or vulnerabilities is an important ethical consideration related to distributive justice (Blumenthal-Barby et al, forthcoming 2016). A financial incentive may paradoxically exacerbate economic disparities if it leads to greater indirect costs associated with using LARC, such as copayments for appointments, the cost of transportation to the medical office and missed opportunities to earn wages. These indirect costs may be addressed by the use of transportation passes and waiving copayments, but should be considered in future research to determine the optimal incentive amount. An incentive programme could create vulnerabilities if adolescents with AOD use are exploited by another party (such as a parent or partner) who pressures them to participate and then takes the incentive. It is therefore important to ensure that the incentive is distributed to the right individual, perhaps by issuing a debit card with the adolescent's name on it or equipping providers with a screening tool to assess whether the adolescent is in an exploitative situation. Additionally, the ethical use of incentives should not lead to unfair treatment of individuals ineligible to obtain the incentive, but adolescents who choose to use LARC without a history of AOD use are unlikely to face significant disadvantages from not receiving a small financial incentive.
While there is potential for incentives to worsen socioeconomic disparities and create new vulnerabilities, they may instead reduce economic disparities and promote adolescents’ personal medical decision-making. Consideration of this ethical domain does not reveal clear contraindications to a trial of an incentive programme, but raises questions about associated costs of participation that would be worth investigating during the study.
Trust and transparency
Incentive trials could strain the provider–patient relationship by requiring the provider to monitor patient compliance with the incentivised behaviour.42 Since the use of LARC does not require regular behaviour monitoring, however, it seems unlikely to harm the provider–patient relationship. Yet the use of multiple smaller incentives for LARC requiring provider certification of continued use, as has been suggested to reduce the threat of coercion from a single larger payment,25 could still damage the relationship. While offering a single incentive for initiating LARC could offset this risk to the provider–patient relationship, it may also be less effective in encouraging adolescents to endure some inconvenient but benign side effects and thus may ultimately be less effective in reducing the number of AOD-exposed pregnancies in adolescents. Given the many challenges adolescent females face in accessing care48 and evidence that increased communication and maintaining confidentiality may foster adolescent trust in physicians,49 it is possible that regular, private visits to the provider to receive an incentive or document continued use of LARC would offer the adolescent more opportunities to build a relationship with the provider and discuss other health or social concerns that would not otherwise be addressed as a result of missed annual visits, time constraints or the presence of parents at appointments. Surveying adolescents prior to and during the trial of an incentive programme could help elucidate its effect on the patient–provider relationship.
Maintaining trust also requires transparency and confidentiality. As with any treatment in adults and adolescents, accurate information about contraindications and side effects of LARC must be disclosed to the patient. Since the incentive programme would not incentivise providers for their patients’ use of contraception, it should not encourage them to withhold important information from the adolescent patient. The sponsoring organisation would need to ensure that the adolescent's history of AOD use, contraceptive choice and other personal information are not revealed as a result of participation in the study. The establishment of certain safeguards and practices for continued assessment during the trial may protect the provider–patient relationship and patient privacy, addressing the ethical concerns pertaining to trust and transparency.
The ethical permissibility of an incentive-based intervention also depends on the extent to which the party providing the incentive is expected to encourage a specific behaviour (Blumenthal-Barby et al, forthcoming 2016). The Centers for Disease Control's (CDC) recognition of teen pregnancy prevention as a winnable battle,35 along with data indicating that substance abuse is a risk factor for teen pregnancy,18 establishes society's and medicine's interest in this outcome. The more difficult question is whether this interest translates into an obligation to promote specific behaviours. The CDC's, American Academy of Pediatrics’ and American College of Obstetricians and Gynecologists' (ACOG) endorsements of LARC for use in sexually active teens demonstrate that society has already taken the position of specifically encouraging its use, indicating the propriety of interventions to promote LARC.35 ,50 ,51 Society's legitimate interest in promoting LARC use among adolescents supports the use of a trial to evaluate whether an incentive programme could provide superior outcomes that warrant investment on a larger scale.
When considering the ethical permissibility of financial incentives to promote LARC in AOD users, the ethical issues are distinct in adolescents and adults. The provider caring for an adolescent is expected to provide more active guidance than the provider caring for an adult. Society's message regarding pregnancy also differs for adolescents and adults, reducing the risk that such a programme would stigmatise the adolescent. For both groups, evidence is lacking regarding the efficacy of providing financial incentives relative to alternative programmes, which is ethically concerning in an environment of limited funding for numerous valid public interests. Our ethical analysis suggests that there are conditions under which a comparative trial of financial incentives for LARC in adolescents with AOD use would be ethically justified.
With respect to the study population, this analysis was intentionally vague in defining AOD use versus abuse for the purpose of a broader ethical discussion, whereas an empirical study would need to use narrower descriptions. An ideal study would have enough participants to determine if this strategy is effective in all AOD users or only in certain groups. To better understand the relationship between incentives and LARC use, the study should measure the effects of different incentive amounts to determine if a dose-dependent response exists. The rate of LARC use should also be compared with a control group to determine if any increase in LARC use over time is due to the incentives versus a general increased uptake of LARC among adolescents.
To minimise risks of coercion, even the highest incentive value in the trial should be small and may be comparable in efficacy to non-monetary incentives. Combining markers of efficacy with qualitative information from surveying adolescents, healthcare providers and potentially also parents would indicate the incentive amount and timing that is effective without being wasteful or perceived as coercive. Providing the incentive at the end of multiple steps that meet specific therapeutic objectives may reduce the appeal to adolescents looking for a way to obtain a quick drug fix,27 and could be accomplished by requiring adolescents to complete an online education module or meet with a healthcare provider before LARC placement to ensure they understand their options and potential side effects and are sober when they agree to participate. Providers should assess the adolescent's reasons for participating and be mindful of the possibility that she could be coerced into using LARC by a parent or partner who desires the incentive. Considering this additional risk of coercion, it would be inappropriate to implement an incentive-based trial in states where adolescents cannot consent to contraceptive services. Participants’ indirect costs should be estimated to ensure the programme is not exacerbating economic disparities, and confidentiality must be protected. Adolescents should be surveyed to evaluate the effect of the programme on the patient–provider relationship. As with all contraceptive care, the programme providing LARC must give the adolescent adequate information for follow-up in case of problems or for removal, and should not require that the incentive be returned in this case so that adolescents may retain the ability to discontinue LARC if they are dissatisfied even if they have used up the incentive.32 Most importantly, appropriate treatment for AOD use should be available to adolescents so they can lead healthier lives with a better chance of safe pregnancies in the future.
The conclusion that a study would be ethically permissible does not equate to a recommendation but should spark discussion about the potential benefits of additional investigation. Although research has identified barriers to LARC use in the general adolescent population,52 ,53 additional qualitative research is needed to design a study grounded in understanding of the specific challenges—such as cost, convenience and motivation—that adolescents with AOD use face in practicing safe sex and in obtaining contraception. Such research on this understudied population is necessary to create a quantitative study that is appropriately designed for and useful in the treatment of these patients. In the meantime, efforts to increase access to effective contraception for all adolescents should continue in order to reduce the poor fetal outcomes and maternal complications associated with teen pregnancy.
Contributors TW conceptualised and drafted the initial manuscript and approved the final manuscript as submitted. JB-B and MC critically reviewed and revised the manuscript and approved the final manuscript as submitted.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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