A 3-year Retrospective Review of Contraceptive Initiation, Continuation, Switching, and Pregnancy Among Adolescents and Young Adults

PURPOSE

To understand contraceptive use patterns (initiation, switching, discontinuation) as well as associations with pregnancy in adolescents and young adults attending a teen family planning clinic.

METHODS

We performed a chart review of adolescent and young adult patients (ages 12-20) attending a teen family planning clinic in Atlanta, GA between January 1, 2017, and December 31, 2019. Using a standardized abstraction form with quality controls, we collected available data on contraceptive methods used and pregnancy test results during the 3-year period. We analyzed contraceptive use patterns descriptively. We calculated and compared pregnancy incidence according to different contraceptive switch patterns.

RESULTS

Our sample included 2,798 individuals who initiated 2,358 prescribed methods. The most commonly prescribed methods of contraception were the contraceptive injection (28.3%), etonogestrel implant (23.5%) and combined hormonal pill (23.2%). There were 599 discontinuations of prescribed methods; side effects like bleeding and headache were the most cited reasons for discontinuation. Most (75.8%) initiated a moderately or highly effective method after discontinuing a moderately or highly effective method. The incidence rate of pregnancy was highest for those who had discontinued an intrauterine device or implant and started a shorter-acting contraceptive method.

DISCUSSION

Employing patient-centered contraceptive counseling that incorporates contraceptive experiences in addition to facts and allows for exploration and change may be valuable for young people. Successful navigation of contraceptive switches may require additional attention, education, and strategy, which could include hypothetical problem solving, close follow-up, and telehealth or virtual care.

Preventing Teen Pregnancy: A Qualitative Study of the Perspectives of Parenting and Expecting Latino Adolescents

STUDY OBJECTIVE

Latino youths in the United States experience disproportionately high rates of teen pregnancy. The aim of this study was to obtain expecting and parenting Latino adolescents' perspectives regarding factors contributing to teen pregnancy and pregnancy prevention.

METHODS

Expecting/parenting Latino adolescents were recruited from high schools with high proportions of Latino youths and teen pregnancy. Participants completed a questionnaire on sociodemographic and background characteristics. Focus groups were stratified by age and gender and audio recorded. Grounded theory was used to identify themes from the transcribed audio recordings.

RESULTS

Thirty-two expecting/parenting Latino adolescents (20 females, 12 males) 14-19 years old participated in four focus groups. Quantitative results revealed that two-thirds of participants at birth had adolescent mothers. Over three-quarters of participants reported that their pregnancies had occurred too soon. Qualitative themes for factors contributing to teen pregnancy included lack of contraceptive knowledge/access, belief of invincibility, influence within relationships, male decisions on contraceptive use, desire to belong among peers, lack of parental support for contraceptive use, lack of parental attention, rebellion, normalization of adolescent parenthood in Latino culture, and media. Themes for pregnancy prevention included time alone with physicians, parenting teens as mentors, reproductive health education, and community pregnancy-prevention programs.

CONCLUSION

Multiple factors contribute to teen pregnancy in Latino youth, including influences from Latino culture, family, peers, partners, and social determinants of health. Pregnancy prevention should incorporate interventions to address these aspects, including disseminating culturally sensitive education materials, providing parenting teens as peer mentors, encouraging time alone with health care providers, and addressing various social determinants of health.

Toward an Effective Innovation Framework for Federal Grant-Making: an Exploration into OPA's Teen Pregnancy Prevention Program

States, local, tribal, and territorial governments received almost 20% of all federal spending in fiscal year 2022, about $1.2 trillion dollars (US Office of Management and Budget, 2023a). For a strong, well-functioning democracy, the federal government must be able to disperse grant funds efficiently and effectively. Rates of teen pregnancy in the USA, while decreasing in recent years, are still consistently higher than that of other western industrialized nations (Centers for Disease Control and Prevention, 2023). The Office of Population Affairs' (OPA) Teen Pregnancy Prevention program combines cutting edge research with innovative grant distribution to creatively tackle this issue. In this commentary, we explore some of the strengths of OPA's grant distribution program in the hope that others may emulate best practices from this program. Specifically, the special issue highlights how OPA's grant program took a customer-centered focus by prioritizing work with end users and community. This evidence-based focus enabled the testing of ideas, which in turn could be iterated and scaled up. Through grantee innovation networks, they created space for external expertise, creative thinking, and diversity of thought. Other programs, policymakers, and their partners may learn from OPA's success, which arises from three core characteristics: (1) their funding stature allows long-term and flexible allocation of funding toward innovation; (2) OPA focuses on creating and supporting local communities and networks of innovation; (3) OPA emphasizes evidence-based decision-making and rigorous evaluation throughout the grant process. With a fifth of the federal budget being dispersed through grant-making and teen pregnancy still at high rates, OPA offers an exciting avenue for innovation and success in both of these areas. This commentary concludes with some recommendations for future practice.

Adolescent Long-Acting Reversible Contraceptive Use, Same-Day Insertions, and Pregnancies Following a Quality Initiative

OBJECTIVE

To compare long-acting reversible contraceptive (LARC) use, pregnancy rate, and same-day LARC insertion among adolescents before and after a Kaiser Permanente Northern California quality initiative.

METHODS

A 2016 Kaiser Permanente Northern California initiative aimed to increase adolescent LARC access. Interventions included patient education resources, electronic protocols, and insertion training for pediatric, family medicine, and gynecology providers. This study examined a retrospective cohort of adolescents aged 15-18 years who used contraception before (2014-2015, n = 30,094) and after (2017-2018, n = 28,710) implementation. Contraceptive types included LARC (intrauterine device or implant), injectable, and contraceptive pill, patch, or ring. We reviewed a random sample of LARC users (n = 726) to identify same-day insertions. Multivariable analysis examined the effects of year of provision, age, race, ethnicity, LARC type, and counseling clinic.

RESULTS

Preintervention, 12.1% of adolescents used LARC, 13.6% used injectable, and 74.3% used pill, patch, or ring. Postintervention, the proportions were 23.0%, 11.6%, and 65.4%, respectively, with the odds of LARC provision of 2.57 (95% confidence interval (CI) 2.44-2.72). The pregnancy rate decreased from 2.2% to 1.4% (p < .0001). Higher rates of pregnancy were observed with injectable contraception and in Black and Hispanic adolescents. Same-day LARC insertion rate was 25.1% without significant variation post intervention (OR 1.44, 95% confidence interval 0.93-2.23). Contraceptive counseling in gynecology clinics increased the odds of same-day provision, while non-Hispanic Black race lowered odds.

DISCUSSION

A multifaceted quality intervention was associated with a 90% increase in LARC use and a 36% decrease in teenage pregnancy rate. Future directions may include promoting same-day insertions, targeting interventions in pediatric clinics, and focusing on racial equity.

Health Characteristics and Birth Outcomes for "Starting Out Right," a Teen Pregnancy Program

PURPOSE

To evaluate differences in health characteristics and birth outcomes for participants of a prenatal education and support program for pregnant teens, "Starting Out Right" (SOR) compared to nonparticipant pregnant teens in Pima, Maricopa, and Gila counties in Arizona to gauge benefits of program participation.

DESCRIPTION

The SOR program is a community education and support program for pregnant teens based on a structured curriculum. All pregnant teens living in the service area are eligible to participate.

ASSESSMENT

Vital statistics birth data from 2014 to 2019 were obtained from three counties in Arizona that identified SOR and non-SOR program participants. Logistic regression was used to calculate multivariable -adjusted odds ratios (aOR) for specific health characteristics (smoking, hypertensive disorders, overweight and obesity, gestational diabetes, sexually transmitted infections) and birth outcomes (C-section, preterm birth, NICU admission, birthweight, and breastfeeding) for SOR participants compared with nonparticipants. Variables in the adjusted models included age, BMI, smoking, gestational diabetes, race, ethnicity, county, WIC participation, insurance type, plurality, and month and year prenatal care began.

CONCLUSION

These results suggest that participation in SOR was associated (p ≤ 0.06) with a reduced odds for low birthweight [aOR 0.7(95% CI 0.5,1.0)] and increased odds (p ≤ 0.05) of breastfeeding [aOR 1.3(95% CI 1.0,1.7)] compared to nonparticipants. These results provide evidence that the education components in the SOR program support improved pregnancy and breastfeeding outcomes for pregnant teens.

The longitudinal association between sexual violence victimization and sexual risk behavior in adolescence

Being a victim of sexual violence (SV) is generally believed to be associated with subsequent sexual risk behavior (SRB) during adolescence. While this assumption makes intuitive sense, it is based on methodologically limited research, including a reliance on cross-sectional data. To address this gap in research, we test whether experiencing SV victimization in early adolescence is associated with self-reported SRB approximately two years later. The sample comprised 4,618 youth (58% female; 52% Hispanic; 39% Black) attending 44 schools in the southern United States. Self-reported data were collected using an audio computer-assisted self-interview (ACASI). Baseline data were collected when students were in 7th or 8th grade and follow-up data were collected approximately 24 months later when students were in 9th or 10th grade. Indices of SRB included behaviors related to oral, vaginal, and anal sex (e.g., number of partners, number of times without a condom). Girls, but not boys, who reported SV victimization at baseline reported engaging more frequently in all oral and vaginal SRBs at 24 month follow-up compared to their non-victimized female counterparts. Additionally, girls reporting SV victimization reported more anal sex partners than non-victimized girls. Girls who are victims of SV engage in significantly more SRB by early high school placing them at greater risk to contract STIs and become pregnant. Victims of SV should be screened for SRB and provided access to the appropriate resources. Teen pregnancy and STI prevention planning should consider SV victimization in their strategy planning.

Long-acting reversible contraception and condom use: A cohort study of female adolescents and young adults in New York City

OBJECTIVES

This study aimed to determine whether condom use varied between adolescents and young women using long-acting reversible contraception (LARC) vs non-LARC hormonal methods and assess if the initiation of LARC was associated with lower condom use.

STUDY DESIGN

This study used data from a large longitudinal study of sexually active females aged 13-25 years. Questionnaires assessed contraception, condom use, sexual history, and partner characteristics at the baseline visit and every 6 months. Log-binomial regression analyses examined associations between hormonal contraceptive methods and condom use, and the moderating effects of age and number of sexual partners. Exploratory analyses compared condom use based on partner characteristics.

RESULTS

Of 1512 participants, 1116 reported LARC or non-LARC hormonal method use during any study visit. Among baseline and new LARC users, 75.7% and 84.7% reported intrauterine device (IUD) use, respectively. Condom use at baseline among hormonal non-LARC users (37.5%) was significantly higher (p < 0.01) than LARC users (23.5%). Condom use among LARC vs non-LARC users was moderated by age in that LARC was associated with lower condom use among participants aged 13-18 years, but not those aged 19-25 years. Number of sexual partners was not a significant moderator. Among participants with increased sexually transmitted infection (STI) risk based on partner characteristics, LARC users had lower condom use compared to non-LARC users.

CONCLUSIONS

Condom discontinuation was common following initiation of LARC and hormonal non-LARC methods. However, condom use was lower in LARC users at baseline, among younger adolescents, and if partners had risk factors for STIs.

IMPLICATIONS

Condom discontinuation following initiation of highly effective contraception increases the risk of STI. Young women using LARC may be at greater risk than non-LARC users given lower condom use despite having partners with risk factors for STIs. Condom use counseling for STI protection is critical for adolescents.

Prenatal care and infant outcomes of teenage births: a Project WATCH study

INTRODUCTION

Infants of teenage births are known to have increased risk of poor infant outcomes. Adequate prenatal care (PNC) is essential to the overall health of infants and their birthing persons. While teenage births continue to be of concern in rural areas, little is known about the association between inadequate PNC and poor infant outcomes in teenage populations.

PURPOSE

To determine the association between inadequate PNC (< 10 visits) and poor infant outcomes neonatal intensive care unit (NICU) stay, low APGAR score, small for gestational age (SGA) and length of stay (LOS).

METHODS

The study used West Virginia (WV) Project WATCH population level data (May 2018-March 2022). Multiple logistic regressions and survival analysis were performed on infant outcomes; NICU stay, APGAR score, infant size, and infant length of stay (LOS) with PNC categories inadequate (< 10 PNC visits) vs adequate (10 or more) adjusting for covariates including maternal race, insurance status, parity, smoking status, substance use status, and diabetes status.

RESULTS

Of births to teenagers, 14% received inadequate PNC. Teens who received inadequate PNC had increased odds of infant admitted to NICU (aOR: 1.84, CI:(1.41, 2.42), p < 0.0001), low 5- minute APGAR score (aOR: 3.26, CI:(2.03,5.22), p < 0.0001), and increased LOS (Est. = -0.33, HR: 0.72, CI:(0.65,0.81), p < 0.0001).

CONCLUSIONS

Results demonstrated that infants of teenagers who received inadequate PNC are at increased risk of requiring a NICU stay, having a low APGAR score and requiring an increased LOS. PNC is particularly important for these groups as they are at increased risk of poor birth outcomes.

Sexual violence in early adolescence is associated with subsequent teen pregnancy and parenthood

Being a victim of sexual violence (SV) has been associated with risk for teen pregnancy in cross-sectional research. However, longitudinal data are necessary to determine if SV victimization plays a causal role in early pregnancy. To address this gap in research, we test whether experiencing SV victimization in early adolescence is associated with pregnancy and having children by mid-adolescence. The current sample comprised 4594 youth (58% female; 51% Hispanic; 39% Black) attending 44 schools in the southern United States. Self-reported data were collected via audio computer-assisted self-interview (ACASI) when students were in 7th or 8th grade and again approximately 24 months later. Approximately 2.9% of boys and 8.2% of girls reported SV victimization at baseline. At follow-up, 3.4% of boys and 4.0% of girls reported being involved with one or more pregnancies; 1.1% of boys and girls reported having one or more children. Being a victim of SV at baseline was associated with pregnancy and having a child at follow-up for girls. SV was not related to outcomes among boys. The present findings indicate that girls victimized by SV are at risk of becoming pregnant and becoming teen parents. The combined sequelae of SV and teen pregnancy impair health, economic, and social functioning across the lifespan and carry forward into future generations. Future research should explore mechanisms through which victimization confers risk for pregnancy to inform prevention strategies.

Evaluating the efficacy of an online, family-based intervention to promote adolescent sexual health: a study protocol for a randomized controlled trial

BACKGROUND

Adolescents in the U.S. experience significant negative sexual health outcomes, representing a public health priority in the U.S. Research shows that while parents play an influential role in shaping adolescent sexual behavior, surprisingly few programs engage parents in existing programming. Moreover, most efficacious parent-based programs focus on young adolescents, and few utilize delivery mechanisms that facilitate broad reach and scale-up. To address these gaps, we propose to test the efficacy of an online-delivered, parent-based intervention adapted to address both younger and older adolescent sexual risk behavior.

METHODS

In this parallel, two-arm, superiority randomized controlled trial (RCT), we propose to evaluate Families Talking Together Plus (FTT+), an adaptation of an existing and efficacious FTT parent-based intervention, in shaping sexual risk behavior among adolescents aged 12-17 and delivered via a teleconferencing application (e.g., Zoom). The study population will include n=750 parent-adolescent dyads recruited from public housing developments in the Bronx, New York. Adolescents will be eligible if they are between the ages of 12 and 17 years of age, self-report as Latino and/or Black, have a parent or primary caregiver, and are South Bronx residents. Parent-adolescent dyads will complete a baseline survey, after which they will be assigned to either the FTT+ intervention condition (n=375) or the passive control condition (n=375) in a 1:1 allocation ratio. Parents and adolescents in each condition will complete follow-up assessments 3 and 9 months post-baseline. The primary outcomes will include sexual debut and ever sex, and the secondary outcomes will include the frequency of sex acts, number of lifetime sexual partners, number of unprotected sex acts, and linkage to health and educational/vocational services in the community. We will utilize intent-to-treat analyses of 9-month outcomes and single degree of freedom contrasts comparing the intervention to the control group for primary and secondary outcomes.

DISCUSSION

The proposed evaluation and analysis of the FTT+ intervention will address gaps in the current cadre of parent-based programs. If efficacious, FTT+ would represent a model for scale-up and adoption of parent-based approaches designed to address adolescent sexual health in the U.S.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04731649. Registered on February 1, 2021.

Factors associated with pregnancy and induced abortion among street-involved female adolescents in two Nigerian urban cities: a mixed-method study

OBJECTIVES

This study determined the correlates of unwanted pregnancy and induced abortion among sexually active female street-involved adolescents (SIAs) aged 10-19 years in two urban cities in South-west, Nigeria.

METHODS

The data for this study were extracted from a larger mixed-method survey dataset on the sexual and reproductive health (SRH) of 1505 street-involved young people aged 10 to 24 years. For the quantitative data, the explanatory variables were age, history of school attendance, employment status, religion, living arrangement and city of residence. The study outcomes were a history of pregnancy and a history of induced abortion of last pregnancy. Binomial regression analysis was performed to determine the association between the explanatory and outcome variables. For the qualitative data generated through focus group discussions and in-depth-interviews, inductive and deductive approaches were used in conducting a thematic analysis to explore the perspectives and experiences of SIA on pregnancy and induced abortion.

RESULTS

Of the 424 female SIAs, 270 (63.7%) reported having had sex. Sixty-four (23.7%) respondents had a history of pregnancy, of which 38 (59.4%) gave a history of induced abortion of the last pregnancy. A history of school attendance significantly reduced the likelihood of being pregnant (AOR: 0.42, 95% C.I: 0.19-0.91), while 15-19-years-old SIAs who were pregnant were significantly less likely to abort (AOR: 0.13, 95% C.I: 0.02-0.77). Qualitative reports indicated that unintended pregnancy and induced abortion was a common experience among the sexually active SIAs. Many participants were aware of the methods of, and places to induce abortion.

CONCLUSION

A large proportion of SIAs are sexually active with a high incidence of unintended pregnancy and a high rate of unsafe abortion. Access of female SIAs to education can reduce the risk of unintended pregnancy. Attention needs to be paid to how SIAs can have access to contraception.

Prevalence and Predictors of Integrated Care Among Teen Mothers and Their Infants

PURPOSE

Integrated models of primary care for parenting teens, in which teens and infants are cared for by the same clinical team on the same day, are associated with reduced repeated pregnancies and increased uptake of contraception and immunization. Our purpose was to determine how frequently teen-infant dyads receive integrated care.

METHODS

This study used Medicaid Analytic eXtract data to create a retrospective cohort of mothers aged 12-17 linked with infants born from 2007-2012 in 12 states. Teen-infant dyads were enrolled in Medicaid throughout the year after birth. The primary outcome was integrated care in the year after birth, defined as ≥ 1 instance when teen and infant had visits on the same day, billed to the same clinician identifier. Logistic regression assessed the relationship between integrated care and maternal demographics, dyad health, clinician specialty, and community factors.

RESULTS

Of 20,203 dyads, 3,371 (16.7%) had integrated care in the year after birth. Dyads with integrated care had a mean of 1.2 (SD 1.3) integrated visits. Dyads with integrated care had more visits (14.9, SD 10.6 vs. 11.7, SD 8.3), including more preventive visits for teens and more acute visits for both teens and infants. In regression, integrated care was associated with maternal factors (younger age, non-Latinx white race, and maternal health risks), residence in rural or high-poverty areas, and ever visiting Family Medicine clinicians.

DISCUSSION

Though uncommon, integrated care was associated with greater engagement in health care. Implementation of integrated care may support increased preventive care for parenting teens.

The Association of Emergency Contraception Legislation with Adolescent Births from 2000 to 2014

STUDY OBJECTIVE

The objective of the study was to examine the association of state-specific emergency contraception (EC) legislation and adolescent births.

DESIGN, SETTING, AND PARTICIPANTS

This was an observational cohort study of adolescents aged 15-19 years in the United States from 2000 through 2014 to determine the association of adolescent birth estimates with EC legislation.

MAIN OUTCOME MEASURES

State-specific birth and abortion estimate data were obtained from the Centers for Disease Control and Prevention's National Vital Statistics and Abortion Surveillance for the years 2000 through 2014.

RESULTS

After controlling for year, abortion estimates, and oral contraception pill utilization, estimated adolescent births for states with an expansive EC policy was 14% lower as compared with states without an expansive policy. Estimated adolescent births were 43% higher in states with a restrictive EC policy as compared with states without a restrictive policy.

CONCLUSION

Restrictive EC policies are associated with increased adolescent birth estimates, whereas expansive EC policies are associated with decreased adolescent birth estimates. Targeted advocacy strategies to reduce legislation that aims to restrict access to contraception may prove to be most beneficial to reducing unintended pregnancies.

What a paediatric nephrologist should know about preeclampsia and why it matters

Preeclampsia is a protean syndrome causing a kidney disease characterised by hypertension and proteinuria, usually considered transitory and reversible after delivery. Its prevalence ranges from 3-5 to 10% if all the related disorders are considered. This narrative review, on behalf of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology, focuses on three reasons why preeclampsia should concern paediatric nephrologists and how they can play an important role in its prevention, as well as in the prevention of future kidney and cardiovascular diseases. Firstly, all diseases of the kidney and urinary tract diagnosed in paediatric age are associated with a higher risk of adverse pregnancy-related outcomes, including preeclampsia. Secondly, babies with low birth weights (small for gestational age, born preterm, or both) have an increased risk of developing the full panoply of metabolic diseases (obesity, hypertension, early-onset cardiopathy and chronic kidney disease) and girls are at higher risk of developing preeclampsia when pregnant. The risk may be particularly high in cases of maternal preeclampsia, highlighting a familial aggregation of this condition. Thirdly, pregnant teenagers have a higher risk of developing preeclampsia and the hypertensive disorders of pregnancy, and should be followed up as high risk pregnancies. In summary, preeclampsia has come to be seen as a window on the future health of both mother and baby. Identification of subjects at risk, early counselling and careful follow-up can contribute to reducing the high morbidity linked with this disorder.

Association of pregnancy attitudes and intentions with sexual activity and psychiatric symptoms in justice-involved youth

Context

With over one-third of detained girls experiencing teenage pregnancy, it is critical that the juvenile justice system better addresses the sexual and reproductive health (SRH) needs of youth. Although pregnancy attitudes and intentions (PAI) are associated with pregnancy outcomes among the general adolescent population, this relationship has not been examined among justice-involved youth.

Methods

Participants were drawn from a longitudinal study characterizing trajectories of behavioral and reproductive health and recidivism among newly justice-involved youth in a Northeast family court. Baseline and four-month follow-up data from 288 justice-involved youth (JIY) were analyzed to characterize PAI; examine associations between pregnancy intentions and unprotected sexual activity (i.e., no hormonal, intrauterine, or barrier protection against pregnancy); and explore the relationship between pregnancy intentions and psychiatric symptoms.

Results

At baseline, 39% of JIY youth were sexually active, 44% of these youth reported inconsistent condom use and 14% had not used birth control at last sexual intercourse. Nearly half of sexually active youth reported some intent around pregnancy and those with any pregnancy intentions were more likely to report depression, low self-esteem, substance use, and trauma history. Pregnancy intentions at baseline predicted higher rates of unprotected sexual activity at four months (OR: 16.9, CI = 2.48-115.7).

Conclusions

This study highlights the importance of developing and implementing more comprehensive SRH assessments and brief interventions for youth entering the justice system.

Maternal and Neonatal Complications in Teen Pregnancies: A Comprehensive Study of 661,062 Patients

PURPOSE

To provide a comprehensive assessment of maternal and neonatal complications associated with teen pregnancies in the United States.

METHODS

Retrospective analysis of the Centers for Disease Control and Prevention natality live births database (2016-2019). Singleton births to women younger than 35 years from the following racial/ethnic groups were included: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic. The risks of various complications were compared between teen patients (<20 years old) and nonteen patients (20-35 years old) using Pearson's chi-square test with the Bonferroni correction. Multivariate logistic regressions were used to adjust outcomes for potential confounders, including body mass index, race/ethnicity, payment method, prenatal care, parity, and the presence of chronic comorbidities.

RESULTS

Teen pregnancies comprised approximately 6% of the study population (661,062 of 11,038,489). Teen pregnancies were associated with increased odds of several maternal complications, such as hypertensive disorders of pregnancy, eclampsia, preterm birth, blood transfusion, and chlamydial and gonorrheal infections. Teen pregnancies were also associated with increased odds of several neonatal complications, including congenital birth defects, low 5-minute Apgar score, suspected neonatal sepsis, and assisted ventilation. Conversely, teen pregnancies were associated with decreased odds of gestational diabetes, unplanned hysterectomy, macrosomia, low birth weight, and neonatal intensive care unit admission.

DISCUSSION

Teen pregnancies in the United States are associated with increased risks of multiple adverse outcomes. This information should inform clinicians and policy makers about the unique risks of this highly vulnerable patient population and provide further knowledge for the important efforts to reduce teen birth rates in the United States.

Implementation of Community‑Wide Initiatives Designed to Reduce Teen Pregnancy: Measuring Progress in a 5‑Year Project in 10 Communities

Introduction

Community-wide initiatives (CWI) to prevent teen pregnancy were implemented in 10 communities in the USA. The CWI supported the implementation of evidence-based teen pregnancy interventions (EBIs) and implementation of best practices for adolescent reproductive health care. Implementation was supported through mobilizing communities, educating stakeholders, and strategies to promote health equity.

Methods

We assessed indicators of progress of the CWI for the following five project components (data collected from 2010 to 2015): community mobilization, stakeholder education, working with diverse communities, evidence-based interventions, and increasing access to clinical services and the potential contributions of training and technical assistance.

Results

Communities engaged multiple stakeholder groups to contribute to planning, community outreach and education, and partnership development and used multiple dissemination methods to share information on adolescent reproductive health needs and teen pregnancy prevention strategies. The amount of training and technical assistance from state- and community-based organizations was associated with increased numbers of youth receiving EBIs and increased provision of contraceptives. The number of health centers implementing best practices for adolescent reproductive health services increased; conducting sexual health assessments, offering hormonal contraception or IUD, and offering quick start of IUDs were associated with increases in long-acting reversible contraception utilization.

Conclusions

These findings demonstrate that scaled prevention efforts can occur with adequate support including training and technical assistance and community awareness and engagement in the process.

Policy Implications

The findings raise important questions for understanding what factors contribute to successful community-wide implementation of EBIs and health center best practices for contraceptive access and whether these lead to reductions in teen pregnancies in highly impacted communities.

Factors Predicting Sexual Risk Behaviors of Adolescents in North-Eastern Thailand

The number of young people who have had sex at an early age increases in proportion, it concerns unsafe sexual behaviors, teenage pregnancy, HIV aids and sexually transmitted infections (STIs). This study examines the health behaviors and factors predicting sexual risk behaviors pertaining to teenage pregnancy among adolescents in Thailand. Adolescents consulted the reproductive health center about problems with the same gender. The factors of adolescent reproductive behaviors were significantly associated with age, education level, and the perception of peer norms. Receiving social support from media information also significantly correlated with those behaviors. The results recommend that to prevent premature pregnancy, adolescents should protect themselves. Parents should take the issue of social media use by their teenagers very seriously.

Adapting to Changes in Teen Pregnancy Prevention Research: Social Media as an Expedited Recruitment Strategy

PURPOSE

Teen pregnancy prevention projects funded by the U.S. Office of Adolescent Health were disrupted by the Trump administration in the July 2017 announcement that funding would be terminated. Although funding was later reinstated toward the end of 2018 after a class-action lawsuit, we needed to change our recruitment protocol to mitigate this disruption to the study timeline and staffing. This led to a natural experiment comparing in person and social media recruitment strategies.

METHODS

The original approach was to recruit girls, aged 15-19 years, who were using intrauterine or subdermal contraception, in person in clinic settings. After the funding disruption, we transitioned to an online recruitment strategy. Costs associated with each approach (in-person and online recruitment) were tracked, and we compared cost of per-person enrollment with each approach.

RESULTS

In-person, clinic-based recruitment enrolled 118 participants over 293 days from eight high-volume clinics. Online recruitment enrolled 518 participants over 146 days. Online recruitment resulted in cost savings and a diverse sample representing a larger geographic region.

CONCLUSION

Online recruitment can cut costs and be more efficient than a clinic-based recruitment strategy, but special considerations are warranted when considering social media recruitment.

Preconception and Interconception Pediatric Primary Care Utilization of Pregnant and Parenting Teens

PURPOSE

Gaps in preventive care may contribute to adverse outcomes among pregnant teens. This study quantified teen preventive care utilization before and after pregnancy.

METHODS

A continuous retrospective cohort identified 150 teens with a positive pregnancy test (July 2015 to May 2017) at two pediatric primary care sites. Chart review assessed office visits for 18 months before and after the pregnancy test. We also assessed contraceptive counseling, pregnancy outcomes (live birth, miscarriage, termination), and continuity with a single clinician. Demographic factors included age, race, ethnicity, primary insurance, and residential zip code. Logistic regression identified factors associated with visits after pregnancy. Separately, for a cohort of 47 parenting teens who received primary care at the same site as their infants, we assessed teen-infant care after birth.

RESULTS

Teens were predominantly non-Latina black (91%) and Medicaid insured (71%). Before pregnancy, most teens had preventive visits (66%) and reported contraceptive use (65%). After pregnancy, 52% discussed pregnancy decisions within a month, 55% reported contraceptive use, and 64% had any primary care visit. Postpregnancy visits were associated with teen age (<18 vs. ≥18 years odds ratio 2.84, 95% confidence interval 1.17-6.90) and pregnancy outcome (termination vs. live birth odds ratio 4.02, 95% confidence interval 1.47-11.01). Among parenting teens, there were more infant visits than teen visits, and continuity was higher for infants.

CONCLUSION

In a primary care cohort of pregnant teens, gaps persisted in pediatric clinical follow-up after pregnancy. Particularly in situations where pregnancy led to a birth, pregnancy frequently prompted a transition away from pediatric care.

Trends in childhood viable pregnancy and risk of stillbirth in the United States

There is limited data on the trends of childhood viable pregnancy and the risk of stillbirth in the United States. Our study assessed the trends in childhood viable pregnancy and associated stillbirth rates over the previous three decades, as well as the risk of stillbirth in these highly vulnerable child mothers aged 10-14 compared with teen mothers aged 15-19. We conducted a population-based retrospective cohort study that used birth datasets, fetal death datasets, and the US population census data: 1982-2017. To assess the association between various sociodemographic and maternal comorbidities and stillbirth, we generated adjusted hazard ratios (AHR) from Cox proportional hazards regression models. From 1982 to 2017, viable pregnancy rates declined among children (from 0.3/1000 to 0.06/1000 population) and teens (from 40.5/1000 in 1982 to 18.1/1000). Overall, there were declines in the stillbirth rates in both teens (15-19 years old) and child mothers aged 10-14 years, but the rate remained consistently higher among child mothers vs. teen mothers (14 per 1000 vs. 8 per 1000 viable pregnancies). Compared to teen mothers, childhood pregnancy was modestly associated with an elevated risk for stillbirth (AHR = 1.09; 95% CI = 1.05-1.12). Other factors significantly associated with increased risk of stillbirth included maternal race, preterm birth, arterial hypertension, diabetes, and eclampsia (P<0.0001).Conclusion: Childhood pregnancy may be a risk factor for stillbirth. This is the first study to assess the trends in childhood viable pregnancy and the associated stillbirth rates in the United States. These findings further underscore the need for sustained efforts and policies to prevent pregnancies in the early years of reproductive development. What is Known: • Childhood pregnancy, defined as pregnancy among 10-14 year-old females, may be associated with a number of pregnancy complications and adverse pregnancy outcomes, including preterm delivery, low birth weight, and infant mortality. • Structural disparities in socioeconomic status and access to healthcare place some teenagers at high risk of teen pregnancy. What is New: • Our study shows the trends in childhood pregnancy over the previous three decades; overall, there were declines in the stillbirth rates in both child mothers aged 10-14 years and teen (15-19 years old) mothers, but the rate remained consistently higher among child mothers. • Child mothers aged 10-14 were more likely to experience stillbirth than teenagers, and Black mothers had an increased risk of stillbirth than White mothers-all of which underscores the effects of structural health disparities.

Putting Rigorous Evidence Within Reach: Lessons Learned from the New Heights Evaluation

PURPOSE

This article uses an evaluation of New Heights, a school-based program for pregnant and parenting teens in the District of Columbia Public Schools, to illustrate how maternal and child health programs can obtain rigorous evaluations at reasonable cost using extant administrative data. The key purpose of the article is to draw out lessons learned about planning and conducting this type of evaluation, including the important role of partnerships between program staff and evaluators.

DESCRIPTION

This article summarizes the evaluation's research design, data sources, and lessons learned about ingredients contributing to the successful implementation of this study. The evaluation employed a difference-in-differences design to estimate program impacts using administrative data merged across agencies.

ASSESSMENT

Several features of New Heights and its context facilitated an evaluation. First, New Heights leaders could clearly describe program components and how the program was expected to improve specific student education outcomes. These outcomes were easy to measure for program and comparison groups using administrative data, which agencies were willing to provide. Second, buy-in from program staff facilitated study approval, data agreements, and unanticipated opportunities to learn about program implementation. Finally, time spent by evaluators and program staff in conversation about the program's components, context, and data resulted in greater understanding and a more useful evaluation.

CONCLUSION

The New Heights evaluation is a concrete example of how a small program with a modest evaluation budget can obtain evidence of impact. Collaborative relationships between researchers and program staff can enable these informative studies to flourish.

Evaluating teen options for preventing pregnancy: Impacts and mechanisms

This paper presents findings from an experimental evaluation of the Teen Options to Prevent Pregnancy (TOPP) program, an 18-month intervention that consists of a unique combination of personalized contraceptive counseling, facilitated access to contraceptive services, and referrals to social services. We find that TOPP led to large and statistically significant increases in the use of long-acting reversible contraceptives (LARCs), accompanied by substantial reductions in repeat and unintended pregnancy among adolescent mothers. We provide an exploratory analysis of the channels through which TOPP achieved its impacts on contraceptive behavior and pregnancy outcomes. A back-of-the-envelope decomposition implies that the increase in LARC use can explain at most one-third of the reduction in repeat pregnancy. We provide suggestive evidence that direct access to contraceptive services was important for increasing LARC use and reducing repeat pregnancy. We did not find any spillover effects on non-targeted outcomes, such as educational attainment and benefit receipt.

A Group Randomized Trial Evaluating High School FLASH, a Comprehensive Sexual Health Curriculum

PURPOSE

To evaluate the effectiveness of a school-based comprehensive sexual health curriculum (FLASH) on high-school students' sexual behavior and related outcomes.

METHODS

A cohort of 1,597 9th and 10th grade students representing 20 schools from two regions in the U.S. (Midwest and South) were enrolled and completed the baseline survey. Following baseline, the 20 schools were randomly assigned to receive FLASH (n = 10 schools, five per region) or a knowledge-based sexual health curriculum (n = 10 schools, five per region). Follow-up surveys were administered at 3 months and 12 months after the instruction period.

RESULTS

There were no statistically significant differences between conditions for the overall sample on rates of vaginal sex in the past 3 months or the rates of vaginal sex without a condom or other birth control. In supplementary subgroup analyses of students who were not sexually experienced at baseline, FLASH showed a statistically significant protective impact at the 3-month follow-up on vaginal sex without a condom or birth control (p = .04). FLASH also showed statistically significant gains in psychosocial outcomes, such as refusal and condom use self-efficacy, attitudes toward birth control and condoms, and perceived norms.

CONCLUSIONS

FLASH demonstrated consistent short-term and long-term impacts on key behavioral determinants. It also showed a significant impact on vaginal sex without a condom or other birth control for the subgroup of students who were not sexually experienced at baseline. Behavioral impacts were not evident for the entire study population.

Trauma exposure and adolescent attitudes toward having a baby: An exploratory survey

Objectives

To examine the association between childhood trauma exposure (i.e., extent of interpersonal trauma experienced in childhood) and attitudes toward teen parenthood.

Study design

We used a cross-sectional sample of 416 urban middle and high school male and female students from Tulsa, OK recruited through a local public school district mailing list. Multinomial logistic regression analyses were used to examine odds of reporting having a baby would make life worse, better, or cause no change according to childhood trauma score.

Results

Approximately 8% of students and their guardians responded to the mailed survey invitation. Among the students, 67% reported having a baby would make their lives worse; 17% reported it would not change their lives much, and 16% reported having a baby would make their lives better. Each increase in trauma score was associated with a 9% increase in reporting an indifferent attitude (p < 0.001) and a 15% increase in reporting a positive attitude toward having a baby (p < 0.01). After controlling for a wide range of sociodemographic, attitudinal, and sexual history variables, childhood trauma remained associated with a positive attitude toward having a baby (p<.01), but not an indifferent attitude toward having a baby.

Conclusions

Greater childhood trauma exposure is associated with indifferent and positive attitudes toward having a baby during adolescence.

Implications

Screening for childhood trauma and utilizing interventions designed to reduce the harmful effects of trauma exposure in childhood may offer a more targeted approach to adolescent pregnancy prevention strategies.

Racial/Ethnic Differences in Prenatal and Postnatal Counseling About Maternal and Infant Health-Promoting Practices Among Teen Mothers

STUDY OBJECTIVE

Disparities in perinatal counseling among all pregnant women exist, yet teen data are lacking. We evaluated racial/ethnic differences in (1) prenatal and (2) postnatal counseling of teen mothers.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included Pregnancy Risk Assessment Monitoring System data from 2012-2016 and included mothers 19 years of age and younger.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Counseling measures included tobacco, alcohol and illicit drugs, weight gain, HIV testing, influenza vaccination, breastfeeding, infant safe sleep, postpartum depression, and contraception. Bivariate associations of maternal/infant characteristics and counseling were estimated using χ² tests. Multivariable logistic regression was used to assess the independent relationship between race/ethnicity and counseling.

RESULTS

A weighted sample of 544,930 teen mothers was analyzed. Compared with non-Hispanic white (NHW) teens, non-Hispanic black teens were more likely to receive counseling on tobacco (adjusted odds ratio [aOR], 1.4; 95% confidence interval [CI], 1.10-1.77), alcohol (aOR, 1.77; 95% CI, 1.28-2.46), illicit drugs (aOR, 1.79; 95% CI, 1.33-2.41), and HIV testing (aOR, 1.62; 95% CI, 1.26-2.09). Compared with NHW teens, Hispanic teens were less likely to receive tobacco counseling (aOR, 0.78; 95% CI, 0.64-0.97) and more likely to receive influenza vaccine counseling (aOR, 1.44; 95% CI, 1.18-1.76). No difference was found in receipt of postnatal counseling.

CONCLUSION

Racial/ethnic differences in receipt of perinatal counseling exist, with non-Hispanic black teens being more likely to receive counseling on substance use and HIV testing and Hispanic teens being more likely to receive influenza vaccine recommendations compared with NHW teens. Ongoing investigation is needed to understand drivers of these differences.

Provision of contraceptive implants in school-based health centers: A cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of providing contraceptive implants in school-based health centers (SBHCs) compared to the practice of referring adolescents to non-SBHCs in New York City.

STUDY DESIGN

We developed a microsimulation model of teen pregnancy to estimate the cost-effectiveness of immediate provision of contraceptive implants at SBHCs over a 3-year time horizon. Model parameters were derived from both a retrospective chart review of patient data and published literature. The model projected the number of pregnancies as well as the total costs for each intervention scenario. The incremental cost-effectiveness ratio was calculated using the public payer perspective, using direct costs only.

RESULTS

The health care cost of immediate provision of contraceptive implants at SBHCs was projected to be $13,719 per person compared to $13,567 per person for delayed provision at the referral appointment over 3 years. However, immediate provision would prevent 78 more pregnancies per 1000 adolescents over 3 years. The incremental cost-effectiveness ratio for implementing in-school provision was $1940 per additional pregnancy prevented, which was less than the $4206.41 willingness-to-pay threshold. Sensitivity analyses showed that the cost-effectiveness conclusion was robust over a wide range of key model inputs.

CONCLUSION

Provision of contraceptive implants in SBHCs compared to non-SBHCs is cost-effective for preventing unintended teen pregnancy. Health care providers and policymakers should consider expanding this model of patient-centered health care delivery to other locations.

The Use of Ripple Effect Mapping to Understand Successes of the SC Pregnancy Assistance Fund: A Participatory Evaluation Approach

OBJECTIVES

The South Carolina Pregnancy Assistance Fund (SCPAF) funded four counties to increase the amount, quality, and awareness of services for young parents; increase educational attainment among expectant and parenting youth; reduce the number of repeat teen pregnancies among youth; and improve parenting skills. The purpose of this paper is twofold: (1) to describe our application of the Ripple Effect Mapping (REM) technique as an innovative evaluation strategy to gather perspectives from SCPAF stakeholders and (2) to share key findings generated by participants in REM sessions on the perceived success of local SCPAF community collaboratives.

METHODS

REM, an innovative evaluation strategy, was used to gather perspectives from SCPAF stakeholders. Five REM sessions were conducted with 52 participants. REM sessions included partner interviews and collective development of visual maps to illustrate stakeholder perspectives of program successes. Visual maps, as well as transcripts of discussions, were analyzed using an inductive approach.

RESULTS

Stakeholders reported that the connections to resources, supports, and services provided through SCPAF had the potential to alter the life trajectories of expectant and parenting teens (EPT). Stakeholders also described that SCPAF fostered growth in collaboration among partners and reduced duplication of services in funded communities CONCLUSIONS FOR PRACTICE: This paper describes how an innovative evaluation strategy was used to provide a space for stakeholders to dialogue, synthesize their experiences, and construct a collective narrative of key program successes. This paper also illustrates how such approaches can be applied to complex community initiatives.

Replication of It's Your Game…Keep It Real! in Southeast Texas

Despite the recent efforts of the Office of Adolescent Health to replicate programs with demonstrated efficacy, there are still few evidence-based HIV, sexually transmitted infection (STI), and teen pregnancy prevention programs that have been replicated in "real-world" settings. To test the effectiveness of It's Your Game…Keep It Real! (IYG), an evidence-based STI and pregnancy prevention program for middle schools, the curriculum was implemented by teachers in urban and suburban middle schools in Southeast Texas from 2012 to 2015. IYG was evaluated using a group-randomized wait-list controlled effectiveness trial design in which 20 middle schools in nine urban and suburban school districts in Southeast Texas were randomized equally, using a multi-attribute randomization protocol, to either the intervention condition (received IYG) (n = 10 schools comprising 1936 eligible seventh graders) or the comparison condition (received usual care) (n = 10 schools comprising 1825 eligible seventh graders). All students were blinded to condition prior to administering the baseline survey. The analytic sample comprised 1543 students (n = 804, intervention; n = 739, comparison) who were followed from baseline (seventh grade) to the 24-month follow-up (ninth grade). Multilevel regression analyses were conducted to assess behavioral and psychosocial outcomes at follow-up. There were no significant differences in initiation of vaginal or oral sex between study conditions at follow-up. However, at 12-month follow-up, compared with students in the comparison condition, students in the intervention condition reported increased knowledge, self-efficacy, and perceived favorable norms related to HIV/STIs, condoms, and/or abstinence; decreased intentions to have sex; and increased intentions to use birth control. Knowledge outcomes were statistically significant at 24-month follow-up. This IYG effectiveness trial did not replicate the behavioral effects of the original IYG efficacy trials. However, it adds to the growing literature on the replication of evidence-based programs, and underscores the need to better understand how variations in implementation, setting, and measurement affect the behavioral impact of such programs.Clinical trial registration clinicaltrials.gov (NCT03533192).

The Teen Access and Quality Initiative: Improving Adolescent Reproductive Health Best Practices in Publicly Funded Health Centers

Quality adolescent sexual and reproductive health (ASRH) services play an important role in supporting the overall health and well-being of adolescents. Improving access to this care can help reduce unintended pregnancies, sexually transmitted diseases (STDs), and human immunodeficiency virus (HIV) infection and their associated consequences, as well as promote health equity. The Centers for Disease Control and Prevention funded three grantees to implement a clinic-based ASRH quality improvement initiative complimented by activities to strengthen systems to refer and link youth to ASRH services. The purpose of this study is to describe the initiative and baseline assessment results of ASRH best practice implementation in participating health centers. The assessment found common use of the following practices: STD/HIV screening, education on abstinence and the use of dual protection, and activities to increase accessibility (e.g., offering after-school hours and walk-in and same-day appointments). The following practices were used less frequently: provider training for Long-Acting Reversible Contraception (LARC) insertion and removal, LARC availability, same-day provision of all contraceptive methods, and consistent sharing of information about confidentiality and minors' rights with adolescent clients. This study describes the types of training and technical assistance being implemented at each health center and discusses implications for future programming.

The Effect of Sexual Literacy on Adolescent Pregnancy in Colombia

STUDY OBJECTIVE

In the present study we investigated the association between receiving information on sexual literacy topics and likelihood of experiencing adolescent pregnancy.

DESIGN

Cross-sectional analysis.

SETTING

Colombia.

PARTICIPANTS

Female Adolescents, 13-19 years old (N = 8525).

MAIN OUTCOME MEASURES

Our primary outcome of interest was adolescent pregnancy.

RESULTS

We created a gradation of public health impact variable that ranged from grade 1 (least impactful) to grade 4 (most impactful) to determine which sexuality-related topics were most strongly associated with teenage pregnancy. We found that not receiving information on grade 4 topics had the strongest association with adolescent pregnancy. These topics were: changes related to puberty (prevalence ratio [PR], 2.15; 95% confidence interval [CI], 1.40-3.30), how sex organs work (PR, 1.90; 95% CI, 1.37-2.66), and sexual orientation (PR, 1.84; 95% CI, 1.38-2.44). In fact, teenagers who did not receive information on any sexuality-related topic were approximately 75% more likely (PR, 1.73; 95% CI, 1.09-2.74) to experience pregnancy during adolescence.

CONCLUSION

The gradation levels of this study could guide sexual education programs in Colombia to prioritize sexuality-related themes, especially when resources are limited.

Adolescent Sex and Psyche in Brazil: Surveillance, Critique and Global Mental Health

Drawing on a historical ethnography conducted in Southern Brazil, this article explores how public health programs for adolescent reproductive and mental health have emerged in Brazil and begun to intersect with the growing field of "global mental health" (GMH). The story I recount begins not in the 2010s with the rapid rise of expert interest in adolescent health within GMH, but in the 1990s, the decade when young teens in Brazil were first coming into contact with practices and approaches in research, schools and clinics that have both underpinned and critiqued the production of an adolescent mental and reproductive health sub-field. In parsing what young women's encounters with the then newly-emerging questionnaires, measurement tools, school-based programs and clinical practices came to mean to them, I use a genealogical approach to consider how histories of education reform, population control, psychoanalysis, social medicine, the transition to democracy, feminism and grass-roots politics all entered the fold, shaping the way adolescent sex-and-psyche materialized as a contested object of expertise. I end by exploring what this case can teach global mental health advocates and social theorists about practices of critique.

Graduated driver licensing and teen fertility

This paper evaluates the effect of implementing nighttime driving curfews and passenger restrictions mandated by graduated driver licensing (GDL) on teen fertility. Both components of GDL potentially restrict the freedom and mobility of minor drivers by requiring adult supervision, and therefore reduces opportunities to become pregnant. Using birth data from the National Vital Statistics (NVSS) and a triple differences approach, I find that the implementation of "tough" GDL decreased fertility by 3-4% among mothers between the ages of 16 and 18. This effect is driven by the states that require driving curfews for at least a year before teenagers can obtain their unrestricted drivers license.

A housing mobility program's impacts on teen and young adult parenting

OBJECTIVE

To assess the impact of Moving to Opportunity for Fair Housing Demonstration Program (MTO) implemented in 1994 in five U.S. cities (Baltimore, Boston, Chicago, Los Angeles, and New York City) on teen births.

METHODS

We analyzed baseline and long-term evaluation data for youth (ages 13-20) and young adults (ages 21-30) (N = 7861) who were children or teens at baseline. We used regression analyses to estimate the impact of housing vouchers on having a teen birth.

RESULTS

Overall, MTO had no significant effect on teen births. However, among young adults whose parent had a child before age 20, the proportion with a teen birth themselves was 21% lower among those offered housing vouchers to low-poverty neighborhoods with no restrictions compared to those not offered housing vouchers (p < 0.05).

CONCLUSION

MTO appeared to decrease intergenerational teen births among young adults. Further exploration of housing relocation may help untangle risks and protective factors for reducing intergenerational teen births.

PUBLIC HEALTH IMPLICATIONS

Reducing intergenerational teen births is important, especially among those facing economic, environmental, and health risks. Comprehensive programs addressing multiple social determinants of health are vital to reducing teen births.

Trends in participation in teen pregnancy and STI prevention programming, 2002-2016

Programs designed to help youth prevent early/unwanted pregnancy and sexually transmitted infection (STI) have been shown to yield a positive impact on youth behavior and key outcomes. However, recent evidence suggests that youth participation in prevention programming for health-risk behavior may be declining. The aim of the present study is to provide up-to-date information on the national trends in adolescent participation in prevention programming targeting early pregnancy and STI in the United States. We examined fifteen years of cross-sectional data (2002-2016, N = 234,803) from the National Survey on Drug Use and Health. Our main outcome was youth self-reported (no/yes) past-year participation in a pregnancy or STI prevention program. Survey adjusted prevalence estimates and logistic regression analysis were used to examine trends in participation. Youth participation in pregnancy and STI prevention programming decreased significantly from a high of 15% in 2003 to a low of 7% in 2016. Representing a 53% proportional decline in youth participation, this downward trend was significant even when controlling for age, gender, race/ethnicity, household income, and urbanicity (AOR: 0.947, 95% CI: 0.943-0.951). The downward trend in participation was observed across racial/ethnic subgroups. A consistent pattern of differences in prevalence was observed with African-American youth reporting the highest levels of participation followed by Hispanic, and then White youth. It is incumbent upon concerned citizens, scientists, and policymakers to push for change that can shift the trend line in adolescent participation in teen pregnancy and STI prevention programming to an upward tilt.

A Matched Cohort Study of the Association Between Childhood Sexual Abuse and Teenage Pregnancy

PURPOSE

This matched cohort study aims to determine whether teenagers with a history of childhood sexual abuse (CSA) are at greater risk of consulting for a pregnancy and related complications than teenagers from the general population. It also aims to compare provoked abortion, live births, and fetal losses of participants who were sexually abused in childhood and those of the general population.

METHODS

A total of 661 girls (aged 13-18 years) with a corroborated by Child Protection Services CSA report between 2001 and 2010 were matched to 661 girls from the general population upon age, biological sex, urban Child Protection Services area, and public drug insurance admissibility at reporting date. Pregnancy consultations and complications during pregnancy and delivery were documented using diagnoses from public health insurance administrative databases from January 1996 to March 2013. Socioeconomic status was controlled.

RESULTS

Results indicate that compared with participants from the general population, those with a history of CSA were 4.6 times more likely to consult for at least one pregnancy, 5.3 times more likely to consult for at least one complication during pregnancy or delivery, and on average 5.2 and 3.3 times more likely to consult for at least one live birth and provoked abortion, respectively. There were too few observations to compare fetal losses between groups.

CONCLUSIONS

Medical interventions for teenage pregnancies and related complications should take into consideration a possible history of CSA to reinforce gynecological follow-up and treatment for girls who were sexually abused and to prevent unfavorable outcomes.

Structural stigma and sexual orientation-related reproductive health disparities in a longitudinal cohort study of female adolescents

INTRODUCTION

Sexual minority female adolescents have worse reproductive health than heterosexual peers; research into the origins of these disparities is limited. Our objective was to examine whether exposure to structural stigma (e.g., societal-level conditions, cultural norms, institutional policies/practices that constrain the lives of the stigmatized) is associated with sexually transmitted infections (STIs) and teen pregnancy in sexual minority female adolescents.

METHODS

Longitudinal data were utilized from 6581 female adolescents aged 9-14 years at baseline (1996) in the U.S.-based Growing Up Today Study and followed through 2007. We used a previously-validated structural stigma scale composed of four state-level items (e.g., employment non-discrimination policies) with one item added relevant to reproductive health. Risk ratios were generated from multivariate models.

RESULTS

Sexual minority female adolescents were significantly more likely than heterosexual peers to have an STI diagnosis and teen pregnancy. Sexual minority female adolescents living in states with lower, compared to higher, levels of structural stigma were significantly less likely to have an STI diagnosis, after adjustment for individual- and state-level covariates (relative risk [RR] = 0.70, 95% confidence interval [CI]: 0.51, 0.97). In contrast, among completely heterosexual adolescents, structural stigma was not associated with STI diagnosis. Teen pregnancy risk-a rare outcome-did not vary by level of structural stigma for sexual minority or heterosexual adolescents.

CONCLUSIONS

Structural stigma is a potential risk factor for adverse reproductive health among sexual minority female adolescents. Changing laws and policies to be inclusive of all people, regardless of sexual orientation, can help alleviate entrenched reproductive health disparities.

Effectiveness of School-Based Teen Pregnancy Prevention Programs in the USA: a Systematic Review and Meta-Analysis

School-based programs have been a mainstay of youth pregnancy prevention efforts in the USA. We conducted a systematic review and meta-analysis to assess their effectiveness. Eligible studies evaluated the effect on pregnancy rates of programs delivered in elementary, middle, or high schools in the USA and Canada, published between January 1985 and September 2016. The primary outcome was pregnancy; secondary outcomes were delay in sexual initiation, condom use, and oral contraception use. Randomized controlled trials (RCTs) and non-RCTs with comparator groups were eligible. We developed a comprehensive search strategy, applied to major bibliographic databases, article bibliographies, gray literature, and contact with authors. We calculated risk ratios (RR) with 95% confidence intervals (CI) for each outcome and pooled data in random effects meta-analysis. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess evidence quality. Ten RCTs and 11 non-RCTs conducted from 1984 to 2016 yielded 30 unique pooled comparisons for pregnancy, of which 24 were not statistically significant. Six showed statistically significant changes in pregnancy rates: two with increased risk (RR 1.30, 95% CI 1.02-1.65; and RR 1.39, 95% CI 1.10-1.75) and four with decreased risk ranging from RR 0.56, 95% CI 0.41-0.77, to RR 0.75, 95% CI 0.58-0.96. All studies were at high risk of bias, and the quality of evidence was low or very low. Identified evidence indicated no consistent difference in rates of pregnancies between intervention recipients and controls.

Revealing a safer sex option to reduce HIV risk: a cluster-randomized trial in Botswana

Background

1.8 million new HIV infections occur every year, disproportionately affecting adolescent girls and young women. Abstinence-only risk avoidance approaches have had limited impact on reducing new infections. This cluster-randomized trial examines a risk reduction approach to curbing risky sex for school-going girls in Botswana.

Methods

The unit of randomization was the school (n = 229). Intervention participants received a 1-h intervention revealing a safer sex option: dating same-age partners which have 5-9x lower HIV prevalence than older partners. Primary outcomes were pregnancy as a proxy for unprotected sex and HIV. Secondary outcomes included self-reported sexual behavior. Generalized linear multilevel models with school-level robust variance for adjusted relative risk ratios were used in an intention-to-treat analysis.

Results

At a 12-month follow up, the intervention reduced pregnancy with an adjusted Relative Risk Ratio (aRRR) of .657 [95% CI .433–.997] significant at the 5% level. Effects were largest at junior school (aRRR = .575 [95% CI .394–.841]) and in rural areas (aRRR = .518 [95% CI .323–.831]), significant at the 1% level. There were no significant effects for primary school students, suggesting age of sexual debut and related mechanisms are critical factors in the intervention’s effectiveness. Moreover, baseline beliefs of which partner is riskiest mediate the magnitude of effects.

Conclusions

Information on safe sex options can change sexual behavior. The success of the intervention working across contexts will depend on various factors, such as age of sexual debut and baseline beliefs.

Trial registration

Pan African Clinical Trials Registry PACTR201901837047199. Registered 31 December 2018. Retrospectively registered. This study adheres to CONSORT guidelines.

Parents' beliefs of the Black Church's role in teen pregnancy prevention

INTRODUCTION

Parents are important decision makers in black churches. The objective of this qualitative study was to identify African American parents' beliefs of the Black Church's role in preventing teen pregnancy and promoting healthy teen relationships.

METHODS

Parent members (n = 36) of 27 predominately Black churches in two southwestern US cities participated in semi-structured interviews from February-June 2017. A question path was developed based on literature searches, key informant interviews, and a previous study with local pastors, and questions focused on parents' knowledge/beliefs about 1) sexuality education, 2) the church's role in preventing teen pregnancy, and 3) implementation obstacles. Interviews were transcribed verbatim, coded using NVivo, and open-coded for themes to investigate patterns across codes and participants. Transcripts were then reviewed for quotes to represent each theme.

RESULTS

Five themes were identified, with multiple subthemes. Most parents said there should be no boundaries on the type of sexuality information shared by their church, but later changed their minds after reviewing a list of potential topics. Parents listed 'parent-child communication', 'goals and dreams', and 'relationships' as the most important topics for teen pregnancy prevention intervention. Parents said information shared during workshops should be judgement-free and realistic. Parents most often said pastors and/or youth pastors/directors should deliver sexual health information. Parents believed older adults and other parents may oppose sexual education.

CONCLUSIONS

By understanding parents' beliefs of teen pregnancy prevention programs, public health practitioners can understand concerns, modify implementation strategies, and utilize parental support to gain buy-in before planning and implementing programs.

Availability and Accessibility of Emergency Contraception to Adolescent Callers in Pharmacies in Four Southwestern States

PURPOSE

To evaluate the availability and accessibility of emergency contraception (EC) to adolescents in U.S. pharmacies across four Southwestern states, 3 years after the federal Food and Drug Administration (FDA) removed age restrictions for over-the-counter sales of levonorgestrel-only pills.

METHODS

Using a mystery-caller approach, we trained male and female data collectors to phone pharmacies posing as 16-year-olds who wanted to prevent a pregnancy after recent unprotected sex. From April to May 2016, they called 1,475 randomly selected retail pharmacies in Arizona, California, New Mexico, and Utah and completed an online survey about their experience. Caller data were analyzed by state and pharmacy type (i.e., national chains, regional outlets, and individually owned outlets).

RESULTS

Of pharmacies contacted, 80.6% had EC available at the time of the call. Availability of EC varied by state (p < .01) and pharmacy type (p < .01), but not by rural/urban location. Even where EC was available, pharmacy personnel often hindered youths' access to EC by mentioning incorrect point-of-sale restrictions, keeping EC in restrictive store locations, or asking personal questions. Individually owned outlets presented significantly more barriers than larger chains. Overall, EC was completely accessible to an adolescent caller in only 28% of pharmacies. Lower EC accessibility was found in states with higher teen pregnancy rates.

CONCLUSIONS

This study found that EC is still not sufficiently available or accessible to adolescents in Southwestern states. Differences in accessibility vary significantly by state and pharmacy type and may be a contributor to teen pregnancy rates.

Can Pediatricians Provide Long-Acting Reversible Contraception?

STUDY OBJECTIVE

In the United States, 40% of high-school students have sex; few use highly effective and safe long-acting reversible contraceptives (LARCs): intrauterine devices and implants. Pediatricians are key health providers for many adolescents, yet few provide LARCs. Our objective was to understand the pragmatics of provision of LARCs (rather than beliefs or attitudes) and identify barriers to and opportunities for LARC provision by community-practicing pediatricians.

DESIGN

We conducted a qualitative descriptive study using semistructured interviews. Qualitative methods are valuable for generating conceptual models of complex phenomena.

SETTING

Set in a midsized Midwestern city, our study was community-based.

PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES

We interviewed 23 pediatricians to understand their views about providing contraception (including LARCs) to adolescents. For analysis, we developed a coding schema and applied it using a priori and open coding.

RESULTS

Several inter-related themes regarding challenges to provision of LARC emerged: limited motivation for on-site LARC provision or referral streams, low pediatric patient interest in LARC, lack of pediatrician training about LARC provision, and inadequate structural elements for on-site placement of LARCs in pediatric offices. Each challenge could be remedied, because pediatricians were motivated to provide adolescent patients with high-quality care. Improvements in these inter-related conditions could facilitate pediatrician provision of LARC.

CONCLUSION

Pediatricians and their patients want to prevent pregnancy, but current practice norms limit LARC provision by pediatricians. To increase LARC access in pediatrician offices, we suggest training in LARC provision and patient education for medical students, residents, and pediatricians; communicating about LARC methods with adolescents to increase patient demand; and systemic changes to improve referral processes and/or allow on-site LARC placements.

Can a conditional cash transfer reduce teen fertility? The case of Brazil's Bolsa Familia

In 2008, Brazil's conditional cash transfer program expanded to cover a wider range of ages. Poor families are now given stipends for their children's school attendance up to age seventeen, whereas prior the maximum age was fifteen. Using a nationally representative household survey, we estimate the impact of this policy on teen fertility with a triple difference analysis on the fertility outcomes of treated cohorts vs. non-treated cohorts based on income eligibility, age eligibility, and timing of program implementation. We find a three percentage point drop in fertility among eligible teens within five years of program implementation. This offsets the difference in fertility between poor and non-poor teens. The impact is concentrated in urban areas, with no program effects found in rural areas. We are able to replicate these findings using National Birth Registry Data.

Changing disparities in teen birth rates and repeat birth rates in Georgia: implications for teen pregnancy prevention

OBJECTIVE

To understand teen birth trends in Georgia by racial and geographic factors.

STUDY DESIGN

We analyzed overall birth and repeat teen birth rates by race, urban/rural status and adequacy of obstetric care from 2008 to 2016 using vital records from all Georgia counties.

RESULTS

Overall birth rates among teens analyzed decreased dramatically in Georgia, from 45.63 births per 1000 teens in 2008-2010 to 26.28 per 1000 teens in 2014-2016. Repeat birth rates followed a similar decline, from 9.40 to 4.53 repeat births per 1000 teens over the same time period. These rates decreased in all subgroups of teens but to varying degrees. The difference in birth and repeat birth rates between black and white teens decreased fourfold during this time period, whereas the declines in these rates for teens living in rural versus urban counties and with inadequate versus adequate obstetric care were less pronounced.

CONCLUSION

While remarkable reductions in teen birth and repeat birth rates have occurred since 2008, these declines have not been equally experienced by all groups of teens.

IMPLICATIONS

Our analysis suggests that persistent disparities in teen birth and repeat birth rates exist, particularly in areas with limited or threatened access to reproductive health care. Applying targeted teen pregnancy prevention initiatives to these areas could help ensure equitable health and social outcomes for teens.

A Comparison of Childbirth Costs for Adolescents and Adults From 2001 to 2010

PURPOSE

Although teenage birth rates in America have fallen to a historic low of 26.2 births per 1,000 teenagers, the U.S. remains behind the rest of the industrialized world. Adolescent pregnancy is relatively well discussed in today's literature, with ever more detailed estimates constantly emerging to quantify the cost of children born to America's teenagers. This study, however, describes the financial cost of childbirth in the U.S. with a specific focus on understanding the impact of adolescent childbirth in comparison to that of adult women and of annual childbirth as a whole.

METHODS

This retrospective cohort study used data from the 2001-2010 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS), a uniform, multistate database containing information regarding approximately 8 million hospital inpatient stays per year of data. Data were analyzed involving payment type, length of stay, and aggregate cost of all childbirths to adolescent girls (under 18 years of age) and to adult women.

RESULTS

This study found that Medicaid pays for the majority (70%) of births to adolescent girls, whereas private insurance pays for the majority (53%) of births to adult women. This was in contrast to the Medicaid coverage of 41% of all childbirths within the study time frame. Furthermore, the aggregate cost of childbirths to adolescent girls paid for by Medicaid was $670 million.

CONCLUSIONS

Beyond their social impact, births to adolescent mothers place a financial burden on the national economy. Stronger efforts must be made to decrease adolescent childbirth.

Family context and individual situation of teens before, during and after pregnancy in Mexico City

Background

In the last 20 years, adolescent pregnancy has become one of the most critical problems affecting women in Latin America and the Caribbean.

Methods

This qualitative study was based on in-depth interviews with 29 teen mothers. All of the pregnant teens were from low- to lower-middle-class social strata in the Mexico City metropolitan area. The family (living with the girl) and the individual context of pregnant teens were analysed on the basis of data from at least three interviews: during pregnancy and at approximately 6 and 24 months following delivery. Additionally, six mothers, four fathers, and four partners of the pregnant girls of the group were interviewed. The information on the individual and family situation before, during and after the pregnancy was recorded and transcribed, then analysed in three phases, comprising pre-analysis, exploration and interpretation.

Results

The pregnant teens had a family background of teen pregnancy. The girls disclosed feelings of repression, loneliness and indifference to their parents, leading them to unprotected sexual relations without fear of pregnancy. After the pregnancy, communication improved between the girls and their parents, but became worse with their partner. Consequently, these teens returned to feeling as they did before getting pregnant. They stated that they would make their situation work for the sake of their child, and regretted dropping out of school and getting pregnant so young. Almost all said they were seeking love outside the family, which revealed a scenario of limited communication and unsatisfactory relations within the family.

Conclusions

Understanding how communication works between parents and children is necessary to avoid teenage pregnancy, as well as early marriage or cohabitation, resulting in dropping out of school and financial constraints, which lead to great frustrations between the couple and affects the child. In addition, it is vitally important that adolescents be motivated in the family setting in order for them to continue their studies. There is also an urgent need to implement measures that compensate for educational inequality, as well as to strengthen strategies aimed at adolescent mothers and pregnant teens that encourage their school performance through the support of scholarship programs and day care centres. Many of the problems inherent in adolescence are related to the lack of affection and support, and in many cases are a reaction to authoritarian rules or limits established unilaterally by parents with little or no dialogue involved.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1570-7) contains supplementary material, which is available to authorized users.

Contributing factors of teenage pregnancy among African-American females living in economically disadvantaged communities

AIM

To identify contributing factors that increased the risk of pregnancy among African-American adolescent females living in economically disadvantaged communities and to evaluate the current pregnancy prevention programs addressing these factors in order to provide suggestions for the development of tailored pregnancy prevention programs for this target population.

BACKGROUND

Pregnancy rates among adolescents in the United States have declined over the past several years. Despite this trend, the pregnancy rate for African-American adolescent females is disproportionately higher than the adolescent pregnancy rates for other ethnicities. Limited attempts have been made to compile and synthesize the factors that increase risk of pregnancy in this population or to evaluate the effectiveness of intervention programs for African-American females that incorporate these risk factors.

METHOD

An integrative literature review was conducted to identify the major contributing factors of pregnancy among African American adolescents living in economically disadvantaged areas.

RESULTS

Of the identified contributing risk factors for early pregnancy among African-American adolescent females, the five most supported risk factors were: parental influence, peer influence, social messages, substance use including alcohol, and pregnancy desire. Twelve pregnancy prevention programs were identified that addressed one or more of the five contributing factors to pregnancy. Parental influence and social messages were the most addressed factors among these programs.

CONCLUSIONS

This review found five contributing factors related to teenage pregnancy; however, current intervention programs are not well addressed substance use as a component of alcohol use. Thus, development of a tailored pregnancy prevention program incorporating those factors will help decrease the high pregnancy rate among this target population.

The effect of spending cuts on teen pregnancy

In recent years, English local authorities have been forced to make significant cuts to devolved expenditure. In this paper, we examine the impact of reductions in local expenditure on one particular public health target: reducing rates of teen pregnancy. Contrary to predictions made at the time of the cuts, panel data estimates provide no evidence that areas which reduced expenditure the most have experienced relative increases in teenage pregnancy rates. Rather, expenditure cuts are associated with small reductions in teen pregnancy rates, a result which is robust to a number of alternative specifications and tests for causality. Underlying socio-economic factors such as education outcomes and alcohol consumption are found to be significant predictors of teen pregnancy.

Applying the Theory of Reasoned Action to Understanding Teen Pregnancy with American Indian Communities

Objectives American Indian girls have higher teen pregnancy rates than the national rate. Intervention studies that utilize the Theory of Reasoned Action have found that changing attitudes and subjective norms often leads to subsequent change in a variety of health behaviors in young adults. The current study goal is to better understand sexual decision-making among American Indian youth using the Theory of Reasoned Action model and to introduce ways to utilize attitudes and subjective norms to modify risky behaviors. Methods The project collected qualitative data at a reservation site and an urban site through 16 focus groups with American Indian young people aged 16-24. Results Attitudes towards, perceived impact of, and perception of how others felt about teen pregnancy vary between American Indian parents and non-parents. Particularly, young American Indian parents felt more negatively about teen pregnancy. Participants also perceived a larger impact on female than male teen parents. Conclusions There are differences between American Indian parents and non-parents regarding attitudes towards, the perceived impact of, and how they perceived others felt about teen pregnancy. Teen pregnancy prevention programs for American Indian youth should include youth parents in curriculum creation and curriculum that addresses normative beliefs about teen pregnancy and provides education on the ramifications of teen pregnancy to change attitudes.

Sometimes You Do Get a Second Chance: Emergency Contraception for Adolescents

Unplanned or unintended pregnancy remains a significant challenge for adolescents; many teens who plan ahead but opt not to choose long-acting reversible contraceptive methods have high failure rates with condom usage, oral contraceptives, and other less long-acting methods. Emergency contraception (EC) remains a necessity for those adolescents seeking a second chance to prevent the unintended consequences of unplanned sexual activity. At present, 5 postcoital methods remain available as EC globally: intrauterine devices, ulipristal acetate, a selective progesterone modulator, mifepristone; levonorgestrel, and ethinyl estradiol plus levonorgestrel or norgestrel (rarely used now that progestin only methods are more readily available).