A comprehensive intervention for preventing unintended pregnancies among teens led to greater use of long-acting reversible contraception (LARC), fewer incidences of unprotected sex, and a big reduction in unintended pregnancies, results of a new study revealed.1
The 18-month Teen Options to Prevent Pregnancy (TOPP) intervention was given to a population of youths, ages 19 years and younger, who were at least 28 weeks pregnant or less than nine weeks postpartum. They also had to be enrolled in Medicaid. They were recruited from seven OhioHealth women’s clinics and the postpartum units of OhioHealth hospitals.
“They were adolescent mothers, and we looked at what we could do to prevent repeat unintended pregnancy,” says Dara Lee Luca, PhD, former senior researcher at Mathematica Policy Research in Cambridge, MA. “Most of their first pregnancies were unintended, and we were mainly focused on reducing rapid repeat pregnancies, such as having a second pregnancy within 24 months of the initial pregnancy.”
Research shows rapid repeat pregnancies among adolescents lead to enduring emotional, psychological, and educational challenges.2
About one-third of recently pregnant adolescents experience a repeat pregnancy within two years of a previous birth or abortion. Enrollment in the TOPP study began in 2011 and continued until 2014.1
“We did a baseline survey at enrollment and a survey 18 months after enrollment, asking them the same questions and looking at whether they had a new pregnancy,” Luca says.
The intervention was compared with a control group with access to existing standard-of-care services provided through their local healthcare organizations, home visiting programs, and community-based organizations. “If you were in the control group and not randomized for the intervention, then it would be business-as-usual services in their area,” Luca says.
TOPP reduced rapid repeat pregnancies and led to significant reductions in unprotected sex. About 21% of women in the TOPP intervention group reported a repeat pregnancy at the 18-month survey, compared with 38% reporting a repeat pregnancy among the control group, Luca says.
In the intervention group, 22.4% of participants reported having sex without an effective contraceptive method in the past three months, compared to 34% of the control group. Both groups had a similar number of sexual partners.
LARC use also was significantly higher among the TOPP group than the control group, and rates of intercourse without a condom were lower.
“Around 40% of treatment group members reported using LARC in the past few months, at time of the survey, compared to 26% of control members,” Luca says. “This is a stark difference. A lot more people were using LARC, and this also was accompanied by a drop in repeat pregnancy.”
TOPP uses phone calls and promotes healthy birth spacing along with effective contraceptive use. Since its population of adolescent mothers is relatively transient, phone communication is easier to schedule and bypasses the need for convenient transportation. It also allows nurses to have a higher caseload than they would have with a home visiting program.
TOPP includes three parts, led by trained nurse educators.
• Contraceptive counseling. “This is personalized counseling on contraceptive use with motivational interviewing techniques,” Luca says. “It’s a collaborative style of communication designed to strengthen personalization and specific goals.”
The participants explore their own goals for change.
The nurse educators were trained extensively on motivational interviewing. First, they met at a two-day retreat. Then, for the first year, they received additional training with a consultant on a weekly basis. After the first year, nurses met with the consultant every other month, Luca explains. At the training sessions, nurses might discuss with the consultant how to troubleshoot challenges in conducting interviews.
While receiving ongoing training, nurse educators connected with the study’s participants at least once a month, making an average of eight connections over 18 months, with a maximum of 24 connections. “This wide range depended on the participant’s needs,” Luca says. “Some people talked to the nurse a lot, and some chose not to use that service a lot.”
Motivational interviewing is a technique of guiding and empowering people through respectful, nonjudgmental listening and giving information. Nurse educators individualized their client-centered, collaborative counseling style with the goal of promoting behavior change, but without sounding paternalistic or authoritative.
“They used motivational interviewing to elicit information about the person’s past experiences and to encourage them to examine their own knowledge base on contraception,” Luca explains. “Based on the goals, they worked collaboratively with participants to provide individualized plans.”
The nurses were cautious and tried to not appear coercive, but the goal was to guide the participants to birth control methods they could use consistently, if that was part of their plan.
• Contraceptive services. “This part was to reduce logistical barriers to contraception use,” Luca says. “It could be transportation barriers or not having access to a provider.”
Barriers to effective contraception include lack of knowledge and difficulty finding a provider and scheduling an appointment. “TOPP provided access to program clinics and free transportation services. There was a board-certified OB/GYN who provides a wide range of contraceptive services,” she says. “If [the participants] needed to reach a healthcare provider, they could get this free van service.”
A program clinic was available for free if a participant did not have a regular provider. “All of the women were on Medicaid, and they already had access to contraceptive services, but we were trying to address these nonfinancial barriers, like how to find a provider and what type of contraceptive service to use,” Luca explains.
• Social support services. A social worker helped participants with social determinants of health barriers.
The social worker provided an initial psychosocial assessment and needs assessment, looking at each person’s risks. Based on the assessment, the social worker would offer support and referrals to various social services, including housing, child care, employment, and mental healthcare. “Some people were referred to employment agencies, and some were interested in continuing education,” she adds. “The role of the social worker was to give the correct referrals.”
The social support piece is to address the types of barriers that might prevent someone from using contraceptives. These include stress from poverty or unstable housing, where it is hard to adhere to a consistent birth control plan. The social worker did not provide follow-up to see if the women contacted the referral sources.
“Social work was less emphasis on that part and more like an initial assessment and then giving referrals,” Luca says.
The investigators received federal funding for the resource-intensive study. It included salaries for a social worker, registered nurse, administrative staff, an OB/GYN, and funds for various contraceptives. “The nurses are registered nurses, and their time is expensive,” Luca says.
A cost-effectiveness analysis showed the program was effective, but it would be difficult to justify its implementation in a setting with limited resources. TOPP cost about $1.7 million to treat 297 participants. This is compared to the public cost of an unintended pregnancy of $24,619 over a five-year period.
“We don’t quite offset the cost, but most of it is offset by the reduced public cost of supporting unintentional births, and there are other benefits,” Luca says. “There are long-term benefits to the labor market that are not captured in the 18-month survey.”
- Luca DL, Stevens J, Rotz D, et al. Evaluating teen options for preventing pregnancy: Impacts and mechanisms. J Health Econ 2021;77:102459.
- Aslam RW, Hendry M, Booth A, et al. Intervention now to eliminate repeat unintended pregnancy in teenagers (INTERUPT): A systematic review of intervention effectiveness and cost-effectiveness, and qualitative and realist synthesis of implementation factors and user engagement. BMC Med 2017;15:155.
- MINT. Understanding motivational interviewing.