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REVIEW
Open Access

Interventions for Preventing Unintended, Rapid Repeat Pregnancy Among Adolescents: A Review of the Evidence and Lessons From High-Quality Evaluations

Maureen Norton, Venkatraman Chandra-Mouli and Cate Lane
Global Health: Science and Practice December 2017, 5(4):547-570; https://doi.org/10.9745/GHSP-D-17-00131
Maureen Norton
aUnited States Agency for International Development, Washington, DC, USA.
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  • For correspondence: mnorton@usaid.gov
Venkatraman Chandra-Mouli
bWorld Health Organization, Geneva, Switzerland.
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Cate Lane
cPathfinder International, Washington, DC, USA.
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    FIGURE 1

    Annual Percentage Point Change in Adolescent Repeat Pregnancy Among USAID Priority Countries,a 2013–2016

    a Data are shown for 22 of 24 USAID priority countries; no data were available for South Sudan and trend data were unavailable for Afghanistan.

    Source of data: Trends are extrapolated from the last 2 survey data points from Demographic and Health Surveys and Reproductive Health Surveys. Analysis conducted by the USAID Knowledge Management Services II project.

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    Article Selection Process

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    A 16-year-old girl holds her first child at a district health facility in Tanzania. © 2014 Megan Ivankovich/WI-HER LLC, Courtesy of Photoshare

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    TABLE 1.

    Number and Percentage of Adolescents Ages 15–19 With a Birth in USAID-Assisted Countries, by Number of Births

    CountryTotal No. of Women 15–19Number of Women 15-19 With:Percentage of Women 15-19 With:
    1 Birth2 Births3+ BirthsAny Birth1 Birth2 Births3+ BirthsAny Birth
    India 2005–200654,635,3185,026,4491,365,883218,5416,610,8739.22.50.412.1
    Bangladesh 20147,787,2791,720,989179,1077,7871,907,88322.12.30.124.5
    Nigeria 20139,955,1731,353,904298,65549,7761,702,33513.63.00.517.1
    Brazil 19968,510,147966,753221,26434,0411,222,05711.42.60.414.4
    DRC 2013–20144,718,045778,477188,72233,0261,000,22616.54.00.721.2
    Indonesia 201211,123,673738,61222,2478,899769,7586.60.20.16.9
    Tanzania 2015–20162,941,151535,28976,4705,882617,64218.22.60.221.0
    Pakistan 201210,722,312493,22685,77810,722589,7274.60.80.15.5
    Ethiopia 20165,805,546516,69463,8615,806586,3608.91.10.110.1
    Mozambique 20111,550,003373,55174,4007,750455,70124.14.80.529.4
    Angola 2015–20161,499,876337,47285,4938,999431,96422.55.70.628.8
    Uganda 20112,283,838303,75091,35415,987411,09113.34.00.718.0
    Philippines 20135,138,070349,38941,1055,138395,6316.80.80.17.7
    Kenya 20142,488,748301,13957,2414,977363,35712.12.30.214.6
    Madagascar 2008–20091,332,247266,44962,61617,319346,38420.04.71.326.0
    Niger 20121,043,873246,14582,46613,362341,97323.67.91.332.8
    Mali 2012-2013971,050241,79167,97411,653321,41824.97.01.233.1
    South Africa 19982,372,020298,8759,4882,372310,73512.60.40.113.1
    Côte d'Ivoire 2011–20121,328,997239,75162,3304,386306,46718.04.70.323.1
    Egypt 20144,369,133253,41039,322–292,7325.80.90.06.7
    Colombia 20151,983,614228,11637,6894,166269,97011.51.90.213.6
    Malawi 2015–20161,091,464223,75016,3722,183242,30520.51.50.222.2
    Burkina Faso 20101,087,568174,66326,6452,175203,48416.12.50.218.7
    Nepal 20161,579,950170,63526,8594,740202,23410.81.70.312.8
    Zambia 2013–2014859,608176,22021,4902,579200,28920.52.50.323.3
    Turkey 20033,230,340155,05619,3829,691184,1294.80.60.35.7
    Guinea 2012654,601142,57236,7893,731183,09221.85.60.628.0
    Afghanistan 20151,992,100123,51031,8743,984159,3686.21.60.28.0
    Ghana 20141,377,890139,16715,1571,378155,70210.11.10.111.3
    Peru 20121,366,132129,78317,486410147,6799.51.30.010.8
    Guatemala 2014–2015841,331116,94515,9853,365136,29613.91.90.416.2
    Zimbabwe 2015773,876119,17710,834–130,01115.41.40.016.8
    Yemen 20131,567,15097,16326,6424,701128,5066.21.70.38.2
    Senegal 2016796,79181,27315,9361,59498,80210.22.00.212.4
    Honduras 2011–2012482,30879,87011,52748291,88016.62.40.119.1
    Dominican Rep. 2013489,49970,97710,13348981,59914.52.10.116.7
    Benin 2011–2012602,73166,05912,2351,32679,62111.02.00.213.2
    Bolivia 2008552,23865,10912,5911,49179,19111.82.30.314.3
    Uzbekistan 19961,234,96968,1706,1752,47076,8155.50.50.26.2
    Liberia 2013257,89957,5118,76925866,53822.33.40.125.8
    Haiti 2012577,90756,6357,5131,15665,3039.81.30.211.3
    Morocco 2003–20041,451,56156,6115,8061,30663,7243.90.40.14.4
    Nicaragua 2001305,86950,77410,8281,49963,10116.63.50.520.6
    Togo 2013-2014403,71148,1635,410–53,57211.91.30.013.3
    Cambodia 2014722,09748,5974,3337253,0026.70.60.07.3
    Burundi 2010597,09835,3484,419–39,7675.90.70.06.7
    Eritrea 2002311,66128,6735,29862334,5949.21.70.211.1
    Rwanda 2014–2015631,07232,8161,262–34,0785.20.20.05.4
    Mauritania 2000–2001200,10118,6096,6031,00126,2139.33.30.513.1
    Kazakhstan 1999576,64823,6431,499–25,1424.10.30.04.4
    Ukraine 2007930,58320,9383,629–24,5672.30.40.02.6
    Jordan 2012500,92014,5273,006–17,5322.90.60.03.5
    Tajikistan 2012398,87314,47987812015,4763.60.20.03.9
    Swaziland 2006–200782,37713,1802,059–15,24016.02.50.018.5
    Azerbaijan 2006305,7959,3572,11027511,7433.10.70.13.8
    Kyrgyzstan 2012228,6418,917183919,1913.90.10.04.0
    Moldova 200593,5734,323159–4,4824.60.20.04.8
    Timor-Leste 2009–201071,0393,1047171994,0214.41.00.35.7
    Albania 2008–2009117,2522,07594–2,1691.80.10.01.9
    Armenia 2015–201683,8852,097––2,0972.50.00.02.5
    Total171,989,22118,320,7093,622,151523,97922,466,83913.1
    Total no. (%) with subsequent births4,146,130 (2%)
    • Abbreviations: DRC, Democratic Republic of the Congo; USAID, United States Agency for International Development.

    • Sources of data: Population of women ages 15–19 from 2017 U.S. Census Bureau data; number of women ages 15–19 with births from the most recent Demographic and Health Survey for each country. Analysis conducted by the USAID Knowledge Management Services II project.

    • View popup
    TABLE 2.

    Intervention Approaches Used in the Evaluations Reviewed (N=40)

    InterventionsDescription
    Comprehensive Services
    Provision of multiple servicesMay include contraceptive services, contraceptive education, maternal/infant/child health services, child care, social work services, and/or home visitation
    Contraceptive Information and Services
    Provision of contraceptive servicesThrough clinical or home-based delivery, includes counseling on correct method use and side effects
    Comprehensive sexuality educationIncludes contraceptive education, availability and correct use of contraceptives, sexual health and responsibility, dispelling myths about contraceptives
    Pregnancy testingProvision of monthly pregnancy tests
    Surveys of contraceptive useRegular assessments to monitor contraceptive use
    Counseling on use of LAM with or without emergency contraceptionContraceptive services organized to provide LAM counseling and education; may include take-home supply of emergency contraception
    Postpartum contraceptionProvision of contraceptive services and counseling in the immediate or extended(24 months) postpartum period
    Planning for Contraceptive Use and Pregnancy Planning
    Antenatal contraceptive planIn antenatal period, clients encouraged to articulate fertility intentions and prepare contraceptive plan to achieve fertility intentions
    “Implementation Intention Formation” trainingTraining in “if-then” planning: “If I am brushing my teeth in the morning, then I will take my contraceptive pill.”21
    Planning the next pregnancyClients encouraged to state the preferred timing of their next pregnancy
    Community-Based Social and Behavioral Change Communication
    Interpersonal counseling on fertility return after live birthClients advised that fertility can return before menses returns and, to avoid unintended pregnancy, not to wait for menses return before starting use of contraceptives
    Interpersonal counseling on healthy pregnancy spacingClients advised of health/quality of life benefits of spacing next pregnancy 24 months after last birth, and potential adverse outcomes for mother and infant of closely spaced births
    Social networks/group discussions in homes of village influentialsGroup discussions to convey accurate information about contraceptive methods, advance understanding of the positive benefits of contraceptive use, and encourage discussions about contraceptive use with husbands and friends
    Peer counseling interactionsCounseling by and discussion with social groups who have similar age, background, and social status as subjects
    Motivating, Mentoring, Goal Setting
    Cell phone counselingUsing cell phones, project counselors use standardized curricula (based on teen's goals and needs) to hold weekly counseling calls for the first 6 months, followed by calls every 2 weeks for the next 12 months, for a total of 42 counseling sessions over 18 months. Cell phone service provided 450 minutes per month of use without surcharge.
    Goal settingNurses/social workers assist teens in preparing short- and long-term plans to achieve life goals
    Mentorship curriculumUse of planned mentorship curriculum by providers who have had similar life experiences and often serve as “big sisters”
    Home visitationPeriodic visits by nurses/community health workers to the homes of postpartum women, usually once a month over a 1–2-year period, to provide education, counseling, and/or contraceptive services
    Motivational interviewingUse of a counseling style that “emphasizes an individual's personal goals and self-efficacy in relation to complex behaviors”20
    Skills training and job placementEducational support for adolescent mothers under age 16 to return them to school, and skills training and job placement for adolescent mothers over age 18
    • Abbreviation: LAM, Lactational Amenorrhea Method.

    • View popup
    TABLE 3.

    Interventions Achieving Statistically Significant Impact on Rapid Repeat Pregnancy or Birth Among High-Quality Evaluations (n=14)

    Intervention DescriptionEvaluationCountryOutcome Measured During Postpartum PeriodRepeat Pregnancy or Birth RateP Value
    InterventionControl
    Contraceptive Services and Information
    Proactive monitoring of contraceptive use, contraceptive education, and inclusion of partner and familiesSullivan 199218USPregnancy <18 months12%28%<.003
    Proactive monitoring of contraceptive use, contraceptive education, and inclusion of partner and familiesRabin 199136USPregnancy over 9 years9%70%<.001
    Postpartum Contraceptive Services
    Postpartum check-ups and provision of contraceptive services within 2 months of index birth in school settingSeitz 199333USBirth <24 months12%36%<.005
    Education on the use of LAM and, for intervention group participants only, education on the use of EC in the event of unprotected intercourse and provision of take-home supply of ECShaaban 201322EgyptPregnancy <6 months0.3%a5%<.001
    Education on the use of LAM and support/increased messaging to transition to another modern method by 6 months postpartum (a sub-intervention of a larger birth spacing intervention evaluated by Ahmed 201539)Ahmed 201539BangladeshBirth <24 months14%b17%b<.01
    Planning Interventions
    Preparation of contraceptive plan in the antenatal period (a sub-intervention of a larger pregnancy spacing intervention evaluated by Olds 200224)Gray 2006 study17 (secondary analysis of Olds 200224)USPregnancy 13–24 months–c–c–c
    Home visitation by nurses to help women plan the timing of the next pregnancy, rather than avoid unintended pregnanciesOlds 200224USPregnancy <24 months29%41%<.02
    Home visitation by nurses to help women plan the timing of the next pregnancy, rather than avoid unintended pregnanciesKitzman 199725USPregnancy <24 months36%47%<.01
    Training adolescents in “if-then” planning for oral contraceptive useMartin 201121UKPregnancy <24 months7%12%<.02
    Community-Based Social and Behavioral Change Communication
    Education on postpartum fertility return before return of menses. This was a sub-intervention of birth spacing intervention evaluated by Ahmed 2015.Cooper 2014 study16 (analysis of sub-intervention carried out in Ahmed 201539)BangladeshBirth <24 months14%d17%<.01
    Interpersonal counseling and community education on the benefits of healthy pregnancy spacing and potential consequences of short pregnancy intervals, with a focus on adolescents and young adults ages 15–24Sebastian 201237IndiaPregnancy at 9 months10.5%e16.4%<.01
    Group discussions in homes of influentials to promote positive views of contraceptives and encourage discussions with husbands and friendsKincaid 200057BangladeshContraceptive continuation over 2.5 years–f–f–f
    Motivating, Mentoring, and Goal Setting
    Assistance to adolescents to prepare plans for achieving short- and long-term life goals (a sub-intervention of a larger pregnancy spacing intervention evaluated by Olds 200224)Gray 2006 study17 (secondary analysis of Olds 200224)USPregnancy 7–12 months–c–c–c
    Use of mentorship curriculum by women from the community who made home visits to postpartum adolescents every 2 weeks until infant's first birthdayBlack 200619USBirth <24 months11%24%<.05
    Cell phone counseling emphasizing teens' own goals and needs, positive youth assets, healthy relationships, and positive reproductive health practicesKatz 201123USPregnancy <24 months26%g39%g<.01
    Motivational interviewing of adolescents, emphasizing personal goals and self-efficacyBarnet 200920USBirth <24 months–h–h–h
    Provision of skills training and job placement for adolescent mothers over age 16 and educational support for mothers under age 16Drayton 200040JamaicaPregnancy over 4 years37%60%<.05
    • Abbreviations: EC, emergency contraception; LAM, Lactational Amenorrhea Method.

    • ↵a Shaaban 2013 reported 2 pregnancies among 579 participants in the intervention group, for a pregnancy rate of 0.3%. The article reported a pregnancy rate of 0.8%, but it is likely a transcription error.

    • ↵b At 3 months postpartum, contraceptive use was 36% (of which 23% was LAM use) in the intervention group compared with 11% (with no LAM use) in the comparison group. In the intervention group, in part due to LAM users' transition to another method at 6 months postpartum, contraceptive use remained significantly higher in the intervention group than the comparison group at 24 months postpartum (46% vs. 35%, respectively; P<.001).

    • ↵c The study indicated that adolescents with a prenatal contraceptive plan were significantly less likely to conceive at 13–24 months postpartum than adolescents without a plan. 18.6% of adolescents who prepared such a plan did not conceive by 13-24 months, while 0% of those who conceived by 13-24 months had prepared a prenatal contraceptive plan (P<.005). Adolescents who formulated short- and long-term goals were significantly less likely to conceive at 7–12 months postpartum than those who did not formulate such goals (P<.05).

    • ↵d Sub-intervention analyzed in Cooper 201416 focused on improving knowledge of postpartum fertility return. The analysis found that 98% of women knew fertility could return before return of menses, and women stated this information motivated them to begin using contraceptives.

    • ↵e 93% of those in the intervention group reported counseling on use of spacing methods after delivery, whereas 69% of those in the control group reported such counseling (P<.01). Women in the intervention group who knew at least 2 spacing messages and at least 2 spacing methods were more likely to adopt a modern method postpartum (P<.05).

    • ↵f Outcome measured was contraceptive continuation for 2.5 years at any point in a woman's life, not necessarily during the postpartum period. In the intervention group, contraceptive continuation for 2.5 years was 43.9% vs. 25.5% in the comparison group (P<.001).

    • ↵g Among adolescents ages 15–17 years.

    • ↵h Controlling for baseline difference, adolescents who received motivational interviews and home visits were more likely to defer a repeat birth than those in the control group (hazards ratio, 0.4; P<.05).

    • View popup
    TABLE 4.

    Magnitude of Effect on Repeat Pregnancy or Birth Among High-Quality Evaluations Measuring Similar Outcomes at Similar Time Periodsa (n=6)

    EvaluationIntervention DescriptionOutcome Measured During Postpartum PeriodRepeat Pregnancy RatesP Value
    InterventionControl
    Higher Magnitude of Effect
    Sullivan 199218Health care model delivered at teen baby clinic for teen mothers, including social workers, pediatrician, and referral for contraceptive service provision; focused on prevention of repeat pregnancy, return to school, immunizations, and reduced use of emergency room.Pregnancy <18 months12%28%<.003
    Black 200619Postpartum home-visitation mentoring intervention; curriculum delivered every other week until infant's first birthday by women from community who served as mentors.Birth <24 months11%24%<.05
    Martin 201121Training for adolescents in “implementation intention formation” (if-then planning) in relation to use of contraceptives.Pregnancy <24 months7%12%<.02
    Lower Magnitude of Effect
    Katz 201123Intensive cell phone counseling intervention to prevent subsequent teen pregnancies by strengthening healthy relationships, reproductive practices, positive youth assets, and teen's own goals and needs.Pregnancy <24 months26%b39%b<.01
    Olds 200224Nurse home-visitation intervention to improve health behaviors, prevent rapid repeat pregnancies, improve parent care of children, and maternal life-course development.Pregnancy <24 months29%41%<.02
    Kitzman 199725Home visitation by nurses to improve newborn and child health and mental development, and to prevent injuries and rapid repeat pregnancies.Pregnancy <24 months36%47%<.006
    • ↵a All 6 evaluations were randomized controlled trials and reported statistically significant impact of the intervention on rapid repeat pregnancy or birth rates. All were conducted in the United States, except Martin (2011),21 which was conducted in the United Kingdom.

    • ↵b Among mothers ages 15–17 years.

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Interventions for Preventing Unintended, Rapid Repeat Pregnancy Among Adolescents: A Review of the Evidence and Lessons From High-Quality Evaluations
Maureen Norton, Venkatraman Chandra-Mouli, Cate Lane
Global Health: Science and Practice Dec 2017, 5 (4) 547-570; DOI: 10.9745/GHSP-D-17-00131

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Interventions for Preventing Unintended, Rapid Repeat Pregnancy Among Adolescents: A Review of the Evidence and Lessons From High-Quality Evaluations
Maureen Norton, Venkatraman Chandra-Mouli, Cate Lane
Global Health: Science and Practice Dec 2017, 5 (4) 547-570; DOI: 10.9745/GHSP-D-17-00131
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