Figures & Tables
Figures
- 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.
- FIGURE 2
Article Selection Process
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
Tables
- TABLE 1.
Number and Percentage of Adolescents Ages 15–19 With a Birth in USAID-Assisted Countries, by Number of Births
Country Total No. of Women 15–19 Number of Women 15-19 With: Percentage of Women 15-19 With: 1 Birth 2 Births 3+ Births Any Birth 1 Birth 2 Births 3+ Births Any Birth India 2005–2006 54,635,318 5,026,449 1,365,883 218,541 6,610,873 9.2 2.5 0.4 12.1 Bangladesh 2014 7,787,279 1,720,989 179,107 7,787 1,907,883 22.1 2.3 0.1 24.5 Nigeria 2013 9,955,173 1,353,904 298,655 49,776 1,702,335 13.6 3.0 0.5 17.1 Brazil 1996 8,510,147 966,753 221,264 34,041 1,222,057 11.4 2.6 0.4 14.4 DRC 2013–2014 4,718,045 778,477 188,722 33,026 1,000,226 16.5 4.0 0.7 21.2 Indonesia 2012 11,123,673 738,612 22,247 8,899 769,758 6.6 0.2 0.1 6.9 Tanzania 2015–2016 2,941,151 535,289 76,470 5,882 617,642 18.2 2.6 0.2 21.0 Pakistan 2012 10,722,312 493,226 85,778 10,722 589,727 4.6 0.8 0.1 5.5 Ethiopia 2016 5,805,546 516,694 63,861 5,806 586,360 8.9 1.1 0.1 10.1 Mozambique 2011 1,550,003 373,551 74,400 7,750 455,701 24.1 4.8 0.5 29.4 Angola 2015–2016 1,499,876 337,472 85,493 8,999 431,964 22.5 5.7 0.6 28.8 Uganda 2011 2,283,838 303,750 91,354 15,987 411,091 13.3 4.0 0.7 18.0 Philippines 2013 5,138,070 349,389 41,105 5,138 395,631 6.8 0.8 0.1 7.7 Kenya 2014 2,488,748 301,139 57,241 4,977 363,357 12.1 2.3 0.2 14.6 Madagascar 2008–2009 1,332,247 266,449 62,616 17,319 346,384 20.0 4.7 1.3 26.0 Niger 2012 1,043,873 246,145 82,466 13,362 341,973 23.6 7.9 1.3 32.8 Mali 2012-2013 971,050 241,791 67,974 11,653 321,418 24.9 7.0 1.2 33.1 South Africa 1998 2,372,020 298,875 9,488 2,372 310,735 12.6 0.4 0.1 13.1 Côte d'Ivoire 2011–2012 1,328,997 239,751 62,330 4,386 306,467 18.0 4.7 0.3 23.1 Egypt 2014 4,369,133 253,410 39,322 – 292,732 5.8 0.9 0.0 6.7 Colombia 2015 1,983,614 228,116 37,689 4,166 269,970 11.5 1.9 0.2 13.6 Malawi 2015–2016 1,091,464 223,750 16,372 2,183 242,305 20.5 1.5 0.2 22.2 Burkina Faso 2010 1,087,568 174,663 26,645 2,175 203,484 16.1 2.5 0.2 18.7 Nepal 2016 1,579,950 170,635 26,859 4,740 202,234 10.8 1.7 0.3 12.8 Zambia 2013–2014 859,608 176,220 21,490 2,579 200,289 20.5 2.5 0.3 23.3 Turkey 2003 3,230,340 155,056 19,382 9,691 184,129 4.8 0.6 0.3 5.7 Guinea 2012 654,601 142,572 36,789 3,731 183,092 21.8 5.6 0.6 28.0 Afghanistan 2015 1,992,100 123,510 31,874 3,984 159,368 6.2 1.6 0.2 8.0 Ghana 2014 1,377,890 139,167 15,157 1,378 155,702 10.1 1.1 0.1 11.3 Peru 2012 1,366,132 129,783 17,486 410 147,679 9.5 1.3 0.0 10.8 Guatemala 2014–2015 841,331 116,945 15,985 3,365 136,296 13.9 1.9 0.4 16.2 Zimbabwe 2015 773,876 119,177 10,834 – 130,011 15.4 1.4 0.0 16.8 Yemen 2013 1,567,150 97,163 26,642 4,701 128,506 6.2 1.7 0.3 8.2 Senegal 2016 796,791 81,273 15,936 1,594 98,802 10.2 2.0 0.2 12.4 Honduras 2011–2012 482,308 79,870 11,527 482 91,880 16.6 2.4 0.1 19.1 Dominican Rep. 2013 489,499 70,977 10,133 489 81,599 14.5 2.1 0.1 16.7 Benin 2011–2012 602,731 66,059 12,235 1,326 79,621 11.0 2.0 0.2 13.2 Bolivia 2008 552,238 65,109 12,591 1,491 79,191 11.8 2.3 0.3 14.3 Uzbekistan 1996 1,234,969 68,170 6,175 2,470 76,815 5.5 0.5 0.2 6.2 Liberia 2013 257,899 57,511 8,769 258 66,538 22.3 3.4 0.1 25.8 Haiti 2012 577,907 56,635 7,513 1,156 65,303 9.8 1.3 0.2 11.3 Morocco 2003–2004 1,451,561 56,611 5,806 1,306 63,724 3.9 0.4 0.1 4.4 Nicaragua 2001 305,869 50,774 10,828 1,499 63,101 16.6 3.5 0.5 20.6 Togo 2013-2014 403,711 48,163 5,410 – 53,572 11.9 1.3 0.0 13.3 Cambodia 2014 722,097 48,597 4,333 72 53,002 6.7 0.6 0.0 7.3 Burundi 2010 597,098 35,348 4,419 – 39,767 5.9 0.7 0.0 6.7 Eritrea 2002 311,661 28,673 5,298 623 34,594 9.2 1.7 0.2 11.1 Rwanda 2014–2015 631,072 32,816 1,262 – 34,078 5.2 0.2 0.0 5.4 Mauritania 2000–2001 200,101 18,609 6,603 1,001 26,213 9.3 3.3 0.5 13.1 Kazakhstan 1999 576,648 23,643 1,499 – 25,142 4.1 0.3 0.0 4.4 Ukraine 2007 930,583 20,938 3,629 – 24,567 2.3 0.4 0.0 2.6 Jordan 2012 500,920 14,527 3,006 – 17,532 2.9 0.6 0.0 3.5 Tajikistan 2012 398,873 14,479 878 120 15,476 3.6 0.2 0.0 3.9 Swaziland 2006–2007 82,377 13,180 2,059 – 15,240 16.0 2.5 0.0 18.5 Azerbaijan 2006 305,795 9,357 2,110 275 11,743 3.1 0.7 0.1 3.8 Kyrgyzstan 2012 228,641 8,917 183 91 9,191 3.9 0.1 0.0 4.0 Moldova 2005 93,573 4,323 159 – 4,482 4.6 0.2 0.0 4.8 Timor-Leste 2009–2010 71,039 3,104 717 199 4,021 4.4 1.0 0.3 5.7 Albania 2008–2009 117,252 2,075 94 – 2,169 1.8 0.1 0.0 1.9 Armenia 2015–2016 83,885 2,097 – – 2,097 2.5 0.0 0.0 2.5 Total 171,989,221 18,320,709 3,622,151 523,979 22,466,839 13.1 Total no. (%) with subsequent births 4,146,130 (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.
Interventions Description Comprehensive Services Provision of multiple services May 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 services Through clinical or home-based delivery, includes counseling on correct method use and side effects Comprehensive sexuality education Includes contraceptive education, availability and correct use of contraceptives, sexual health and responsibility, dispelling myths about contraceptives Pregnancy testing Provision of monthly pregnancy tests Surveys of contraceptive use Regular assessments to monitor contraceptive use Counseling on use of LAM with or without emergency contraception Contraceptive services organized to provide LAM counseling and education; may include take-home supply of emergency contraception Postpartum contraception Provision of contraceptive services and counseling in the immediate or extended(24 months) postpartum period Planning for Contraceptive Use and Pregnancy Planning Antenatal contraceptive plan In antenatal period, clients encouraged to articulate fertility intentions and prepare contraceptive plan to achieve fertility intentions “Implementation Intention Formation” training Training in “if-then” planning: “If I am brushing my teeth in the morning, then I will take my contraceptive pill.”21 Planning the next pregnancy Clients encouraged to state the preferred timing of their next pregnancy Community-Based Social and Behavioral Change Communication Interpersonal counseling on fertility return after live birth Clients 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 spacing Clients 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 influentials Group 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 interactions Counseling by and discussion with social groups who have similar age, background, and social status as subjects Motivating, Mentoring, Goal Setting Cell phone counseling Using 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 setting Nurses/social workers assist teens in preparing short- and long-term plans to achieve life goals Mentorship curriculum Use of planned mentorship curriculum by providers who have had similar life experiences and often serve as “big sisters” Home visitation Periodic 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 interviewing Use of a counseling style that “emphasizes an individual's personal goals and self-efficacy in relation to complex behaviors”20 Skills training and job placement Educational 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.
- TABLE 3.
Interventions Achieving Statistically Significant Impact on Rapid Repeat Pregnancy or Birth Among High-Quality Evaluations (n=14)
Intervention Description Evaluation Country Outcome Measured During Postpartum Period Repeat Pregnancy or Birth Rate P Value Intervention Control Contraceptive Services and Information Proactive monitoring of contraceptive use, contraceptive education, and inclusion of partner and families Sullivan 199218 US Pregnancy <18 months 12% 28% <.003 Proactive monitoring of contraceptive use, contraceptive education, and inclusion of partner and families Rabin 199136 US Pregnancy over 9 years 9% 70% <.001 Postpartum Contraceptive Services Postpartum check-ups and provision of contraceptive services within 2 months of index birth in school setting Seitz 199333 US Birth <24 months 12% 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 EC Shaaban 201322 Egypt Pregnancy <6 months 0.3%a 5% <.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 201539 Bangladesh Birth <24 months 14%b 17%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) US Pregnancy 13–24 months –c –c –c Home visitation by nurses to help women plan the timing of the next pregnancy, rather than avoid unintended pregnancies Olds 200224 US Pregnancy <24 months 29% 41% <.02 Home visitation by nurses to help women plan the timing of the next pregnancy, rather than avoid unintended pregnancies Kitzman 199725 US Pregnancy <24 months 36% 47% <.01 Training adolescents in “if-then” planning for oral contraceptive use Martin 201121 UK Pregnancy <24 months 7% 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) Bangladesh Birth <24 months 14%d 17% <.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 15–24 Sebastian 201237 India Pregnancy at 9 months 10.5%e 16.4% <.01 Group discussions in homes of influentials to promote positive views of contraceptives and encourage discussions with husbands and friends Kincaid 200057 Bangladesh Contraceptive 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) US Pregnancy 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 birthday Black 200619 US Birth <24 months 11% 24% <.05 Cell phone counseling emphasizing teens' own goals and needs, positive youth assets, healthy relationships, and positive reproductive health practices Katz 201123 US Pregnancy <24 months 26%g 39%g <.01 Motivational interviewing of adolescents, emphasizing personal goals and self-efficacy Barnet 200920 US Birth <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 16 Drayton 200040 Jamaica Pregnancy over 4 years 37% 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).
- TABLE 4.
Magnitude of Effect on Repeat Pregnancy or Birth Among High-Quality Evaluations Measuring Similar Outcomes at Similar Time Periodsa (n=6)
Evaluation Intervention Description Outcome Measured During Postpartum Period Repeat Pregnancy Rates P Value Intervention Control Higher Magnitude of Effect Sullivan 199218 Health 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 months 12% 28% <.003 Black 200619 Postpartum home-visitation mentoring intervention; curriculum delivered every other week until infant's first birthday by women from community who served as mentors. Birth <24 months 11% 24% <.05 Martin 201121 Training for adolescents in “implementation intention formation” (if-then planning) in relation to use of contraceptives. Pregnancy <24 months 7% 12% <.02 Lower Magnitude of Effect Katz 201123 Intensive 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 months 26%b 39%b <.01 Olds 200224 Nurse home-visitation intervention to improve health behaviors, prevent rapid repeat pregnancies, improve parent care of children, and maternal life-course development. Pregnancy <24 months 29% 41% <.02 Kitzman 199725 Home visitation by nurses to improve newborn and child health and mental development, and to prevent injuries and rapid repeat pregnancies. Pregnancy <24 months 36% 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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