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Interventions to reduce the rate of teenage pregnancy - Community

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In this section:

• Key Messages |
• Interventions |
• References |
• Contributors |

Key Messages

• A meta-analysis of studies of primary pregnancy prevention programmes including community-based and school-based programmes; and clinic-based and non-clinic-based programmes (young people aged 11-20), found that clinic-based programmes increased contraceptive use and decreased pregnancy rates, compared with non-clinic-based programmes.
• Services that are targeted at particular demographic and risk groups of young people are on the whole more effective than non-targeted programmes.
• Confidentiality influences clinic attendance and has been shown to have the potential to reduce teenage conception rates.
• Despite the importance of engaging with young people less likely to attend clinic settings, little is known about the effectiveness of outreach services. What evidence there is, however, testifies to their importance in reducing teenage pregnancy rates.
• Not enough is known about the role of counselling in reducing teenage pregnancy rates. The quality of the existing research does not provide strong guidance for recommendations about clinical practice.
• Enhanced access to emergency contraception increases use and does not promote sexual activity, but studies have shown no effect on pregnancy rates in teenagers younger than 18.
• There is no robust evidence on the relative merits of providing integrated services (combining contraceptive care and care for sexually transmitted infections (STIs)); and little is known about the relative advantages of providing services in particular settings (primary care, community-based clinics and hospital-based contraceptive service).

Population Interventions

Population interventions that work

Targeted services

A study on targeted services showed that involving older adolescents, mixed male and female groups, black and minority ethnic groups, and mixed groups of virgins and non-virgins increased the effect of the intervention. ²

The evidence generally favours targeted programmes. Programmes targeting young people specifically and those targeting groups with particular demographic and risk characteristics are more successful than broad spectrum approaches. However, programmes targeting young women at very high risk have not shown an advantage over standard care.

One RCT (386 women who had already had an abortion) compared women receiving specialist contraceptive advice and enhanced contraceptive provision (271 women) with women receiving routine clinic care (115 women). ³ The trial showed that women receiving the enhanced package were more likely to leave hospital with contraception (P<0.001), which was more likely to be a long-acting method (P<0.001) than women receiving standard care, but they were no less likely to have repeat abortions. ³

A systematic review (17 studies) assessed the impacts of youth-specific primary care on access, utilisation, mental health, health outcomes and emergency department use. ⁴ This review reported significantly greater use of health services by young people, especially females, and those who were more socio-economically disadvantaged and at risk. ⁴

Confidentiality

The studies showed that confidential reproductive health care has significant benefits over services with reduced confidentiality. They found a significant increase in pregnancies, births, and abortions, and pelvic inflammatory disease (PID) in young women under 18, associated with the implementation of a new law that limited adolescents' ability to obtain confidential reproductive healthcare services. ^{5 6}

A systematic review of 15 studies and one survey in the United States compared the effect of providing confidential reproductive health care with reproductive health care with parental consent. ^{5 6} Variations between US states’ laws relating to confidentiality, and changes in these laws over time, enabled researchers to model the impact of loss of confidentiality on clinic use and teenage pregnancy rates.

Outreach

One RCT based in six agencies in New York assigned 100 disadvantaged 13-15 year olds to either their usual youth programme or the Children's Aid Society-Carrera programme (a year round after school programme with a comprehensive youth development orientation) for three years. ⁷ The study showed that after three years the teenagers in the Carrera programme were significantly less likely to be sexually active, to have had unsafe sex, and to have experienced a pregnancy than teenagers who followed their usual youth programme.

The programme had no significant impact on the sexual and reproductive behaviour of the young men, although there were benefits in terms of good primary health care. This programme was one of only four whose evaluation has successfully documented declines in teenage pregnancy by using a random-assignment design. ⁷

See Factfile: Children's Aid Society-Carrera programme

Population interventions that may work

Counselling

Counselling would seem, at face value, to have the potential to reduce pregnancy rates among young people, but the evidence base is too poor to know for sure.

A systematic review of studies of the effectiveness, benefits, and harms of counselling in a clinical setting to prevent unintended pregnancy concluded that no experimental or observational literature reliably answers questions about the effectiveness of counselling in the clinical setting to reduce rates of unintended pregnancies. ⁸

Existing studies suffer from threats to internal validity and loss to follow-up and are too heterogeneous in terms of populations studied and outcomes measured. The quality of the existing research does not provide strong guidance for recommendations about clinical practice but does suggest directions for future investigations.

Population interventions that do not work

Access to emergency contraception

The evidence, somewhat counter-intuitively, is that providing easier access to emergency contraception has little impact on teenage pregnancy rates. Several well conducted RCTs, in the UK and the US, have explored the potential benefits of increasing access to emergency contraception by providing advance supplies and pharmacy access to young people. ^{9 10 11}

In a US RCT, 2117 women (age 15-24, not desiring pregnancy) were randomly assigned to one of three interventions - pharmacy access to emergency contraception; advance provision of three packs of levonorgestrel emergency contraception, or the clinic access (control group). ⁹ The study found that women in the pharmacy access group were no more likely than controls to use the emergency contraception (P=0.25) but women in the advance provision group were almost twice as likely to use emergency contraception than controls (P<0.001). However, women in the pharmacy access and advance provision group did not experience a significant reduction in pregnancy rates compared with the control group (pharmacy access group odds ratio 0.98, 95% confidence interval 0.58 to 1.64; P=0.93; advance provision group 1.10, 0.66 to 1.84; P=0.71). ⁹

Another RCT (2117 women including 964 adolescents, 90 of whom were under 16 years) randomised young adolescents (<16 years); middle adolescents (16-17 years); older adolescents (18-19 years); and adults (20-24 years) to one of three interventions - pharmacy access to emergency contraception; advance provision of three packs of levonorgestrel emergency contraception or clinic access (control group). ¹⁰ Contingency table and logistic regression analysis were used to measure the effect of the intervention on risk behaviours in young adolescents (<16 years), compared with middle adolescents (16-17 years), older adolescents (18-19 years), and adults (20-24 years). The study compared the effect of interventions on contraceptive and sexual risk behaviour between age groups at six months and tested for pregnancy and STIs. The study found that young adolescents behaved no differently in response to increased access to emergency contraception than the other age groups. Use of emergency contraception was greater among adolescents in the advance provision group than in the clinic access group (44% compared to 29%, P≤0 .001), and other behaviours were unchanged by intervention group including unprotected intercourse, condom use, STIs, or pregnancy. ¹⁰

A fear among the opponents of increased provision of emergency contraception is that it may make young women less cautious about who they have sex with, knowing they have a ‘fail-safe’. However, in this study, those with increased access to emergency contraception did not become more vulnerable to unwanted sexual activity. ¹¹

What we don’t know

One stop shops

Although there is anecdotal evidence that young people prefer, and benefit from, integrated sexual health provision (combined care relating to contraception and sexually transmitted infection on one site), there is little reliable evidence on their effectiveness compared with separately run services. The results of the evaluation of the government-funded pilot of “one stop shops” providing integrated care to young people is awaited, and should provide a definitive answer to the question.

Sexual health clinics

Little reliable evidence exists on the relative effectiveness of providing sexual health care to young people in primary care, in community clinics or in hospital-based services.

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