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Programs that Work to Prevent Subsequent Pregnancy among Adolescent Mothers
Program Components - School-based program offering case management, comprehensive medical care and support group
- Intensive case management by a school-based social worker with frequent home visits and continuous availability by cell phone
- Weekly, school-based peer education / support group including involvement in service learning
- Comprehensive medical care for the adolescent mother and her child and continuous availability of pediatrician by pager
- Coordination between the social worker and the adolescent’s physician
For Use With - Low-income, African American adolescent females, enrolled in high school
Evaluation Methodology - Prospective cohort study among pregnant and parenting adolescent females enrolled in a South Carolina high school
- Pregnant or parenting students known to the school or to their peers or self-referred (n=63) and a propensity-matched comparison group (n=252), randomly selected from state birth certificate data
- Follow-up at age 20 or three years after the index birth, whichever came later
Evaluation Findings - Reduced incidence of births
Program Description This home visiting model offers case management by a social worker who is based at the students’ high school. The social worker is culturally matched to the adolescents, has a master’s degree in social work, and also has an office, provided by the school, in a convenient but private location. The social worker provides client-centered care and support, ranging from coaching to direct assistance, referral to other services and agencies, and follow-up on each referral. In addition, the social worker facilitates the weekly group meetings that have no set curriculum but are designed by the social worker to address topics pertinent to the members. Such topics might include risk-taking behaviors, healthy relationships, parenting skills, academic performance, careers, contraception, and sexually transmitted infections (STIs). The group establishes a contract of behavior expected of each member. Each year, group members select a service learning project for the community and implement it with the assistance of the social worker.18
The program offers comprehensive medical care to each participant. A female pediatrician specializing in adolescent medicine sees participants and their children together on a designated weekly afternoon at the nearby university ambulatory care center. The physician uses a patient-centered approach with motivational interviewing techniques. The physician also uses: a developmental scrapbook, completed by the mother at well-child visits and including a new photo, taken at each visit; frequent developmental screening of the child, including involving the mother in interpreting and understanding the results of the screening; and a child’s book, given at each visit. Participants also have 24-hour access to the pediatrician via her pager.18
The program requires cross-disciplinary collaboration. Weekly team staff meetings include positively-framed assessment of each participant. The social worker attends each participant’s medical visits. The pediatrician occasionally attends group meetings and sometimes accompanies the social worker on home visits.18
Evaluation Methodology Every eligible female student, known to the participating high school or to her peers as pregnant or parenting, as well as students who self-referred, were offered enrollment in the project. Seventy-two young women enrolled (97 percent of eligible pregnant or parenting female students). Two miscarried within two weeks and were removed from the program and one withdrew her consent prior to participating; these three were removed from analysis. Of the remaining 69 participants, 63 were in the program long enough to have an adequate period of risk (>24 months) and were included in the intent-to-treat analysis. Participants were African American (99 percent); had a mean age of 16 years; were all Medicaid eligible and eligible for free or reduced lunch. At enrollment, 52 percent of participants were currently pregnant; 47 percent were parenting and not currently pregnant.18
One participant was disruptive and removed from participation in group activities; however, she continued to receive other services and is included in the analysis. One participant had a toddler who failed to thrive. After prolonged unsuccessful intervention, including two hospitalizations, frequent medical appointments, coordination with WIC, and home visits by the pediatrician and the social worker, this young mother was reported to Social Services. She withdrew from participation in case management but continued to participate in other aspects of the program, including medical visits (without her child). She, too, was included in analysis of the program’s effectiveness.18
Comparisons (n=252) were a propensity-matched group of adolescent females, four for each participant, randomly selected from the state’s birth certificate data. Each comparison group member matched a participant for demographic information, including date of birth of the mother plus or minus six months, date of birth of the infant plus or minus three months, parity at the initial birth, and race/ethnicity. The only excluding factor was residence in either of two zip codes that constituted the attendance zone for the participating high school.18
The analysis was based on intent to treat and compared the intervention and comparison groups at enrollment on demographic and socioeconomic factors and differences in medical care, contraceptive choice, and other program components between those who were pregnant and parenting at enrollment. The Kaplan-Meier method was used to compute the rate of subsequent birth free survival at each observed time, calculated as the time from enrollment to when the mother’s name or social security number reappeared in the state’s birth registry, either within 24 months or until the mother reached age 20, whichever was later.18
In addition, a research assistant not involved in the program conducted focus group research with participants, using scripted questions. The project evaluator then reviewed the transcribed answers and summarized the common themes for each focus group. The research assistant also held qualitative interviews with parents and school personnel, using semi-structured, scripted interviews. The evaluator summarized answers from these interviews, too.18
Long-Term Outcomes - Decreased Incidence of Births—“This intensive school-based intervention for teen mothers [was] effective in achieving a 50 percent reduction in the rate of subsequent births during adolescence.” The rate of subsequent births was lower in participants (17 percent) than in the comparison group (33 percent). The difference was statistically significant (P=.001); was similar over time; and became significant at 30 months (P=.05). At 24 months, 11 percent of participants had another birth versus 20 percent of comparisons. At 30 months, 14 percent of participants had another birth versus 26 percent of comparisons. At 36 months, 17 percent of participants had another birth versus 29 percent of comparisons. The survival curve of time was also significantly different between participants and comparisons (P=.001).18
Among program participants, there was also a trend of fewer subsequent births in those who participated more in two of the program components, specifically coordinated medical care and case management. Subsequent births occurred in 30 percent of participants who did not receive the medical care compared with 10 percent of those who did (P=.08) and in 66 percent of those who did not participate in case management, compared with 15 percent of those who did (P=.07).18
Notes: Participation in program components was not as great as intended. For example, 63 percent of participants (n=40) took advantage of the offered medical care and saw the pediatrician for a mean number of slightly over six visits. However, overall participation in medical care was not statistically significant (P=.17). Participation in group meetings (76 percent; n=48; P=.06) was better, as was participation in case management (95 percent; n=60; P=.04). Participants’ use of contraception included medroxyprogesterone (77 percent), combined oral contraceptives (12 percent), and transdermal contraceptive patch (eight percent). However, evaluation found no significant difference in overall use of contraception by participation in any of the three program components (group meetings, case management, or medical care). Finally, evaluation showed that there were fewer subsequent births in participants who graduated, transferred to another school, or were still enrolled in the intervention school (11 percent) than in those who dropped out, were expelled, or enrolled in a GED program (27 percent); but this difference, too, was not significant.18 For More Information, Contact - Janice D. Key, M.D., The Medical University of South Carolina, Department of Pediatrics, 135 Rutledge Avenue, PO Box 250561, Charleston, SC 29425.
References
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