REVIEW

CURRENT
OPINION Teen pregnancy prevention: current perspectives
Claudia Lavin a and Joanne E. Cox b,c

Purpose of review
Teen pregnancy has been subject of public concern for many years. In the United States, despite nearly
2 decades of declining teen pregnancy and birth rates, the problem persists, with significant disparities
present across racial groups and in state-specific rates. This review examines recent trends, pregnancy
prevention initiatives and family planning policies that address the special needs of vulnerable youth.
Recent findings
Unintended teen pregnancies impose potentially serious social and health burdens on teen parents and
their children, as well as costs to society. Trends in teen pregnancy and birth rates show continued decline,
but state and racial disparities have widened. Demographic factors and policy changes have contributed to
these disparities. Research supports comprehensive pregnancy prevention initiatives that are multifaceted
and promote consistent and correct use of effective methods of contraception for youth at risk of becoming
pregnant.
Summary
There is strong consensus that effective teen pregnancy prevention strategies should be multifaceted,
focusing on delay of sexual activity especially in younger teens while promoting consistent and correct use
of effective methods of contraception for those youth who are or plan to be sexually active. There is a need
for further research to identify effective interventions for vulnerable populations.
Keywords
adolescent, pregnancy prevention, teen birth rates, teen pregnancy rates

INTRODUCTION FRAMING THE ISSUE

Most teen pregnancies in the United States are The US teen pregnancy rate continues to be one of
unplanned and unintended and have far reaching the highest in the developed world – more than
consequences [1]. Teen mothers are at high risk twice the rates in Canada (28 per 1000 women aged
for school failure, low self-esteem and depression 15–19) and Sweden (31 per 1000) [11]. Although the
&
[1–3,4 ]. Mothers younger than 17 years of age are teen pregnancy rates increased in 2006 and 2007, in
at higher risk for premature births, low infant birth 2008, the US teen pregnancy rate reached its lowest
weights, infant mortality in the first year of life and point in more than 30 years (67.8 per 1000 women
child abuse. The children of teen mothers are more aged 15–19 years old) down 42% from its peak in
likely to perform poorly in school and engage in 1990 (116.9 per 1000) [11]. Similarly, the US overall
high-risk behaviors in adolescence and are less adolescent birth rate reached a nadir of 39.1 per
likely to be economically successful as adults 1000 women aged 15–19 in 2009 [12]. That year,
[2,5–9]. approximately 750 000 women younger than 20
Adolescent parenting results in loss of human became pregnant and 414 879 gave birth [13]. To
potential. More than 75% of teen mothers receive understand the trends in teen pregnancy, we have to
public assistance within 5 years of their child’s
birth [2]. Teen childbearing in the United States a
Harvard School of Public Health, bDivision of Adolescent/Young Adult
cost taxpayers $10.9 billion dollars in 2008 [10].
Medicine and cDepartment of Pediatrics, Children’s Hospital Boston,
Many biological and social factors have been Harvard Medical School, Boston, Massachusetts, USA
associated with these poor outcomes, including Correspondence to Claudia Lavin, MD, Division of General Pediatrics,
nutrition, poverty (approximately two-thirds of Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115,
pregnant adolescent women already live below USA. Tel: +1 617 55 181; fax: +1 617 39 458; e-mail: claudialavin@
the level of poverty), social disorganization, poor hotmail.com
access to prenatal care and stigmatization Curr Opin Pediatr 2012, 24:462–469
[1,6,9]. DOI:10.1097/MOP.0b013e3283555bee

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 Teen pregnancy prevention: current perspectives Lavin and Cox

to reduced sexual activity [20]. But the federal

KEY POINTS mandate for funding abstinence-only programs

Teen pregnancy rates in the United States continue to after 2002 and lack of comprehensive programs
be the highest in the developed world, and significant that address contraceptive promotion and condom
disparities exist between states and regions. use may contribute to states’ disparities in teen
&
pregnancy rates [21 ] and has been attributed to

Programs that use a comprehensive approach and
the recent increase in STIs, including the number
include correct information about contraceptives in
addition to promoting delay of sexual activity are more of young men infected with HIV [22]. Although
effective than abstinence-only programs. other industrialized countries use abstinence in
their programs, they also include contraceptive

Age and culture of target populations should be use promotion and sexual education programs [23].
considered when developing pregnancy prevention
intervention.
CURRENT TEEN PREGNANCY
PREVENTION MODELS
look at the factors that influence adolescent sexual Evaluating the effect of evidence-based teen
behaviors and current demographic and govern- pregnancy prevention interventions is important
ment policies. in order to frame national and state policies.
Variables that affect teen pregnancy trends Multiple interventions have been developed over
include shifts in the racial and ethnic composition the years to address teen pregnancy. The most
of the population, with an increasing Hispanic effective teen programs that incorporate evidence-
population as a driving force for high teen birth based approaches can be placed into one of three
rates [1,8,14]. There are long-standing disparities in categories: clinic-based interventions, school-based
rates by race and by state. The overall prevalence of and school-linked interventions (community
having ever had sexual intercourse in 9th–12th programs). These interventions share common
grade students is 65.2% for blacks, 49.1% for characteristics, including longer appointments
Hispanics and 42% for whites, as reported by the and individual counseling, educational programs,
2009 National Youth Risk Survey [15]. Yet, when confidential services, contraceptives (although, due
controlling for other factors, poverty is strongly to policy funding barriers, many of the interven-
associated with risk for teenage pregnancy tions do not specify whether contraceptives or pre-
[1,6,16]. Teen birth rates also vary considerably by scriptions were offered on site), free-cost or low-cost
state; in Mississippi, 65.7 per 1000 women aged services, referrals and active outreach [24].
15–19 years old gave birth in 2008 compared with The evaluations of most of these programs
19.8 per 1000 in New Hampshire [17]. From another focusing on sexual behaviors, HIV/STI and preg-
perspective, the decline in teen birth rates from 1991 nancy prevention have been rigorously analyzed
to 2006 was only 17% in Oklahoma compared with by The National Campaign to Prevent Teen Preg-
47% in Vermont [1]. The disparities can be large nancy. The 2010 ‘What Works’ report reviewed
enough that some of the birth rates in southern evidence-based experimental designs that are effec-
states of the United States compare to levels in some tive in preventing teen pregnancy and STIs [24]. In
developing countries [18]. 2002, the CDC’s Division of Reproductive Health
To examine this issue, a prospective cohort funded the national project, promoting science-
study examined teen birth rates in 24 states for girls based approaches in teen HIV and STI prevention
15–17 years old from 1997 through 2005 and found with the goal to decrease STI and HIV rates and teen
significant evidence that increased sexuality edu- pregnancy [25]. Curriculums for these programs are
cation within school was associated with lower birth available at the ETR associates website [24] and the
rates. However, when controlling for demographic CDC’s Reproductive Health website [25]. Some of
characteristics, religiosity and abortion laws, states these programs are difficult to replicate and expens-
with greater conservatism and religiosity had sig- ive, or may not work outside the setting in which
nificantly higher teen birth rates despite sexuality they were implemented. However, other programs
&&
education curriculums [19 ]. Possible explanations are less expensive and easy to implement. Never-
of these findings are public policies related to access theless, due to funding restrictive policies, many did
to contraception, abortion and sexual education. not measure their effects on teen pregnancy,
Recent research concluded that a significant decline although they reported significant positive effects
in pregnancy rates between 1995 and 2002 among on sexual behaviors, such as increased condom use,
15–19-year-olds was mainly attributed to an use of contraceptives and decreased number of
increase in contraceptive use and, to a lesser extent, partners. For the purpose of this review, we will

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 464
Table 1. Teen Pregnancy Prevention Programs

Reference Year Study type Population N Intervention Follow-up Results Comments

Programs focusing on sexual factors

Jemmott et al. [26] 2010 RCT, abstinence-only F and M, grades 6–7, Comprehensive intervention Eight 1-h modules during 24 months The abstinence-only intervention The middle school-based study found
‘Theory-Based study AA long n ¼ 131, two sessions or significantly reduced sexual significant effects of comprehensive
Abstinence-Only comprehensive short 12 1-h modules over initiation, but no significant interventions on HIV/STD-related
Adolescent medicine

Program’ n ¼ 134, safer sex three sessions changes in other sexual behaviors. Pregnancy prevention
n ¼ 129, abstinence only behaviors, compared with NM. The abstinence program did
n ¼ 134, control n ¼ 134 other groups or control not meet the Federal criteria for
abstinence programs and did not
criticize the use of condoms
Villarruel et al. [27] 2006 RCT, STD/HIV and F and M, grades 8–11, Total 553 Six 1-h modules, group 12 months Significantly reduced the number Culturally based school program " HIV

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‘Cuidate!’ pregnancy prevention Hispanic, urban discussions, role play, of partners and frequency of knowledge and vulnerability, and
video, interactive sex and increased condom use safer sex. Pregnancy and delay
games and skill-building consistently, compared with initiation NM. Mueller et al. [28]
activities used controls started a pilot program in Denver
Tortolero et al. 2010 RCT, STD/HIV and F and M, grades 7–8, Control 558, Twelve 45-min lessons, 24 months Twenty-three percent of teens School-based program, showed
[29] ‘It’s Your pregnancy prevention AA and Hispanic, intervention 349 group based, individual initiated sex vs. 30% in the evidence strongest in Latino teens.
Game. Keep It Real’ urban computer activities control group. Significantly, Pregnancy rates NM
increase in condom knowledge
and use, STIs knowledge and
self-efficacy to refuse sex vs.
controls
Graves et al. [30] 2011 RCT, STD/HIV, pregnancy, F, grade 7, mixed, Control 221, Eight weekly 45-min 6 months No significant differences on School-based program developed in
‘Smart Girls Way’ violence, self-esteem urban intervention 633 sessions sexuality expectations (such as response to the Healthy People
dating violence) and perceived 2010 objectives. Pregnancy
susceptibility. Significant rates NM
changes of personal sexuality
expectations and parental
communication vs. controls
Coyle et al. [31] 2006 RCT, STD/HIV and F and M, 14–18 yo, Control 597, Fourteen 26 total-hour 18 months Significant increase of condom Study performed in alternative high
‘All4You!’ pregnancy prevention mixed, urban intervention 391 sessions use with steady and nonsteady schools, results were modest and
partners and decreased short term. Pregnancy rates: no
frequency of sex at 6 months. statistically significant differences
Effects did not hold at 12 and between intervention vs. controls.
18 months 25% lost at f/u (jail time, death
and lack of address)
Sikkema et al. [32] 2005 RCT, STD/HIV, F and M, 12–17 yo, CLI n ¼ 392, WI n ¼ 428, Two 3-h workshops with 18 months Teens in the CLI group were Program performed in low-income
’Teen Health Project’ pregnancy prevention mixed, urban AIDS standard two f/u sessions. significantly more likely to community settings
community education Community intervention remain abstinent and more
n ¼ 352 had four program likely to use condoms compared
activities, two events with the WI group (control) and
and 90-min parent better than the standard AIDS
workshop community intervention group
DiClemente 2004 RCT, HIV F, high school, AA, Control 271, Four 4-h sessions 12 months Girls in the intervention group After school program in urban high
et al. [33] ‘SiHLE’ urban intervention 251 significantly reported more schools. Initiation delay NM
condom use, decreased
frequency of sex partners,
decreased pregnancy rates at
6 months f/u only, decreased
STD incidence

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 Table 1 (Continued)

Reference Year Study type Population N Intervention Follow-up Results Comments

Kerr et al. [34] 2009 RCT, pregnancy F, 13–17 yo, mixed, Control 85, MTFC and trained foster 24 months Girls in control group were Case management program for
prevention urban intervention 81 parents, daily phone 2.4 times more likely to become girls in the juvenile system
calls, weekly support pregnant than girls in MTFC placed in out of home care
meetings group (P < 0.01) and 27%
became pregnant in the MTFC
group compared with 47%
in the control group
DiClemente 2009 RCT, STD/HIV F, 15–21 yo, AA, Control 367, Two 4-h sessions and four 3 months after Significantly reduced the number Performed in clinic setting.
et al. [35] urban intervention 348 15-min phone calls for last call of new and recurrent chlamydia Pregnancy and frequency of
‘HORIZONS HIV’ 9 months approximately infections and increased sex NM
condom use, compared with
controls
Gruchow and 2011 RCT, sex knowledge and M, grade 7, mixed, Control 106, Questionnaires, pre/post 6 months Significantly greater post This is a cohort of the Wise Guys
Brown [36] ‘Wise attitudes (including urban intervention 124 and f/u 6 months. True/ and f/u knowledge of sex, school-based program. The results
Guys Male violence), STD false or five-point Likert reproductive biology, STD indicate the curriculum may
Responsibility scale items. Curriculum transmission and attitudes promote greater condom use
Curriculum’ delivered 8–10 weekly toward sex and appropriate and contraception among sexually
45-min sessions behavior in sexual relationships active men
Dilorio et al. 2007 RCT, STD/HIV M, 11–14 yo, AA, Control 277, 14-h contact 12 months Thirty-one percent of intervention Boys and girls after school
[37] ‘REAL Men’ urban intervention 277 group reported ever having sex programs. Teens with fathers.
without a condom compared Pregnancy rates NM
with 60% in the control group.
Fathers were more likely to talk
about sex-related topics with
their sons
Programs focusing on both sexual and nonsexual factors (includes youth development programs)

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Carrera et al. 2002 RCT, pregnancy and F and M, 13–15 yo, Control 600, 5 days a week for 3 years Girls in the intervention group This after school program requires
‘Children’s Aid youth development AA and Hispanic, intervention 3-h each were significantly less likely to significant financial and staff
Society (CAS)-Carrera’ program urban 600 day activities have had sex and become resources. Men did not change
[38] pregnant (by half), and more sexual behaviors significantly
likely to use dual methods of
contraception (including
condoms)
&
Sieving et al. [39 ] 2010 RCT, pregnancy F, 13–17 yo, mixed, Intervention 125, Intervention included 12-month Significantly more consistent use of Clinic-based, multicomponent
‘‘Prime Time’ prevention urban control 127 SCT, resilience interim condoms and contraception than program for adolescent girls at
paradigm through study controls. Better stress management high risk of pregnancy. Peer
case management skills and social connectedness leadership model included.
and peer leaders. with school and family Pregnancy rates NM
Monthly visits
Salihu et al. [40] Federal 1998–2007 Ecologic study, on F and M, 10–19 yo, Total 3155 community 4–5-h session on a Trend over The decline in primary teen Community Program. The main
Healthy Start Program, primary and AA, urban intervention, county monthly basis. a decade pregnancy in the catchment program goal is the improvement
‘Prime Time’ repeat pregnancy 12 589 and state Preconception area was 60 and 80% greater of knowledge, attitudes and
190 397 as and interconception than the reduction at the county behaviors of teenagers regarding
comparisons care, youth and state level, respectively. preconception, encouraged
developmental skills No success in repeat pregnancy use of condoms, use of family
provided levels planning methods including
abstinence and avoidance of
multiple partners

AA, African American; CLI, community level intervention; F, female; f/u, follow up; LSK, life skills program; M, male; MTFC, multidimensional treatment foster care; NM, not measured; RCT, randomized controlled trial;

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SCT, social cognitive theory; WI, workshop intervention.
Teen pregnancy prevention: current perspectives Lavin and Cox

465

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 Adolescent medicine

include only the most recent or up-to-date studies. Comprehensive education programs
&
Table 1 [26–38,39 ,40] summarizes programs by Sexuality and HIV education programs that include
type, design, strength of evidence and outcomes. discussion of condoms and contraception do not
increase sexual intercourse and do not increase the
number of sexual partners. In fact, there is evidence
COMPREHENSIVE REVIEW OF that they decrease the number of partners. HIV
EVIDENCE-BASED PROGRAMS programs that included sexual education had a
Strategies used in evidence-based programs vary. positive impact on sexual behavior for up to 31
Some use an abstinence-only approach with no dis- months [9]. In school-based models, providing con-
cussion of contraception. Comprehensive programs traceptives and condoms did not hasten the onset of
focus on educating teens about healthy relationships, sexual intercourse or increase its frequency. These
safe sex and contraception. Multicomponent pro- programs also increase the opportunity for one-on-
grams often recommend abstinence as one approach one counseling and aim to delay initiation of sex
but include information about contraception. using abstinence prevention techniques [9].
Programs that fall in this category are very
diverse. Examples of the most up-to-date evi-
Abstinence programs dence-based programs are as follows: school-based
The US government, through the Adolescent Family programs: all are comprehensive RCTs, and, even
Life Act, Community Based Abstinence Education, though most of them showed increases in condom
Title V and welfare reform, supported abstinence use and other safer sex practices, pregnancy rates
only as a teen pregnancy reduction strategy with were not measured. Examples are ‘Cuidate!’ [27],
delay of sexual activity until marriage. Under 2002 ‘It’s Your Game. Keep It Real’ [29], ‘Smart Girls
federal funding regulations, abstinence policies Way’ [30] and ‘All4You!’ [31]. Community programs
became so restrictive that most of these programs that have experimental designs include ‘Teen
could not include information about contraception Health Project’ [32], ‘Keepin’It R.E.A.L’ (Dilorio
or safe sex practices [20]. The most recent national et al., unpublished observation) and ‘SiHLE’ [33].
data (2005) shows the diversity of abstinence-only Again pregnancy rates were not measured; however,
programs, and recent evidence suggests that absti- condom use increased significantly compared with
nence-only education is positively correlated with controls and the number of partners at follow-up
increased teenage pregnancy, birth rates and STIs, decreased. In a program for very high-risk teens out
even when adjusting for socioeconomic status, edu- of the juvenile system, Kerr et al. [34] used an intense
cational attainment, race and family planning serv- multidimensional treatment foster care (MTFC).
&& &
ices [19 ,20,21 ,22,41]. In 2008, the ‘Labor,Health Women in the control group were 2.5 more likely
and Human Services, Education and Other Agencies’ to become pregnant than women in the MTFC
bill provided 114 million dollars for new evidence- group. Clinic-based programs include ‘Horizons
&
based teen prevention initiatives in 2010 [21 ]. This HIV’, a RCT [35]. The study, based on social cogni-
will provide opportunity for studying a wider range of tive theory and the theory of gender and power, did
teen pregnancy prevention interventions. not measure pregnancy rates, but found signifi-
An example of a well-developed randomized con- cantly higher rates of condom use and fewer
trolled trial (RCT) on abstinence-only intervention chlamydial infections. Despite progress in the
is the ‘Efficacy of a Theory-Based Abstinence-Only experimental quality of the majority of these inter-
Intervention Over 24 Months’ by Jemmott et al. [26]. ventions, there is still need for more rigorous
The study was performed in an urban public school of research with wider reporting of results and demon-
predominantly African–American students in grades stration of reproducible results [9].
6 and 7. The self-reported outcomes showed a sig- Although men are often the initiators of teen
nificant decrease in ever having sexual intercourse in sexual activity, most pregnancy prevention pro-
the abstinence-only intervention compared with the grams target women. In this review, we found two
school’s health promotion group over the 24-month current experimental design studies that address
period. However, there were no differences in other pregnancy prevention in men. The first is ‘The Wise
sexual behaviors, such as condom use or multiple Guys Male Responsibility Curriculum’ [36] and the
partners [26]. One of the limitations of this study is second ‘REAL Men’ [37]. The former demonstrated
that a 24-month follow-up was relatively short for significant increases in knowledge of sex, reproduc-
middle school students with low baseline rates of tive biology and STD transmission with more desir-
sexual activity, questioning how effective this pro- able attitudes toward sexual relationships and
gram would be in maintaining abstinence for the promoted greater condom and contraceptive use
long term. among participants. The latter involved fathers in

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 Teen pregnancy prevention: current perspectives Lavin and Cox

the intervention, and results included significantly that targeted an underserved, African–American
more use of condoms and an increase in fathers’ population aged 10–19 years. The intervention con-
likeliness to talk about sex and related topics with sisted of offering sex education, family planning,
their sons. These programs are a great resource for drug and violence prevention and communication
schools and parents and they have shown great and negotiation skills. Some of the participating
educational outreach for this population. community organizations had interactive forums
for youth to enhance physical, mental and pro-
fessional development. Over a decade, primary teen
Multicomponent programs pregnancy decreased by 27%, which was 60 and 80%
These programs address motivation and skills build- better, respectively, than county and state rate
ing along with comprehensive sexual education reductions. Efforts to reduce repeat pregnancy were
programs. One of the most effective RCTs is the not statistically different among the community,
‘Children’s Aid Society (CAS) Carrera’ [38]. This is county and state levels.
an extensive urban New York city intervention that In a recent meta-analysis, teen pregnancy inter-
provides strong results showing a 50% decline in ventions that appear to be most effective include a
teenage pregnancy, and increases in both condom multifaceted or multicomponent approach. Indivi-
and contraceptive use through 3 years of follow-up. dual and clustered trial analysis of these inter-
However, the program was only successful in ventions reports that the concurrent use of
women, but had no significant impact on men’s multiple interventions such as education, skills
sexual behavior. The CAS–Carrera curriculum has building, abstinence and contraception promotion
been replicated partially in other states with little significantly reduces the risk of unintended teenage
success, mostly because CAS program staff educators pregnancy [44].
were not utilized for training and not all parts of the
program were implemented [42]. The program is
expensive to implement and maintain. However, Other strategies
in a recent economic evaluation of the CAS–Carrera A controversial strategy to prevent teen pregnancy
program, the results showed that, whereas the includes programs with infant simulators targeting
economic benefits of the short-term intervention teens’ perceptions of pregnancy and parenting using
may seem to be overshadowed by the operating the model of virtual infant parenting classes. Most of
costs, extrapolation analysis showed that the total the studies have shown mixed results. A majority
benefit to society exceeded operating costs by on have small sample sizes and short follow-up inter-
average $10 474.77 per adolescent per year by age 30 vals [45]. In 2012, the largest school-based RCT of
[43]. this kind, with 1267 female participants and 1567
Another recent example is the ‘Prime Time’ matching controls, aged 13–15 years on entry, will
&
study [39 ]. Preliminary 12-month outcomes have be completed. Data through age 19 years will be
been reported. This is a clinic program that includes obtained via data linkage to hospital medical
female teens aged 13–17 years meeting specific records, abortion clinics and education records from
high-risk criteria. The program uses case manage- 2003 to 2012. The study will evaluate the influence
ment and peer leadership support. At 12 months, of infant simulators on teens’ behavior, reduction in
the intervention group reported more consistent rates of teenage births, abortion rates, self-efficacy to
use of condoms and/or hormonal contraception make informed decisions and increased knowledge
compared with the control group. Other benefits of/or use of services relating to having a child and
reported include better stress management skills and child and maternal outcomes, if any [46].
more social connectedness with school and family Medicaid waivers for family planning have
compared with controls, suggesting that youth funded access to contraceptives and have been
development interventions along with sexual edu- shown to decrease the incidence of unplanned preg-
cation and contraceptive promotion in a clinic nancy, especially in low-income women and teens
&
setting are promising in preventing teen pregnancy [6,16,21 ]. The cost of one Medicaid-covered birth in
in high-risk youth. the United States, including prenatal care, delivery,
Of publicly supported programs, the Healthy postpartum care and infant care for the first year of
Start Program is uniquely positioned in the com- life, was $12 613 in 2008. During the same year, the
munity to address the needs of youth at risk of cost of contraception per client was $257. During
becoming pregnant or repeat pregnancy. In Tampa, 2008, an estimated 1.9 billion dollars were spent in
Florida, the Federal-Funded Healthy Start in public funding for family planning programs. The
Hillsborough community developed the ‘REACHUP’ investment resulted in 7 billion dollars of savings for
program [40] with community-based organizations Medicaid for the cost of unplanned pregnancies.

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 Adolescent medicine

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