Association for Public Policy Analysis & Management

Despite recent declines, rates of teen pregnancy in the United States remain high. In particular, teen mothers have the highest risk of a closely spaced repeat pregnancy, which is associated with adverse outcomes for both mother and child (Copen et al. 2015). Further, the majority of such pregnancies are unintended (Mosher et al. 2012). Unintended pregnancy results mainly from not using contraception, or inconsistent or incorrect use of effective contraceptive methods. Most family planning experts now propose long-acting reversible contraceptives (LARCs) – which include intrauterine devices (IUDs) and subdermal implants – as first-line contraceptive options due to their low risk of failure and high continuation rates.

In this paper, we present findings from an experimental evaluation of the Teen Options to Prevent Pregnancy (TOPP) program, an 18-month intervention that aims to reduce rapid repeat pregnancy among adolescent mothers. The program comprises of a unique combination of personalized contraceptive counseling delivered by nurse educators, facilitated access to contraceptive services, and referrals to social support services. The contraceptive counseling is delivered by a registered nurse through telephone calls on a monthly basis, and aims to influence demand of contraceptives by promoting knowledge of the benefits of birth spacing and providing information about birth control methods. Given the top-tier effectiveness, high rates of satisfaction and continuation of LARCs, nurse educators emphasized promoting the knowledge of LARCs, although the participants were not required to use any particular form of (or any) birth control. The program also aimed to reduce logistical barriers to effective and consistent contraceptive use, by providing participants direct access to both a program clinic and free transportation services. The TOPP clinic featured a clinician who was available to provide any contraceptive services of the participant's choice, including LARCs. Finally, the TOPP program gave participants access to a program social worker who can refer participants to appropriate support services. This component of the program attempts to address other barriers to adoption of and adherence to an effective birth control regimen, such as poverty, lack of child care, and homelessness.

To assess the impacts of the TOPP program, we conducted a large-scale random assignment evaluation involving close to 600 pregnant or postpartum low-income adolescent women from the Columbus, Ohio area. We find that TOPP led to large, statistically significant reductions in repeat pregnancy. At the end of the intervention, 20.8 percent of treatment group members experienced a repeat pregnancy, compared to 38.2 percent of control group members. Further, the program led to substantial increases in LARC use, with 41.1 percent of treatment group participants reporting using a LARC method in the past 3 months, relative to 25.7 percent of women in the control group. There was no significant changes in use of other types of contraceptives at the extensive margin, including short-acting hormonal or barrier methods. We did not find negative spillover effects on other sexual risk behaviors, such as the number of sexual partners.