Perspectives on Adolescent Pregnancy Prevention Strategies in the United States: Looking Back, Looking Forward

Pregnant WomanIn a recent Adolescent Health, Medicine and Therapeutics article, Claire Brindis, DrPH, Abigail Gutmann-Gonzalez, MS, Mara Decker, PhD and Nancy Berglas, DrPH reflect upon key strategies aimed at preventing adolescent pregnancy, as well as the hard-earned lessons learned through generations of efforts and present ideas for future directions for the field.

While notable reductions in adolescent pregnancy and childbearing have occurred across all sociodemographic groups, racial/ethnic, geographic, and socioeconomic disparities persist, often reflecting broader societal disparities in access and other social determinants of health.   Many adolescents in greatest need of sexual health information and services remain underserved by current programs and policies. 

While disaggregated data, such as by race/ethnicity, age, and rural/urban areas, help policymakers, program directors, and health care providers develop targeted strategies, additional data are needed to capture the intersection and complexities within populations such as youth in urban areas may also be involved in the foster care system.

The complexities of adolescent pregnancy’s root causes, such as poverty and limited educational opportunities, require that interventions go beyond the traditional sexual health education approaches that had addressed only abstinence and/or contraception. Communities and the political arena continue to shape prevention interventions, with the pendulum shifting with federal and state administrations that support abstinence-only education vs comprehensive, evidence-based sexual health education approaches.  

Improving access to free or subsidized confidential sexual health care for adolescents, supported through the federal Title X program, Medicaid, and the Affordable Care Act, represents another key adolescent pregnancy prevention strategy. Clinics and programs need to address and respond to the barriers that adolescents face when seeking sexual health services.  While most adolescents receive some form of sexual health education in school, few receive concrete information regarding the availability of confidential sexual health services within their own community.  Greater efforts are needed to engage parents and other adult caregivers in supporting their children’s use of services, while also maintaining individual adolescents’ preferences for the confidentiality of services. 

In response to the historical efforts and lessons learned, the researchers have several recommendations for adolescent pregnancy prevention efforts moving forward.  Improving the content, quality and sustainability of education programs can be assisted through the growing interest in the role and acceptability of technology among adolescents, where text or other platforms respond to the changing context of young people’s lives. Many such models are being developed and tested now, and hold promise to be a component of the next generations of educational approaches. At the same time, technology must be used thoughtfully to improve health literacy, as there are there are serious challenges about adopting online strategies, particularly as schools transition to online learning due to the COVID-19 pandemic, without the necessary pedagogical refinements and support; such efforts are widely needed.

Engaging youth as full and authentic partners is key in assuring that programs remain fresh, relevant to their targeted audiences, and offer the quality of care that is needed, while also furthering efforts to ameliorate disparities. “To proactively address disparities that contribute to unintended adolescent pregnancy truly requires a multi-pronged strategy that has as much or more to do with equity in education and assuring that young people have resources in their communities that enable them to live in safe, supportive, and nurturing environments with a sense of real hope for the future,” said Brindis.

Recognizing the variety of barriers that adolescents may encounter in accessing sexual health services in traditional clinic settings, policies, and programs should consider new service delivery models. Recently, several telehealth and other online platforms have been developed for adolescent sexual health services that have successfully addressed common barriers and concerns, including confidentiality and accessibility.  However, digital divides exist that must be considered. “While the vast majority of youth have access to a smart phone or computer, said Decker, “there is still a gap between those who have strong internet connectivity in their homes and those who lack this consistent access. In particular, youth who are homeless, in juvenile detention centers, or living in foster care homes face additional challenges.”

Finally, programs and services must be designed that recognize and address structural racism, health equity and inclusion. Developing initiatives that take into account social determinants and adopt a lens of equity and racial justice requires the active involvement and reckoning of a number of different segments of society – from the individual and their family to schools, social services, housing, the business sector, the legal and judicial systems, to health care, and many others.

In the Know (ITK), a five-year randomized-controlled trail led by Decker that is putting many of these recommended strategies into practice. ITK combines group-based, comprehensive sexual health education with digital technologies, and targets the needs of homeless and unstably housed youth, youth of color, and LGBTQ+ youth ages 13–19 in Fresno County, California. ITK was built on three strategies: positive youth development, youth-centered design, and digital technologies. In addition to covering information on sexual health and contraceptive use, it also addresses healthy relationships, educational and career development, and life skills. ITK takes a trauma-informed approach and involves youth in every step of the intervention to make it as relevant to their lives experiences and needs as possible.  

Claire BrindisClaire Brindis, DrPH

Dr. Brindis’ policy research focuses on how disparities impact health outcomes, including access to quality care and health insurance coverage. Additional research focuses on examining the impact of migration and acculturation, as well as social determinants of health, on Latinx people. 

Abigail GuzmanAbigail Gutmann-Gonzalez, MPH

Abigail Gutmann-Gonzalez is a researcher and program evaluator at the Philip R. Lee Institute for Health Policy Studies and the Bixby Center for Global Reproductive Health. Currently, she evaluates the Adolescent Sexual Health program sponsored by the California Department of Public Health’s Maternal, Child and Adolescent Health (MCAH) division and a PREIS funded sexual health intervention that combines traditional classroom instruction with wraparound digital technologies.

Mara DeckerMara Decker, PhD

Mara Decker is an Assistant Professor of Epidemiology and Biostatistics at the Philip R. Lee Institute for Health Policy Studies and the Bixby Center for Global Reproductive Health. She oversees a portfolio of applied research projects and evaluations focusing on sexual and reproductive health both domestically and globally.

Perspectives on Adolescent Pregnancy Prevention Strategies in the United States: Looking Back, Looking Forward. Brindis CD, Decker MJ, Gutmann-Gonzalez A, Berglas NF. Adolescent Health, Medicine and Therapeutics2020 Oct 12;11:135-145. doi: 10.2147/AHMT.S219949. eCollection 2020.