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Interventions to Prevent Unintended and Repeat Pregnancy Among Young People in Low- and Middle-Income Countries: A Systematic Review of the Published and Gray Literature

      Abstract

      Adolescent pregnancy, particularly unintended pregnancy, can have lasting social, economic, and health outcomes. The objective of this review is to identify high-quality interventions and evaluations to decrease unintended and repeat pregnancy among young people in low- and middle-income countries. PubMed, Embase, PsycInfo, Cinahl Plus, Popline, and the Cochrane Databases were searched for all languages for articles published through November 2015. Gray literature was searched by hand. Reference tracing was utilized, as well as unpacking systematic reviews. Selected articles were those that were evaluated as having high-quality interventions and evaluations using standardized scoring. Twenty-one high-quality interventions and evaluations were abstracted. Nine reported statistically significant declines in pregnancy rates (five cash transfer programs, one education curriculum, two life-skills curricula, and a provision of contraception intervention), seven reported increases in contraceptive use (three provision of contraception interventions, two life-skills curricula, a peer education program, and a mass media campaign), two reported decreases in sexual activity (a cash transfer program and an education and life-skills curriculum), and two reported an increase in age of sexual debut (both cash transfer programs). The selected high quality, effective interventions included in this review can inform researchers, donors, and policy makers about where to make strategic investments to decrease unintended pregnancy during young adulthood. Additionally, this review can assist with avoiding investments in interventions that failed to produce significant impact on the intended outcomes. The diversity of successful high-quality interventions, implemented in a range of venues, with a diversity of young people, suggests that there are multiple strategies that can work to prevent unintended pregnancy.

      Keywords

      Implications and Contribution
      Of the 21 interventions identified as high quality, 17 reduced pregnancy or had a positive impact on proximal outcomes to pregnancy. This study can help inform strategic investments to reduce unwanted pregnancy among young people in low- and middle-income countries.
      Adolescent pregnancy, while on the decline globally, remains an important health issue with consequences that persist through adulthood. In some settings, where early marriage is common, adolescent pregnancy and births may be wanted; however, in many settings, adolescent pregnancies and births are unintended—either mistimed or unwanted. Each year, 12 million adolescents give birth, and 3.2 million will have an unsafe abortion [
      • Singh S.D.
      • Darroch J.E.
      • Ashford L.S.
      Adding it up: The costs and benefits in investing in sexual and reproductive health 2014.
      ]. The United Nations Population Fund reports that the greatest increase in pregnancy among adolescent girls less than 18 years of age over the next 20 years is likely to happen in sub-Saharan Africa [
      United Nations Population Fund (UNFPA). UNFPA
      Adolescent pregnancy: A review of the evidence.
      ]. Authors project that over the next 15 years, numbers of early pregnancies will grow by 1.8 million and 1.5 million per year for West and Central Africa and Eastern and Southern Africa, respectively [
      United Nations Population Fund (UNFPA). UNFPA
      Adolescent pregnancy: A review of the evidence.
      ]. Recent estimates have shown that approximately one third of adolescent pregnancies in these regions are unintended [
      • Woog V.
      • Singh S.
      • Browne A.
      • et al.
      Adolescent women's need for and use of sexual and reproductive health services in developing countries.
      ]. In some settings, rapid repeat pregnancy (within 2 years of the index pregnancy) is also a concern. While data in low- and middle-income countries (LMIC) are limited, a review of U.S.-based rapid repeat pregnancy notes that 35% of adolescents have another pregnancy in less than 2 years, and that most of these pregnancies are unintended [
      • Baldwin M.K.
      • Edelman A.B.
      The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: A review.
      ,
      • McDaid L.A.
      • Collier J.
      • Platt M.J.
      Previous pregnancies among young women having an abortion in England and Wales.
      ]. Recent evidence from the United Kingdom shows that one in four women under the age of 20 presenting for an abortion had a previous pregnancy [
      • McDaid L.A.
      • Collier J.
      • Platt M.J.
      Previous pregnancies among young women having an abortion in England and Wales.
      ].
      Pregnancy during adolescence or young adulthood can have adverse social and economic consequences as well as adverse health consequences [
      • Nerlander L.
      • Callaghan W.
      • Smith R.
      • et al.
      Short interpregnancy interval associated with preterm birth in US adolescents.
      ]. Current studies point to higher rates of adverse newborn outcomes for adolescent mothers [
      • Ganchimeg T.
      • Mori R.
      • Ota E.
      • et al.
      Maternal and perinatal outcomes among nulliparous adolescents in low- and middle-income countries: A multi-country study.
      ], and the social, educational, and economic consequences of young motherhood can be profound [
      • Urdinola B.P.
      • Ospino C.
      Long-term consequences of adolescent fertility: The Colombian case.
      ,
      • Timæus I.M.
      • Moultrie T.A.
      Teenage childbearing and educational attainment in South Africa.
      ] and long lasting [
      • Gibb S.J.
      • Fergusson D.M.
      • Horwood L.J.
      • et al.
      Early motherhood and long-term economic outcomes: Findings from a 30-year longitudinal study.
      ]. While researchers have been debating the actual risk of dying during pregnancy in adolescence (see [
      • Blanc A.K.
      Excess risk of maternal mortality in adolescent mothers.
      ,
      • Nove A.
      • Matthews Z.
      • Neal S.
      • et al.
      Maternal mortality in adolescents compared with women of other ages: Evidence from 144 countries.
      ] for recent examples), it is evident that the maternal mortality ratio is elevated during adolescence compared with older women. In lower income countries, pregnant adolescents face additional risks such as anemia, spontaneous abortion, obstructed labor, and obstetric fistulae [
      • Temin M.T.
      • Levine R.
      Start with a girl: A new agenda for global health.
      ,
      World Health Organization
      Adolescent pregnancy: Unmet needs and undone deeds: A review of the literature and programmes.
      ,
      • Pradhan R.
      • Wynter K.
      • Fisher J.
      Factors associated with pregnancy among adolescents in low-income and lower middle-income countries: A systematic review.
      ]. Data on rapid repeat pregnancy during adolescence is scarce in low- and middle-income settings, but the evidence suggests that short birth intervals increase the risk of infant and child mortality [
      • Fotso J.C.
      • Cleland J.
      • Mberu B.
      • et al.
      Birth spacing and child mortality: An analysis of prospective data from the nairobi urban health and demographic surveillance system.
      ] and other adverse child outcomes [
      • Cecatti J.G.
      • Correa-Silva E.P.B.
      • Milanez H.
      • et al.
      The associations between inter-pregnancy interval and maternal and neonatal outcomes in Brazil.
      ,
      • Kozuki N.
      • Lee A.C.
      • Silveira M.F.
      • et al.
      The associations of birth intervals with small-for-gestational-age, preterm, and neonatal and infant mortality: A meta-analysis.
      ].
      Prevention of unintended pregnancy among young people is of paramount importance in the global arena, as well as for national policy makers. To inform prevention efforts, this review is motivated by the continuing need for rigorous evaluation and stronger evidence about what works and, does not work, to prevent unintended and repeat pregnancy during young adulthood. We focus on interventions and evaluations of the highest quality to create an evidence base that can be better used to inform future programming and policy initiatives. The objective of this systematic review is to identify high-quality interventions and evaluations targeting unintended and repeat pregnancy among young people in LMIC.

      Methods

       Definition of outcomes

      As pregnancy is difficult to measure in many settings, we also included search terms on birth and abortion. We considered articles that included childbirth rates, total number of live births, time between pregnancies or births, and time between marriage and first birth. As contraceptive use is an intermediary outcome, we also included interventions that targeted contraceptive uptake although we did not specifically search for contraceptive interventions.

       Search strategy

      We undertook a systematic search of published literature to identify interventions that address “early pregnancy” and “repeat pregnancy” in LMIC. We used six databases—PubMed, Embase, PsycInfo, Cinahl Plus, Popline, and the Cochrane Databases—in conducting these searches. In building the searches, we combined a list of terms that describe young people with a list of terms that describe pregnancy and repeat pregnancy. We then combined this search with a list of LMIC, as defined by the World Bank at the time of the search and regional search terms. We searched the literature from 2000 to November 2015.
      We also searched gray literature for both “early pregnancy” and “repeat pregnancy” by first targeting organizations involved in prevention of early pregnancy as well as through the use of the Google search engine for publications about early pregnancy and repeat pregnancy interventions, separately. We also hand searched the literature based on identified citations in the published and gray literature for additional titles.
      The results of the initial search of both published and gray literature were stored using EndNote reference manager software. All titles resulting from the searches were screened for interventions related to early pregnancy or repeat pregnancy among adolescents or young people and these remaining articles were abstracted.

       Inclusion/exclusion criteria

      Articles were included for abstract screening if they met all the following criteria: (1) they report on interventions addressing early pregnancy or repeat pregnancy; (2) the intervention addressed young people, ages (10–24); (3) the intervention was in a low- or middle-income country; (4) the article or publication was written in English, French, Spanish, or Portuguese; and (5) and the article was published in 2000 or later.

       Abstraction ranking strategy

      We devised a spreadsheet for abstracting and ranking all articles that met the inclusion criteria (available on request from the corresponding author). Each abstractor was given two sample articles, and the abstractions were reviewed for comparability. The abstraction spreadsheet includes basic information on the design of the intervention and evaluation as well as a ranking of each.
      For each of the abstracted articles, the quality of both the intervention and the evaluation of the intervention's effects were assessed and rated on a scale from 1 (weak) to 5 (strong). To assess the strengths and weaknesses of the intervention, reviewers were asked to consider whether the intervention was grounded in theory, if the intervention was first pilot tested to assess feasibility and acceptability, whether and what kind of training personnel involved in the intervention received, what steps were taken to prevent crossover or contamination between intervention and control groups, the duration of the intervention, and whether and how randomization, of the intervention and/or evaluation took place. A ranking of 1 or 2 was given when the weaknesses of the intervention and study design heavily outweighed any identified strengths. Articles were ranked as a 3 when, on balance, the study design had about as many strengths as weaknesses. Those that were ranked as 4 or more had more identified strengths than weaknesses, and those assigned a 5 had few, if any, weaknesses.
      To assess the strengths and weaknesses of the evaluation, reviewers were asked to consider several aspects of the evaluation design and evaluate the strengths and weaknesses before assigning a ranking score. These included the analytic techniques used to evaluate change attributable to the intervention, the use of an appropriate comparison group, sample size, operationalization, and measurement of exposure to the intervention, length of follow-up, and the number of evaluation time points (particularly whether there was baseline and endline data collection or just endline). To assign a ranking score (1–5) for the evaluation, the same methodology was used as for ranking the intervention. The quality of the intervention and evaluation of each included article was assessed by two reviewers, and discrepancies were arbitrated by a third reviewer.
      Each abstracted article then received a total score that combined both the intervention score and the evaluation score for a range of 2–10. Overall, an article was considered high quality if it had a total score of 8 or above, and both the intervention score and evaluation score were at least a 4. Following this ranking process, only high-quality articles were retained, regardless of the intervention's impact on the outcome.

       Analysis

      The most common goals of the identified pregnancy interventions were to prevent pregnancy including unintended pregnancies, promote contraceptive use, decrease sexual activity (including ever/never having sex and recent sex), increase age of sexual debut, and promote abstinence or secondary abstinence for the purpose of pregnancy prevention. The most common goal of interventions targeting repeat pregnancy was uptake of contraceptive use following a birth or abortion. While many studies included knowledge, norms, and behavioral outcomes, this review focuses on behavioral outcomes, as changes in knowledge and norms are not necessarily sufficient to produce behavior change. Studies that did not include behavioral outcomes were excluded from this review. In addition, due to the heterogeneity of the interventions, populations, and outcomes, a meta-analysis was not performed. However, results are summarized to show the features of the interventions, populations, and impact of the interventions on preventing unintended and repeat pregnancy. Table 1 provides the description of the intervention and the key impact on the targeted behavior by outcome. The description includes the age range of participants at the time of the intervention, the duration of the intervention, the age range at the time of the evaluation, the venue of the intervention, and participant characteristics. Table 2 summarizes the findings of each article by study across all targeted behavioral outcomes, highlighting the main finding for each outcome.
      Behavioral outcomes
      • Primary outcome
        • Pregnancy rates
      • Proximal outcome
        • Contraceptive use
      • Distal outcomes
        • Recent sexual activity
        • Age of sexual debut
        • Abstinence
      Table 1Description of high-quality pregnancy interventions and evaluations
      CountryInterventionEvaluationVenue and participantsMain intervention componentsImpact
      AgeLengthAge
      Pregnancy (primary outcome)
       Jamaica
      • Drayton V.L.
      • Montgomery S.B.
      • Modeste N.N.
      • et al.
      The impact of the Women's Centre of Jamaica Foundation programme for adolescent mothers on repeat pregnancies.
      11–16Not specified15–20Community: GirlsSkills training and job placement assistance for mothers over 16; classroom instruction and support for mothers under 16+
       Kenya
      • Hubacher D.
      • Olawo A.
      • Manduku C.
      • et al.
      Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants.
      18–247 months19–26Facility: Girls seeking contraceptionProvision of implant or originally preferred method+
       Kenya
      • Handa S.
      • Peterman A.
      • Huang C.
      • et al.
      Impact of the Kenya cash transfer for orphans and vulnerable children on early pregnancy and marriage of adolescent girls.
      4 yearsNot specified12–24Community: GirlsUnconditional cash transfer to households, eligibility based on the presence of an OVC or poverty level+
       Mexico
      • Gulemetova-Swan M.
      Evaluating the impact of conditional cash transfer programs on adolescent decisions about marriage and fertility: The case of opportunidades.
      9–21Ongoing14–21Community: GirlsCash transfers conditioned on school attendance; provision of SRH education and services+
       South Africa
      • Rosenberg M.
      • Pettifor A.
      • Nguyen N.
      • et al.
      Relationship between receipt of a social protection grant for a child and second pregnancy rates among South African women: A cohort study.
      None specifiedNot specified<21Household: Boys and girlsUnconditional cash transfer program, eligibility determined by poverty level+
       South Africa
      • Heinrich C.J.
      • Brill R.
      Stopped in the name of the law: Administrative burden and its implications for cash transfer program effectiveness.
      None specifiedNot specified13–18Household: Boys and girlsUnconditional cash transfer program, eligibility determined by poverty level+
       Uganda
      • Banderia O.
      • Buehern N.
      • Burgess R.
      • et al.
      Empowering adolescent girls: Evidence from a randomized control trial in Uganda.
      14–204 months16–22Community: GirlsLife-skills curriculum, vocational training+
       Kenya
      • Dupas P.
      Do teenagers respond to HIV risk information? Evidence from a field experiment in Kenya.
      15 on average8 months (4 months per arm)16 on averageSchool: Boys and girlsSexual and reproductive health (SRH) education curriculum; teacher training program+/--
       Malawi
      • Baird S.
      • McIntosh C.
      • Özler B.
      Cash or condition? Evidence from a cash transfer experiment.
      13–222 years14–23Community: GirlsCash transfers, conditioned on school attendance or unconditional+/--
       China
      • Zhu J.L.
      • Zhang W.H.
      • Cheng Y.
      • et al.
      Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: A cluster randomised trial.
      <256 months<25Facility: GirlsProvision of contraceptive materials, counseling, involvement of male partnerNS
       Kenya
      • Duflo E.
      • Dupas P.
      • Kremer M.
      Education, HIV and early fertility: Experimental evidence from Western Kenya.
      13.5 on average5 months20.5 on averageSchool: Boys and girlsProvision of school uniforms, teacher training program (7-year follow-up)NS
       Malawi
      • Baird S.J.
      • Garfein R.S.
      • McIntosh C.T.
      • et al.
      Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: A cluster randomised trial.
      13–222 years14–23Community: Boys and girlsCash transfers conditioned on school attendance and payment of school feesNS
       South Africa
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      14 on average4 months15 on averageSchool: Boys and girlsSRH education curriculum: 12 weekly lessonsNS
       Zambia
      • Palermo T.
      • Handa S.
      • Peterman A.
      • et al.
      Unconditional government social cash transfer in Africa does not increase fertility.
      None specified3 years<25Household: Boys and girlsUnconditional cash transfer to households, eligibility based on poverty levelNS
       South Africa
      • Jewkes R.
      • Nduna M.
      • Levin J.
      • et al.
      Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial.
      15–2612 months17–28Community: Boys and girlsReproductive health education program including lectures, plays, and dramas-
      Contraceptive use (proximal outcome)
       Cameroon
      • Speizer I.S.
      • Tambashe B.O.
      • Tegang S.P.
      An evaluation of the “Entre Nous Jeunes” peer-educator program for adolescents in Cameroon.
      None specified18 months12–25Community: Boys and girlsPeer education program+
       China
      • Lou C.H.
      • Wang B.
      • Shen Y.
      • et al.
      Effects of a community-based sex education and reproductive health service program on contraceptive use of unmarried youths in Shanghai.
      15–2420 months17–26Community: Boys and girlsEducational materials, counseling, provision of free contraception+
       China
      • Zhu J.L.
      • Zhang W.H.
      • Cheng Y.
      • et al.
      Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: A cluster randomised trial.
      <256 months<25Facility: GirlsProvision of contraceptive materials, counseling, involvement of male partner+
       Ethiopia
      • Erulkar A.S.
      • Muthengi E.
      Evaluation of Berhane Hewan: A program to delay child marriage in rural Ethiopia.
      10–192 years10–19Community: GirlsSocial mobilization, nonformal education, and livelihood training+
       India
      • Sebastian M.P.
      • Khan M.E.
      • Kumari K.
      • et al.
      Increasing postpartum contraception in rural India: Evaluation of a community-based behavior change communication intervention.
      15–244 months15–25Community: Girls (with at least 1 child or pregnant)Community education campaign via mass media+
       Kenya
      • Hubacher D.
      • Olawo A.
      • Manduku C.
      • et al.
      Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants.
      18–247 months19–26Facility: Girls seeking contraceptionProvision of implant or originally preferred method+
       Uganda
      • Banderia O.
      • Buehern N.
      • Burgess R.
      • et al.
      Empowering adolescent girls: Evidence from a randomized control trial in Uganda.
      14–204 months16–22Community: GirlsLife-skills curriculum, vocational training+
       India
      • Kanesathasan A.
      • Cardinal L.J.
      • Pearson E.
      • et al.
      Catalyzing change: Improving youth sexual and reproductive health through DISHA, an integrated program in India.
      14–242 years14–24Community: Boys and girlsYouth groups; peer education; income-generating skills; youth-friendly services+/--
       South Africa
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      14 on average4 months15 on averageSchool: Boys and girlsSRH education curriculum: 12 weekly lessons+/--
       Senegal
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      10–1915 months10–19Community: Boys and girlsLife-skills training, radio programming, adolescent-friendly health services, reproductive health curriculum-
      Sexual activity (proximal outcome)
       Senegal
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      10–1915 months10–19Community: Boys and girlsLife-skills training, radio programming, adolescent-friendly health services, reproductive health curriculum+/--
       South Africa
      • Heinrich C.J.
      • Brill R.
      Stopped in the name of the law: Administrative burden and its implications for cash transfer program effectiveness.
      None specifiedNot specified13–18Household: Boys and girlsUnconditional cash transfer program, eligibility determined by poverty level+/--
       South Africa
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      14 on average4 months15 on averageSchool: Boys and girlsSRH education curriculum: 12 weekly lessonsNS
      Age at sexual debut (proximal outcome)
       Mexico
      • Gulemetova-Swan M.
      Evaluating the impact of conditional cash transfer programs on adolescent decisions about marriage and fertility: The case of opportunidades.
      9–21Ongoing14–21Community: GirlsCash transfers conditioned on school attendance; provision of SRH education and services+
       Kenya
      • Handa S.
      • Peterman A.
      • Huang C.
      • et al.
      Impact of the Kenya cash transfer for orphans and vulnerable children on early pregnancy and marriage of adolescent girls.
      4 yearsNot specified12–24Community: GirlsUnconditional cash transfer to households, eligibility based on the presence of an OVC or poverty level+/--
      Abstinence (proximal outcome)
       Senegal
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      10–1915 months10–19Community: Boys and girlsLife-skills training, radio programming, adolescent-friendly health services, reproductive health curriculumNS
      Studies appear more than once based on number of measured behavioral outcomes.
      + = statistically significant positive effect; +/-- = mixed effects; − = statistically significant negative effect; NS = no statistically significant effect; OVC = orphan or vulnerable child.
      Table 2Impact summary of high-quality pregnancy interventions and evaluations among young people
      CountryInterventionBehavioral outcome
      Pregnancy (decrease expected)Contraceptive use (increase expected)Sexual activity (decrease expected)Age at sexual debut (increase expected)Abstinence (increase expected)
      China
      • Lou C.H.
      • Wang B.
      • Shen Y.
      • et al.
      Effects of a community-based sex education and reproductive health service program on contraceptive use of unmarried youths in Shanghai.
      Provision of contraception; counseling
      China
      • Zhu J.L.
      • Zhang W.H.
      • Cheng Y.
      • et al.
      Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: A cluster randomised trial.
      Provision of contraception; counseling
      Kenya
      • Hubacher D.
      • Olawo A.
      • Manduku C.
      • et al.
      Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants.
      Provision of contraception
      Ethiopia
      • Erulkar A.S.
      • Muthengi E.
      Evaluation of Berhane Hewan: A program to delay child marriage in rural Ethiopia.
      Life-skills training; school support
      Jamaica
      • Drayton V.L.
      • Montgomery S.B.
      • Modeste N.N.
      • et al.
      The impact of the Women's Centre of Jamaica Foundation programme for adolescent mothers on repeat pregnancies.
      Life-skills training; school support
      Uganda
      • Banderia O.
      • Buehern N.
      • Burgess R.
      • et al.
      Empowering adolescent girls: Evidence from a randomized control trial in Uganda.
      Life-skills training
      Senegal
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      Life-skills training; SRH services; SRH education
      No impact among out of school boys.
      Kenya
      • Dupas P.
      Do teenagers respond to HIV risk information? Evidence from a field experiment in Kenya.
      SRH education program; teacher training
      Declines among education curriculum arm; no impact among teacher training arm.
      South Africa
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      SRH education program
      No impact on condom use consistency.
      India
      • Kanesathasan A.
      • Cardinal L.J.
      • Pearson E.
      • et al.
      Catalyzing change: Improving youth sexual and reproductive health through DISHA, an integrated program in India.
      Peer education program; life-skills training
      Declines among girls; no impact among boys.
      Cameroon
      • Speizer I.S.
      • Tambashe B.O.
      • Tegang S.P.
      An evaluation of the “Entre Nous Jeunes” peer-educator program for adolescents in Cameroon.
      Peer education program
      India
      • Sebastian M.P.
      • Khan M.E.
      • Kumari K.
      • et al.
      Increasing postpartum contraception in rural India: Evaluation of a community-based behavior change communication intervention.
      Mass media campaign
      South Africa
      • Jewkes R.
      • Nduna M.
      • Levin J.
      • et al.
      Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial.
      Mass media campaign
      Kenya
      • Handa S.
      • Peterman A.
      • Huang C.
      • et al.
      Impact of the Kenya cash transfer for orphans and vulnerable children on early pregnancy and marriage of adolescent girls.
      Unconditional cash transfers
      Declines among girls; no impact among boys.
      Malawi
      • Baird S.
      • McIntosh C.
      • Özler B.
      Cash or condition? Evidence from a cash transfer experiment.
      Conditional/unconditional cash transfers
      Declines among unconditional transfer arm; no impact among conditional transfer arm.
      Malawi
      • Baird S.J.
      • Garfein R.S.
      • McIntosh C.T.
      • et al.
      Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: A cluster randomised trial.
      Conditional cash transfers
      Mexico
      • Gulemetova-Swan M.
      Evaluating the impact of conditional cash transfer programs on adolescent decisions about marriage and fertility: The case of opportunidades.
      Conditional cash transfers; provision of SRH services
      South Africa
      • Rosenberg M.
      • Pettifor A.
      • Nguyen N.
      • et al.
      Relationship between receipt of a social protection grant for a child and second pregnancy rates among South African women: A cohort study.
      Unconditional cash transfers
      South Africa
      • Heinrich C.J.
      • Brill R.
      Stopped in the name of the law: Administrative burden and its implications for cash transfer program effectiveness.
      Unconditional cash transfers
      Declines among girls; no impact among boys.
      Zambia
      • Palermo T.
      • Handa S.
      • Peterman A.
      • et al.
      Unconditional government social cash transfer in Africa does not increase fertility.
      Unconditional cash transfers
      Kenya
      • Duflo E.
      • Dupas P.
      • Kremer M.
      Education, HIV and early fertility: Experimental evidence from Western Kenya.
      School uniforms; teacher training
      Effect significant at p < .05.
      Effect significant at p < .01.
      Effect significant at p < .001.
      a No impact among out of school boys.
      b Declines among education curriculum arm; no impact among teacher training arm.
      c No impact on condom use consistency.
      d Declines among girls; no impact among boys.
      e Declines among unconditional transfer arm; no impact among conditional transfer arm.

      Results

      Figures 1 and 2 are flow diagrams showing the identification, screening, and included articles. The initial search of published literature yielded more than 28,000 articles for pregnancy. After title and abstract screenings, 112 published or gray articles were abstracted, resulting in 30 articles that had high-quality interventions and evaluations. Thirteen were excluded for two reasons: not having a behavioral outcome (n = 10) or because they were an earlier evaluation of an intervention that had multiple time points of follow-up (n = 3). Ultimately, we had 17 pregnancy articles (12 published and 5 gray literature) that were included for this review.
      More than 2,300 articles were identified for repeat pregnancy. Following title screening to remove articles that were duplicates, had no adolescents in the intervention or evaluation groups, and had no specific intervention, 13 articles remained for abstraction. Following abstraction, seven low-quality interventions and two low-quality evaluations were eliminated resulting in four retained articles for repeat pregnancy—three published and one from the gray literature.
      Based on the number of articles retained out of the number identified, our search result's yield was approximately .05% and .13% for pregnancy and repeat pregnancy, respectively, when only the published literature is considered (see Figures 1 and 2). Although we undertook the initial searches separately (early and repeat pregnancy), given the few results we had for repeat pregnancy and that the intervention strategies are similar, we have combined these outcomes for the purposes of reporting. Thus, in total, we report on 21 total articles.
      We considered three categories of behavioral outcomes—the primary outcome (pregnancy), proximal outcome (contraceptive use), and distal outcomes (sexual activity, including ever having sex, recent sex, and number of partners, primary abstinence and secondary abstinence, and age of sexual debut) (Box 1). Table 1 provides the description of the intervention and the key impact on the targeted behavior by outcome. The description includes the age range of participants at the time of the intervention, the duration of the intervention, the age range at the time of the evaluation, the venue of the intervention, and participant characteristics. Table 2 summarizes the findings of each article by study across all targeted behavioral outcomes, highlighting the main finding for each outcome.

       Quality of the evidence

      For each of the abstracted articles, the quality of both the intervention and the evaluation of the intervention's effects were assessed and rated on a scale from 1 (weak) to 5 (strong). High-quality interventions often included common positive aspects such as including relevant stakeholders in the design and implementation of the intervention, including a pilot phase or formative work, basing the intervention on a theory of change, and being well planned and organized. Notable limitations of these high-quality interventions focused on the difficulties of implementing a complex set of components simultaneously and spillover/contamination effects of the intervention to control groups or populations. Lower quality interventions often had limited information about the intervention and the activities, the intervention was too short or limited, concerns that the intervention had too many components or concurrent activities to sort out the intervention effect, had an unclear implementation strategy, or simply did not provide enough detail to assess the strengths and weaknesses.
      We also evaluated the strength of the evaluation. The positive aspects of high-quality evaluations included sophisticated statistical analyses able to attribute findings to the intervention, randomization, a measure of exposure to the intervention, and use of an appropriate control groups. Weaknesses included loss-to-follow-up in longitudinal studies or the inability to follow the same group from baseline to endline. Lower quality evaluations had many more limitations including concerns of spillover/contamination, limitations in analytic techniques, no baseline evaluation (post test only), lack of randomization, no to very limited data, limited statistical power to make inferences, no measure of exposure to the intervention, no true measure of impact of the intervention, the evaluation did not match the intervention in terms of measured outcomes, or having no or an inappropriate comparison group.

       Primary outcome

       Pregnancy

      Pregnancy as an outcome was measured in a number of ways across the identified studies. Some measured pregnancies since baseline, others ever pregnant, while still others as pregnant at the time of the follow-up interview. We identified 16 articles that reported on interventions that measured impact on pregnancy [
      • Drayton V.L.
      • Montgomery S.B.
      • Modeste N.N.
      • et al.
      The impact of the Women's Centre of Jamaica Foundation programme for adolescent mothers on repeat pregnancies.
      ,
      • Hubacher D.
      • Olawo A.
      • Manduku C.
      • et al.
      Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants.
      ,
      • Handa S.
      • Peterman A.
      • Huang C.
      • et al.
      Impact of the Kenya cash transfer for orphans and vulnerable children on early pregnancy and marriage of adolescent girls.
      ,
      • Gulemetova-Swan M.
      Evaluating the impact of conditional cash transfer programs on adolescent decisions about marriage and fertility: The case of opportunidades.
      ,
      • Rosenberg M.
      • Pettifor A.
      • Nguyen N.
      • et al.
      Relationship between receipt of a social protection grant for a child and second pregnancy rates among South African women: A cohort study.
      ,
      • Heinrich C.J.
      • Brill R.
      Stopped in the name of the law: Administrative burden and its implications for cash transfer program effectiveness.
      ,
      • Banderia O.
      • Buehern N.
      • Burgess R.
      • et al.
      Empowering adolescent girls: Evidence from a randomized control trial in Uganda.
      ,
      • Dupas P.
      Do teenagers respond to HIV risk information? Evidence from a field experiment in Kenya.
      ,
      • Baird S.
      • McIntosh C.
      • Özler B.
      Cash or condition? Evidence from a cash transfer experiment.
      ,
      • Zhu J.L.
      • Zhang W.H.
      • Cheng Y.
      • et al.
      Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: A cluster randomised trial.
      ,
      • Duflo E.
      • Dupas P.
      • Kremer M.
      Education, HIV and early fertility: Experimental evidence from Western Kenya.
      ,
      • Baird S.J.
      • Garfein R.S.
      • McIntosh C.T.
      • et al.
      Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: A cluster randomised trial.
      ,
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      ,
      • Palermo T.
      • Handa S.
      • Peterman A.
      • et al.
      Unconditional government social cash transfer in Africa does not increase fertility.
      ,
      • Jewkes R.
      • Nduna M.
      • Levin J.
      • et al.
      Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial.
      ], with two specifically focusing on repeat pregnancy [
      • Drayton V.L.
      • Montgomery S.B.
      • Modeste N.N.
      • et al.
      The impact of the Women's Centre of Jamaica Foundation programme for adolescent mothers on repeat pregnancies.
      ,
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      ]. Of these, nine had a statistically significant impact on pregnancy—six with a positive impact [
      • Drayton V.L.
      • Montgomery S.B.
      • Modeste N.N.
      • et al.
      The impact of the Women's Centre of Jamaica Foundation programme for adolescent mothers on repeat pregnancies.
      ,
      • Hubacher D.
      • Olawo A.
      • Manduku C.
      • et al.
      Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants.
      ,
      • Handa S.
      • Peterman A.
      • Huang C.
      • et al.
      Impact of the Kenya cash transfer for orphans and vulnerable children on early pregnancy and marriage of adolescent girls.
      ,
      • Gulemetova-Swan M.
      Evaluating the impact of conditional cash transfer programs on adolescent decisions about marriage and fertility: The case of opportunidades.
      ,
      • Rosenberg M.
      • Pettifor A.
      • Nguyen N.
      • et al.
      Relationship between receipt of a social protection grant for a child and second pregnancy rates among South African women: A cohort study.
      ,
      • Heinrich C.J.
      • Brill R.
      Stopped in the name of the law: Administrative burden and its implications for cash transfer program effectiveness.
      ,
      • Banderia O.
      • Buehern N.
      • Burgess R.
      • et al.
      Empowering adolescent girls: Evidence from a randomized control trial in Uganda.
      ], two with a mixed impact [
      • Dupas P.
      Do teenagers respond to HIV risk information? Evidence from a field experiment in Kenya.
      ,
      • Baird S.
      • McIntosh C.
      • Özler B.
      Cash or condition? Evidence from a cash transfer experiment.
      ]—and five with no measurable impact on pregnancy [
      • Zhu J.L.
      • Zhang W.H.
      • Cheng Y.
      • et al.
      Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: A cluster randomised trial.
      ,
      • Duflo E.
      • Dupas P.
      • Kremer M.
      Education, HIV and early fertility: Experimental evidence from Western Kenya.
      ,
      • Baird S.J.
      • Garfein R.S.
      • McIntosh C.T.
      • et al.
      Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: A cluster randomised trial.
      ,
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      ,
      • Palermo T.
      • Handa S.
      • Peterman A.
      • et al.
      Unconditional government social cash transfer in Africa does not increase fertility.
      ]. One intervention, a sexual and reproductive health education program in South Africa, found a statistically significant increase in pregnancy [
      • Jewkes R.
      • Nduna M.
      • Levin J.
      • et al.
      Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial.
      ]. The intervention strategies that were effective in decreasing pregnancy included five that utilized economic incentives (e.g., cash transfers and school uniforms) [
      • Gulemetova-Swan M.
      Evaluating the impact of conditional cash transfer programs on adolescent decisions about marriage and fertility: The case of opportunidades.
      ,
      • Rosenberg M.
      • Pettifor A.
      • Nguyen N.
      • et al.
      Relationship between receipt of a social protection grant for a child and second pregnancy rates among South African women: A cohort study.
      ,
      • Heinrich C.J.
      • Brill R.
      Stopped in the name of the law: Administrative burden and its implications for cash transfer program effectiveness.
      ,
      • Baird S.
      • McIntosh C.
      • Özler B.
      Cash or condition? Evidence from a cash transfer experiment.
      ,
      • Handa S.
      • Halpern C.T.
      • Pettifor A.
      • et al.
      The government of Kenya's cash transfer program reduces the risk of sexual debut among young people age 15-25.
      ], three that implemented education or life-skills curricula as part of a multicomponent campaign [
      • Drayton V.L.
      • Montgomery S.B.
      • Modeste N.N.
      • et al.
      The impact of the Women's Centre of Jamaica Foundation programme for adolescent mothers on repeat pregnancies.
      ,
      • Banderia O.
      • Buehern N.
      • Burgess R.
      • et al.
      Empowering adolescent girls: Evidence from a randomized control trial in Uganda.
      ,
      • Dupas P.
      Do teenagers respond to HIV risk information? Evidence from a field experiment in Kenya.
      ], and one that provided a contraceptive method to those seeking the intervention at a facility [
      • Hubacher D.
      • Olawo A.
      • Manduku C.
      • et al.
      Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants.
      ] (see Table 1, Table 2).

       Proximal outcome

       Contraceptive use

      We identified 10 articles [
      • Hubacher D.
      • Olawo A.
      • Manduku C.
      • et al.
      Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants.
      ,
      • Banderia O.
      • Buehern N.
      • Burgess R.
      • et al.
      Empowering adolescent girls: Evidence from a randomized control trial in Uganda.
      ,
      • Zhu J.L.
      • Zhang W.H.
      • Cheng Y.
      • et al.
      Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: A cluster randomised trial.
      ,
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      ,
      • Kanesathasan A.
      • Cardinal L.J.
      • Pearson E.
      • et al.
      Catalyzing change: Improving youth sexual and reproductive health through DISHA, an integrated program in India.
      ,
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      ,
      • Lou C.H.
      • Wang B.
      • Shen Y.
      • et al.
      Effects of a community-based sex education and reproductive health service program on contraceptive use of unmarried youths in Shanghai.
      ,
      • Erulkar A.S.
      • Muthengi E.
      Evaluation of Berhane Hewan: A program to delay child marriage in rural Ethiopia.
      ,
      • Sebastian M.P.
      • Khan M.E.
      • Kumari K.
      • et al.
      Increasing postpartum contraception in rural India: Evaluation of a community-based behavior change communication intervention.
      ,
      • Speizer I.S.
      • Tambashe B.O.
      • Tegang S.P.
      An evaluation of the “Entre Nous Jeunes” peer-educator program for adolescents in Cameroon.
      ] that reported on contraceptive use, a proximal outcome to pregnancy. The definition of contraceptive use as an outcome varied between studies, with some reporting on modern use, others on current or ever use (see Table 1). Of these 10 articles, the majority had a positive impact on contraceptive use [
      • Hubacher D.
      • Olawo A.
      • Manduku C.
      • et al.
      Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants.
      ,
      • Banderia O.
      • Buehern N.
      • Burgess R.
      • et al.
      Empowering adolescent girls: Evidence from a randomized control trial in Uganda.
      ,
      • Zhu J.L.
      • Zhang W.H.
      • Cheng Y.
      • et al.
      Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: A cluster randomised trial.
      ,
      • Lou C.H.
      • Wang B.
      • Shen Y.
      • et al.
      Effects of a community-based sex education and reproductive health service program on contraceptive use of unmarried youths in Shanghai.
      ,
      • Erulkar A.S.
      • Muthengi E.
      Evaluation of Berhane Hewan: A program to delay child marriage in rural Ethiopia.
      ,
      • Sebastian M.P.
      • Khan M.E.
      • Kumari K.
      • et al.
      Increasing postpartum contraception in rural India: Evaluation of a community-based behavior change communication intervention.
      ,
      • Speizer I.S.
      • Tambashe B.O.
      • Tegang S.P.
      An evaluation of the “Entre Nous Jeunes” peer-educator program for adolescents in Cameroon.
      ], one had a mixed impact [
      • Kanesathasan A.
      • Cardinal L.J.
      • Pearson E.
      • et al.
      Catalyzing change: Improving youth sexual and reproductive health through DISHA, an integrated program in India.
      ], and the final two saw significant impacts in the opposite direction, decreasing contraceptive use [
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      ,
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      ]—both included a sexual and reproductive health education component. Among those with a positive impact, five were community based while two were at facilities. Three of the effective interventions included provision of contraception [
      • Hubacher D.
      • Olawo A.
      • Manduku C.
      • et al.
      Preventing unintended pregnancy among young women in Kenya: Prospective cohort study to offer contraceptive implants.
      ,
      • Zhu J.L.
      • Zhang W.H.
      • Cheng Y.
      • et al.
      Impact of post-abortion family planning services on contraceptive use and abortion rate among young women in China: A cluster randomised trial.
      ,
      • Lou C.H.
      • Wang B.
      • Shen Y.
      • et al.
      Effects of a community-based sex education and reproductive health service program on contraceptive use of unmarried youths in Shanghai.
      ], while three had a life-skills training or education component [
      • Banderia O.
      • Buehern N.
      • Burgess R.
      • et al.
      Empowering adolescent girls: Evidence from a randomized control trial in Uganda.
      ,
      • Kanesathasan A.
      • Cardinal L.J.
      • Pearson E.
      • et al.
      Catalyzing change: Improving youth sexual and reproductive health through DISHA, an integrated program in India.
      ,
      • Erulkar A.S.
      • Muthengi E.
      Evaluation of Berhane Hewan: A program to delay child marriage in rural Ethiopia.
      ], and one was a mass media campaign [
      • Sebastian M.P.
      • Khan M.E.
      • Kumari K.
      • et al.
      Increasing postpartum contraception in rural India: Evaluation of a community-based behavior change communication intervention.
      ].

       Distal outcomes

      We include three distal outcomes as part of our assessment of effective interventions—sexual activity, abstinence, and age at sexual debut. While these outcomes may impact unwanted and repeat pregnancy, these outcomes alone (with the exception of abstinence) do not directly impact pregnancy. We include articles in this list that either had pregnancy or contraceptive use as an outcome in addition to these distal measures.

       Sexual activity

      We identified three articles that included sexual activity as an outcome of the intervention [
      • Heinrich C.J.
      • Brill R.
      Stopped in the name of the law: Administrative burden and its implications for cash transfer program effectiveness.
      ,
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      ,
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      ]. Two, a multicomponent intervention and an unconditional cash transfer program, had mixed results [
      • Heinrich C.J.
      • Brill R.
      Stopped in the name of the law: Administrative burden and its implications for cash transfer program effectiveness.
      ,
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      ], and the third, an education curriculum, had no significant impact on ever or recent sex [
      • Taylor M.
      • Jinabhai C.
      • Dlamini S.
      • et al.
      Effects of a teenage pregnancy prevention program in KwaZulu-Natal, South Africa.
      ].

       Age of sexual debut

      One of the interventions, the conditional cash transfer program by the Mexican government [
      • Gulemetova-Swan M.
      Evaluating the impact of conditional cash transfer programs on adolescent decisions about marriage and fertility: The case of opportunidades.
      ], showed a statistically significant increase in the reported age of sexual debut by recipients of the intervention while an unconditional cash transfer program reported an increase in the age of sexual debut among female recipients but not among males [
      • Handa S.
      • Peterman A.
      • Huang C.
      • et al.
      Impact of the Kenya cash transfer for orphans and vulnerable children on early pregnancy and marriage of adolescent girls.
      ].

       Abstinence

      One article with abstinence as an outcome of the intervention—a multicomponent intervention—had no significant impact on secondary abstinence [
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      ].

      Discussion

      Unintended pregnancy, primarily mistimed, among young people, remains a serious concern, despite the lifting of restrictions to access for young people and efforts on the global level to make contraception readily available and affordable to all. Overall, we find very few high-quality articles (both intervention and evaluation) for intervening to prevent pregnancy and repeat pregnancy. When reviewing the interventions that worked to prevent pregnancy, the primary outcome in this review, the majority with the strongest results were cash transfer programs, both conditional and unconditional. While recent debates have suggested that national or government-sponsored cash transfer programs may increase pregnancy rates (see [
      • Palermo T.
      • Handa S.
      • Peterman A.
      • et al.
      Unconditional government social cash transfer in Africa does not increase fertility.
      ] for an excellent summary of this debate), our review suggests that many successfully reduced pregnancy, although some have no impact. Importantly, none found an increase in pregnancy among young people. Despite the success of cash transfer programs, they may be unsustainable in terms of cost, and it is unclear whether changing norms is needed for sustained long-term change.
      For the proximal outcome of contraceptive use, those with the strongest results were those that provided contraception directly to young people. The three included interventions had uniformly significant impact on contraceptive use. Direct provision has several strengths; however, careful attention to informed choice is particularly important for young people. In addition, getting young people to health services is often a barrier to provision of contraception. Interventions that take advantage of young people already at the site of services (postpartum, postabortion) have potential to have significant impact on reduction of repeat pregnancy.
      The most common intervention design targeting contraceptive use was life-skills training programs, with very mixed results. Limited evidence of effective evaluations on distal outcomes (sexual activity, abstinence) showed mostly mixed or null results. Given the time it takes to follow-up for sexual activity, contraception, and pregnancy, it is perhaps not reasonable to expect life-skills programs to have a direct effect on these outcomes. Despite the relatively weak findings for life-skills training, life-skills, or comprehensive sexuality education is important for young people and is still a worthwhile intervention to improve knowledge and gender norms [
      • Haberland N.
      • Rogow D.
      Sexuality education: Emerging trends in evidence and practice.
      ].
      Three of the interventions described in this review had unintended or unexpected impacts on the outcomes. Contraceptive use and condom use decreased in one of the intervention sites in Senegal. The authors suggest that the decline may be due to a shift from more casual partners at baseline to more regular partners in the follow-up period [
      • Diop N.
      • Bathidja H.
      • Touré I.D.
      • et al.
      Improving the reproductive health of adolescents in Senegal. Frontiers in Reproductive Health.
      ]. The second found that one of the intervention arms had a significant increase in multiple partners, ever having sexual intercourse, and transactional sex among boys. For girls, it led to an increase in ever having sexual intercourse. This was explained by the author as a change or shift in patterns of sexual behavior, away from older partners to same-aged partners [
      • Dupas P.
      Do teenagers respond to HIV risk information? Evidence from a field experiment in Kenya.
      ]. A third found that combining two intervention strategies—a teacher training and school uniform provision—decreased the impact of the school uniform intervention alone on pregnancy [
      • Duflo E.
      • Dupas P.
      • Kremer M.
      Education, HIV and early fertility: Experimental evidence from Western Kenya.
      ]. This unintended impact is particularly important to note, as the authors were able to tease out the effect of different intervention components—something that many multicomponent interventions are unable to do.
      There are a number of limitations from this review to consider. First, pregnancy is likely underreported, particularly for pregnancies that ended in early spontaneous abortion or induced abortion. This limitation results in more conservative estimates of intervention impact. Interventions did not distinguish intended from unintended pregnancy. In addition, although we include both gray and published literature, and did not limit our reporting to only positive results, it is likely that some interventions with null findings were never reported. Furthermore, as is described in the literature review, there is no clear evidence for exact age of potential adverse impact of early pregnancy, but it is likely that pregnancies in the later age range in our study may not carry the same degree of consequences. It is, for example, less clear that pregnancy during the early 20s is as much of problem as those that occur under the age of 18. The included studies and evaluations in this review represent a broad range of ages that may mask heterogeneity in potential adverse consequences within these age groups within an evaluation. Finally, we include the most recent evaluation of a particular intervention with the same outcome. For example, if a group reported on short-term and longer term follow-up of pregnancy, we use the most recent report on the intervention and its impact. This limitation is important to consider as some interventions may have short-term impact but not long-term impact (or vice versa). This decision was made to avoid redundancy but may not fully represent all the effects of a given intervention.
      Despite the above-mentioned limitations, the selected high-quality effective interventions included in this review can inform researchers, donors, and policy makers about where to make strategic investments to decrease the health and economic consequences of unintended pregnancy during young adulthood. Additionally, this review can assist with avoiding investments in interventions that failed to produce significant impact on the intended outcomes.
      There is no single answer to the best intervention strategy to prevent unintended pregnancy or repeat pregnancy among young people—it depends on the outcome of interest, the setting, and resources. The analysis suggests that the direct provision of contraception will increase contraceptive use but this intervention strategy is not feasible in settings where young people do not access health services. Similarly, cash transfer programs decrease pregnancy in most settings but not all and are resource intensive. The diversity of successful high-quality interventions, implemented in a range of venues, with a diversity of young people, suggests that there are multiple strategies that can work to prevent unintended pregnancy among young people.

      Acknowledgments

      Advisory committee: Bob Blum, Bruce Dick, and Jane Ferguson.
      Review team: A.M.K., Angela Bayer, Akin Omisore, Carie Cox Muntifering, Jaya, Hannah Lantos, Susan Lee-Rife, T-A.T., U.D.U., and Virginia Bowen. M.J.H. and Adesegun O. Fatusi were Principal Investigators.

      Funding Sources

      This work was supported by a grant to Johns Hopkins Bloomberg School of Public Health, Department of Population, Family and Reproductive Health from the John D. and Catherine T. MacArthur Foundation .

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