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What Will It Take to Further Reduce Teen Pregnancy in the U.S.?

      See Related Article on p.582
      This issue of the Journal of Adolescent Health includes a particularly noteworthy paper based on a cross-national comparison of adolescent sexual activity, contraceptive use, and pregnancy in the U.S. and Britain [
      • Scott R.
      • Wellings K.
      • Lindberg L.
      Adolescent sexual activity, contraceptive use and pregnancy in Britain and the United States: A multi-decade comparison.
      ]. The data presented are important because although we all celebrate significant declines in teen pregnancy in each nation, rates remain higher in both nations than in other wealthy industrialized nations. If we can pinpoint the factors associated with past progress in both nations, it may be possible to find ways to ensure that the declines continue and perhaps even accelerate. In addition, a careful assessment of factors driving the declines might also suggest new, innovative approaches.
      Scott et al. takes advantage of the felicitous fact that the U.S. and Britain both conducted comprehensive surveys in recent decades that address a wide variety of topics related to adolescent pregnancy (and many other topics as well) and center on roughly the same periods. In the case of the U.S., the data derive from the National Survey of Family Growth conducted in 2002–2003 and in 2010–2012. The parallel effort in Britain is the British National Survey of Sexual Attitudes and Lifestyles conducted in 2000–2001 and 2010–2012.
      The analysis of Scott et al. rests on the simple reality that as a general matter and holding individual fertility constant, pregnancy rates at any age are driven by two fundamental factors: vaginal sexual intercourse (yes/no? when? how often?) and the use of contraception (some method used? effective method used? method used properly?). At the most basic level, it is only through changes in one or both of these factors that pregnancy rates can be affected among adolescents and older women too.
      In this context, and using the helpful “pregnancy risk index” developed by Santelli et al., [
      • Lindberg L.
      • Santelli J.
      • Desai S.
      Changing patterns of contraceptive use and the decline in rates of pregnancy and birth among U.S. Adolescents, 2007–2014.
      ,
      • Santelli J.
      • Abma J.
      • Ventura S.
      • et al.
      Can changes in sexual behaviors among high school students explain the decline in teen pregnancy rates in the 1990s?.
      ,
      • Lindberg L.
      • Santelli J.
      • Desai S.
      Understanding the decline in adolescent fertility in the United States, 2007--2012.
      ,
      • Santelli J.S.
      • Lindberg L.D.
      • Finer L.B.
      • Singh S.
      Explaining recent declines in adolescent pregnancy in the United States: The contribution of abstinence and improved contraceptive use.
      ] which combines a variety of important variables, the authors note that British progress over the two periods studied is largely attributed to improvements in contraceptive use among teens. In the U.S., a decline in sexual activity in the first period analyzed accounts for about half of the decline noted; in the second period, better contraceptive use is clearly the dominant factor.
      These findings suggest at least four important pathways to lowering rates of teen pregnancy in the U.S. First is a crisp focus on increasing teens' knowledge about the wide variety of contraceptive methods available; second is improving teens' access to high-quality contraceptive services; third is strengthening social norms about the significance of pregnancy and the reasons for avoiding too-early childbearing; and fourth is building high-quality research into all such efforts.
      It is well known in the public health community that U.S. teens continue to have many myths, misinformation, and confusion about contraception and basic reproductive biology. One obvious remedy is to harness the power of technology to help, especially given the immense amount of time that teens now spend online. Well-designed platforms can be confidential, powerful, and easily accessible sources that help inform teens and others about contraception and many associated topics. Bedsider.org, for example, offers extensive, accurate, and user-friendly information in an engaging manner carefully crafted for teens and young adults. Moreover, there is good evidence that it has important positive effects [
      • Antonishak J.
      • Kaye K.
      • Swiader L.
      Impact of an online birth control support network on unintended pregnancy.
      ].
      The second imperative suggested by Scott et al.'s research is that ready access to all methods of contraception is critical to reducing teen pregnancy and unintended pregnancy more generally. The phrase “all methods” bears emphasis. Teens, like adults, have varying preferences, experiences, health profiles, and more that may well shape their choice of methods. Indeed, offering full information about and access to all methods is a cornerstone of patient autonomy and good family planning. As this article and others have noted, using virtually any birth control method rather than nothing at all makes the biggest impact on decreasing the probability of pregnancy. That is, something is better than nothing.
      But it is also true that some methods are significantly more effective than others. In particular, the new generation of intrauterine devices and subdermal implants are important options for adolescents to consider. And indeed, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics now recommend these highly effective methods as first-line choices for teens [
      American College of Obstetrics and Gynecology
      Adolescents and long-acting reversible contraception: Implants and intrauterine devices.
      ,
      American Academy of Pediatrics
      AAP updates recommendations on teen pregnancy prevention.
      ]. Moreover, the pioneering work of Upstream USA (Upstream.org) in reducing unintended pregnancy is showcasing new ways to increase low-cost, same-day access to all contraceptive methods—including intrauterine device and implants—for teens as well as older women, by providing billing and coding support, patient education, provider training, and more [
      • Welti K.
      • Manlove J.
      Estimated reductions in unintended pregnancy among Delaware family planning clients after contraceptive access intervention.
      ].
      These twin strategies of increasing knowledge of and access to the full range of contraceptive options require action on many levels. Parents, schools, community groups, and agencies can all contribute, and as already noted, online resources may be particularly well suited to reaching teens. There are also a wide variety of publicly financed efforts that can help and that are currently either under funded, under attack, or both. This list includes, at a minimum, the Title X program, Medicaid, the Teen Pregnancy Prevention Program, and the Personal Responsibility Education Program, along with many state-level initiatives as well. It is also critical that the basic benefit packages offered through private health insurance always include full coverage of contraceptive methods and services to teens as well as older individuals, with special attention to confidentiality.
      A third remedy focuses more on values and attitudes by encouraging teens to take sexual activity and pregnancy seriously and respectfully. Getting pregnant—as well as causing a pregnancy—is one of the most consequential things any of us ever does, and it deserves to be considered carefully; there are also powerful reasons to suggest that it is best undertaken after education is completed, and other markers of young adult life are reached [
      • Sawhill I.V.
      Generation unbound.
      ]. Such messages are fundamentally about social norms surrounding sexual activity, pregnancy planning, and prevention, as distinct from knowledge about and access to contraception.
      One powerful way to affect adolescent attitudes and norms is by harnessing the tremendous power of media messages to reach teens where they are and in ways that are persuasive to them. The National Campaign to Prevent Teen and Unplanned Pregnancy (recently renamed, Power to Decide) has a long history of working in partnership with leaders of the entertainment industry—broadcast, print, and online—to embed issues of pregnancy planning and prevention into various media content popular with teens. Research on television programs such as “16 and Pregnant” and “Teen Mom” that were very popular several years ago suggests that this particular approach has a variety of positive effects on teen viewers about the risk and reality of early pregnancy and child bearing [
      • Kearney Melissa S.
      • Levine Phillip B.
      Media influences on social outcomes: The impact of MTV's 16 and pregnant on teen childbearing.
      ].
      A fourth and final implication of Scott et al.’s analysis is the importance of high-quality research to deepen our understanding of the antecedents of teen pregnancy and the relative efficacy of various approaches to reducing it. Given the intense engagement of teens in media, learning more about the types of messages, platforms, and voices that connect especially well with different teenaged populations would be particularly useful.

      Acknowledgments

      The author thanks Andrea Kane and Bill Albert for their help and advice, as always.

      References

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        Changing patterns of contraceptive use and the decline in rates of pregnancy and birth among U.S. Adolescents, 2007–2014.
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        (Available at:)
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