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Meta-Analysis
. 2016 Feb 3;2(2):CD005215.
doi: 10.1002/14651858.CD005215.pub3.

Interventions for preventing unintended pregnancies among adolescents

Chioma Oringanje  1 , Martin M Meremikwu, Hokehe Eko, Ekpereonne Esu, Anne Meremikwu, John E Ehiri
Affiliations
Meta-Analysis

Interventions for preventing unintended pregnancies among adolescents

Chioma Oringanje et al. Cochrane Database Syst Rev. .

Abstract

Background: Unintended pregnancy among adolescents represents an important public health challenge in high-income countries, as well as middle- and low-income countries. Numerous prevention strategies such as health education, skills-building and improving accessibility to contraceptives have been employed by countries across the world, in an effort to address this problem. However, there is uncertainty regarding the effects of these interventions, hence the need to review the evidence-base.

Objectives: To assess the effects of primary prevention interventions (school-based, community/home-based, clinic-based, and faith-based) on unintended pregnancies among adolescents.

Search methods: We searched all relevant studies regardless of language or publication status up to November 2015. We searched the Cochrane Fertility Regulation Group Specialised trial register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015 Issue 11), MEDLINE, EMBASE, LILACS, Social Science Citation Index and Science Citation Index, Dissertations Abstracts Online, The Gray Literature Network, HealthStar, PsycINFO, CINAHL and POPLINE and the reference lists of articles.

Selection criteria: We included both individual and cluster randomised controlled trials (RCTs) evaluating any interventions that aimed to increase knowledge and attitudes relating to risk of unintended pregnancies, promote delay in the initiation of sexual intercourse and encourage consistent use of birth control methods to reduce unintended pregnancies in adolescents aged 10 years to 19 years.

Data collection and analysis: Two authors independently assessed trial eligibility and risk of bias, and extracted data. Where appropriate, binary outcomes were pooled using a random-effects model with a 95% confidence interval (Cl). Where appropriate, we combined data in meta-analyses and assessed the quality of the evidence using the GRADE approach.

Main results: We included 53 RCTs that enrolled 105,368 adolescents. Participants were ethnically diverse. Eighteen studies randomised individuals, 32 randomised clusters (schools (20), classrooms (6), and communities/neighbourhoods (6). Three studies were mixed (individually and cluster randomised). The length of follow up varied from three months to seven years with more than 12 months being the most common duration. Four trials were conducted in low- and middle- income countries, and all others were conducted in high-income countries. Multiple interventionsResults showed that multiple interventions (combination of educational and contraceptive-promoting interventions) lowered the risk of unintended pregnancy among adolescents significantly (RR 0.66, 95% CI 0.50 to 0.87; 4 individual RCTs, 1905 participants, moderate quality evidence. However, this reduction was not statistically significant from cluster RCTs. Evidence on the possible effects of interventions on secondary outcomes (initiation of sexual intercourse, use of birth control methods, abortion, childbirth, sexually transmitted diseases) was not conclusive.Methodological strengths included a relatively large sample size and statistical control for baseline differences, while limitations included lack of biological outcomes, possible self-report bias, analysis neglecting clustered randomisation and the use of different statistical tests in reporting outcomes. Educational interventionsEducational interventions were unlikely to significantly delay the initiation of sexual intercourse among adolescents compared to controls (RR 0.95, 95% CI 0.71 to 1.27; 2 studies, 672 participants, low quality evidence).Educational interventions significantly increased reported condom use at last sex in adolescents compared to controls who did not receive the intervention (RR 1.18, 95% CI 1.06 to 1.32; 2 studies, 1431 participants, moderate quality evidence).However, it is not clear if the educational interventions had any effect on unintended pregnancy as this was not reported by any of the included studies. Contraceptive-promoting interventionsFor adolescents who received contraceptive-promoting interventions, there was little or no difference in the risk of unintended first pregnancy compared to controls (RR 1.01, 95% CI 0.81 to 1.26; 2 studies, 3,440 participants, moderate quality evidence).The use of hormonal contraceptives was significantly higher in adolescents in the intervention group compared to those in the control group (RR 2.22, 95% CI 1.07 to 4.62; 2 studies, 3,091 participants, high quality evidence)

Authors' conclusions: A combination of educational and contraceptive-promoting interventions appears to reduce unintended pregnancy among adolescents. Evidence for programme effects on biological measures is limited. The variability in study populations, interventions and outcomes of included trials, and the paucity of studies directly comparing different interventions preclude a definitive conclusion regarding which type of intervention is most effective.

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Conflict of interest statement

Chioma Oringanje: none Martin M Meremikwu: none Hokehe Eko: none Ekpereonne Esu: none Anne Meremikwu: none John E Ehir: none

Figures

1
1
Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Multiple interventions, Outcome 1 Unintended pregnancy [individually randomised trials].
1.2
1.2. Analysis
Comparison 1 Multiple interventions, Outcome 2 Unintended pregnancy [cluster‐randomised trials].
1.3
1.3. Analysis
Comparison 1 Multiple interventions, Outcome 3 Initiation of sexual intercourse ‐ individually RCT.
1.4
1.4. Analysis
Comparison 1 Multiple interventions, Outcome 4 Initiation of sexual intercourse ‐ cluster RCT.
1.5
1.5. Analysis
Comparison 1 Multiple interventions, Outcome 5 Use of birth control methods ‐ individually RCT.
1.6
1.6. Analysis
Comparison 1 Multiple interventions, Outcome 6 Use of birth control methods ‐ cluster RCT.
1.7
1.7. Analysis
Comparison 1 Multiple interventions, Outcome 7 Sexually Transmitted Diseases ‐ individually RCT.
1.8
1.8. Analysis
Comparison 1 Multiple interventions, Outcome 8 Sexually Transmitted Diseases ‐ cluster RCT.
1.9
1.9. Analysis
Comparison 1 Multiple interventions, Outcome 9 Childbirth ‐ cluster RCT.
1.10
1.10. Analysis
Comparison 1 Multiple interventions, Outcome 10 Childbirth ‐ individually RCT.
1.11
1.11. Analysis
Comparison 1 Multiple interventions, Outcome 11 Second unintended pregnancy ‐ individually RCT.
1.12
1.12. Analysis
Comparison 1 Multiple interventions, Outcome 12 Abortion (cluster RCT).
2.1
2.1. Analysis
Comparison 2 Sensitivity analysis [Multiple interventions]: Unintended pregnancy, Outcome 1 Unintended pregnancy ‐ cluster‐randomi sed trials .
2.2
2.2. Analysis
Comparison 2 Sensitivity analysis [Multiple interventions]: Unintended pregnancy, Outcome 2 Unintended pregnancy ‐ individually‐randomi sed trials .
2.3
2.3. Analysis
Comparison 2 Sensitivity analysis [Multiple interventions]: Unintended pregnancy, Outcome 3 Unintended pregnancy ‐ cluster‐adjusted + individual .
3.1
3.1. Analysis
Comparison 3 Sensitivity analysis [Multiple interventions]: Initiation of intercourse, Outcome 1 Initiation of sexual intercourse ‐ individually RCT.
3.2
3.2. Analysis
Comparison 3 Sensitivity analysis [Multiple interventions]: Initiation of intercourse, Outcome 2 Initiation of sexual intercourse ‐ cluster RCT.
3.3
3.3. Analysis
Comparison 3 Sensitivity analysis [Multiple interventions]: Initiation of intercourse, Outcome 3 Initiation of sexual intercourse ‐ cluster‐adjusted + individual.
4.1
4.1. Analysis
Comparison 4 Educational interventions , Outcome 1 Initiation of sexual intercourse ‐ cluster RCT.
4.2
4.2. Analysis
Comparison 4 Educational interventions , Outcome 2 Use of birth control methods ‐ cluster RCT.
4.3
4.3. Analysis
Comparison 4 Educational interventions , Outcome 3 Use of contraceptives ‐ individually RCT.
5.1
5.1. Analysis
Comparison 5 Contraceptive‐promoting interventions, Outcome 1 Unintended pregnancy ‐ individually RCT.
5.2
5.2. Analysis
Comparison 5 Contraceptive‐promoting interventions, Outcome 2 Initiation of sexual intercourse ‐ cluster RCT.
5.3
5.3. Analysis
Comparison 5 Contraceptive‐promoting interventions, Outcome 3 Use of birth control methods ‐ cluster RCT.
5.4
5.4. Analysis
Comparison 5 Contraceptive‐promoting interventions, Outcome 4 Use of birth control methods ‐ individually RCT.
5.5
5.5. Analysis
Comparison 5 Contraceptive‐promoting interventions, Outcome 5 Sexually Transmitted Diseases ‐ individually RCT.
See this image and copyright information in PMC

Update of

References

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Fitzgerald 2002 {published data only}
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Gallegos 2008 {published data only}
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Garbers 2012 {published data only}
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Gaughran 2014 {published data only}
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Guilamo‐Ramos 2011a {published data only}
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Harvey 2004 {published data only}
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Havens 1997 {published data only}
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Howard 1990 {published data only}
    1. Howard M, McCabe JB. Helping teenagers postpone sexual involvement. Family Planning Perspectives 1990;22(1):21‐7. - PubMed
Hutchinson 2003 {published data only}
    1. Hutchinson MK, Jemmott JB, Jemmott LS, Braverman P, Fong GT. Role of a mother‐daughter sexual risk communication in reducing sexual risk behaviours among urban adolescent females: a prospective study. Journal of Adolescent Health 2003;33:98‐107. - PubMed
James 2005 {published data only}
    1. James S, Reddy PS, Ruiter RAC, Taylor M, Jinabhai CC, Empelen P, et al. The effects of a systematically developed photo‐novella on knowledge, attitudes, communication and behavioural intention with respect to sexually transmitted infections among secondary school learners in South Africa. Health Promotion International 2005;20(2):157‐65. - PubMed
Jay 1984 {published data only}
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Jennings 2014 {published data only}
    1. Jennings JM, Howard S, Perotte CL. Effects of a school‐based sexuality education program on peer educators: the Teen PEP model. Health Education Research 2014;29(2):319‐29. - PMC - PubMed
Jewkes 2006 {published data only}
    1. Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Khuzwayo N, et al. A cluster randomized controlled trial to determine the effectiveness of stepping stones in preventing HIV infections and promoting safer sex sexual behaviours amongst youth in the rural Eastern Cape, South Africa: trial design, methods and baseline findings. Tropical Medicine and International Health 2006;11(1):3‐16. - PubMed
Kaljee 2005 {published data only}
    1. Kaljee LM, Genberg B, Riel R, Cole M, Tho le H, Thoa le TK, et al. Effectiveness of a theory‐based risk reduction HIV prevention program for Vietnamese adolescents. AIDS education and prevention 2005;17(3):185‐99. - PubMed
Kamali 2002 {published data only}
    1. Kamali A, Kinsman J, Nalweyiso N, Mitchell K, Kanyesigye E, Kengeya‐Kayondo JF, et al. A community randomized controlled trial to investigate impact of improved STD management and behavioural interventions on HIV incidence in rural Masaka, Uganda: trial design, methods and baseline findings. Tropical Medicine and International Health 2002;7(12):1053‐63. - PubMed
Katz 2011 {published data only}
    1. Katz KS, Rodan M, Milligan R, Tan S, Courtney L, Gantz M, et al. Efficacy of a randomized cell phone‐based counseling intervention in postponing subsequent pregnancy among teen mothers. Maternal and Child Health Journal 2011;15 Suppl 1:S42‐53. - PubMed
Kirby 2002a {published data only}
    1. Kirby D. Effective approaches to reducing adolescent unprotected sex, pregnancy and childbearing. The Journal of Sex Research 2002;39(1):51‐7. - PubMed
Kirby 2002c {published data only}
    1. Kirby D. The impact of schools and school programs upon adolescent sexual behaviour. The Journal of Sex Research 2002;39(1):27‐33. - PubMed
Kuroki 2008 {published data only}
    1. Kuroki LM, Allsworth JE, Redding CA, Blume JD, Peipert JF. Is a previous unplanned pregnancy a risk factor for a subsequent unplanned pregnancy?. American Journal of Obstetrics and Gynecology 2008;199:517.e1‐517.e7. - PMC - PubMed
Kyrychenko 2006 {published data only}
    1. Kyrychenko P, Kohler C, Sathiakumar N. Evaluation of a school‐based HIV/AIDS educational intervention in Ukraine. Journal of Adolescent Health 2006;39:900‐7. - PubMed
Legardy 2005 {published data only}
    1. Legardy JK, Macaluso M, Artz L, Brill I. Do participants' characteristics influence the effectiveness of behavioural intervention? Promoting condom use of women. Sexually Transmitted Diseases 2005;32(1):665‐71. - PubMed
Liberman 2000 {published data only}
    1. Liberman LD, Gray H, Wier M, Fiorentino R, Maloney P. Long‐term outcomes of an abstinence‐based small‐group pregnancy prevention program in New York City schools. Family Planning Perspectives 2000;32(5):237‐45. - PubMed
Magnani 2005 {published data only}
    1. Magnani R, MacIntyre K, Karim AM, Brown L, Hutchinson P. The impact of life skills education on adolescent sexual risk behaviours in KwaZulu‐Natal, South Africa. Journal of Adolescent Health 2005;36:289‐304. - PubMed
Martiniuk 2003 {published data only}
    1. Martiniuk ALC, O'Connor KS, King WD. A cluster randomized trial of sex education programme in Belize, Central America. International Journal of Epidemiology 2003;32:131‐6. - PubMed
Matteson 2006 {published data only}
    1. Matteson KA, Peipert JF, Allsworth J, Phipps MG, Redding CA. Unplanned pregnancy. Does past experience influenced use of a contraceptive method?. Obstetrics & Gynecology 2006;107(1):121‐7. - PubMed
McBride 2000 {published data only}
    1. McBride D, Glenapp A. Using randomized designs to evaluate client‐centered programs to prevent adolescent pregnancy. Family Planning Perspectives 2000;32(5):227‐35. - PubMed
Metcalf 2005 {published data only}
    1. Metcalf CA, Malotte CK, Douglas JM, Paul SM, Dillon BA, Cross H, et al. Efficacy of a booster counselling session 6 months after HIV testing and counselling. A randomized controlled trial (RESPECT‐2). Sexually Transmitted Diseases 2005;32(2):123‐9. - PubMed
Mitchell 2014 {published data only}
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O'Donnell 2005 {published data only}
    1. O'Donnell L, Stueve A, Agranick G, Wilson‐Simmons R, Duran R, Jeanbaptistie V. Saving sex for later: an evaluation of a parent education intervention. Perspectives on Sexual and Reproductive Health 2005;37(4):166‐73. - PubMed
Ochiogu 2011 {published data only}
    1. Ochiogu IN, Miettola J, Ilika AL, Vaskilampi T. Impact of timing of sex education on teenage pregnancy in Nigeria: cross‐sectional survey of secondary school students. Journal of Community Health 2011;36(3):375‐80. - PubMed
Olsen 1991 {published data only}
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Padian 2007 {published data only}
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Peipert 2008 {published data only}
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Peipert 2011 {published data only}
    1. Peipert JF, Zhao Q, Meints L, Peipert BJ, Redding CA, Allsworth JE. Adherence to dual‐method contraceptive use. Contraception 2011;84(3):252‐8. - PMC - PubMed
Peipert 2012 {published data only}
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Peragallo 2005 {published data only}
    1. Peragallo N, Deforge B, O'Campo P, Lee SM, Kim YJ, Cianelli R, et al. A randomized clinical trial of an HIV‐Risk reduction intervention among low income Latina women. Nursing research 2005;54(2):108‐18. - PubMed
Peterson 2007 {published data only}
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Rickert 2007 {published data only}
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Robin 2004 {published data only}
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Schreiber 2010 {published data only}
    1. Schreiber CA, Ratcliffe SJ, Barnhart KT. A randomized controlled trial of the effect of advanced supply of emergency contraception in postpartum teens: a feasibility study. Contraception 2010;81(5):435‐40. - PubMed
Schwarz 2008 {published data only}
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    1. Secura GM. Adams T, Buckel CM, Zhao QH, Peipert JF. Change in sexual behavior with provision of no‐cost contraception. Obstetrics and Gynecology 2014;123(4):771‐6. - PMC - PubMed
Shuey 1999 {published data only}
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Stout 1989 {published data only}
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Thomas 2000 {published data only}
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Van 1985 {published data only}
    1. Van D, Leslie J. Use of nurse‐client contracting to reduce risk of unintended pregnancy in an adolescent population. The American Public Health Association Annual Meeting 1985.
Van Devanter 2002 {published data only}
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Wiggins 2009 {published data only}
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Zabin 1986 {published data only}
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Zabin 1988 {published data only}
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References to studies awaiting assessment

Murray 2015 {published data only}
    1. Murray PJ, Ashcraft AM, Downs J. Can you get an STI from a virgin? The answer might surprise you: Intervention improves knowledge about sexual risk perception. Journal of Pediatric Adolescent Gynecology (Poster Abstracts) 2015; Vol. 28:e41‐e78.
Shafii 2014 {published data only}
    1. Shafii T, Benson SK, Morrison DM, Hughes JP, Golden MR, Holmes KK. Results from ekiss (electronic kiosk intervention for safer‐sex): A pilot randomized controlled trial to test an interactive computer‐based intervention for sexual health in adolescents and young adults. Journal of Adolescent Health 2014;54(2 Suppl. 1):S10. - PMC - PubMed

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