Elimination of Teen Pregnancy Prevention Funds Threatens Progress, Experts Say

Tara Haelle

Disclosures

October 04, 2017

The recent decision by the Trump administration to abruptly slash $213.6 million slated for teen pregnancy prevention programs has left program coordinators reeling and experts in adolescent medicine anxious about jeopardizing two decades of progress in reducing teen pregnancy rates.[1,2]

The decision cuts short the 5-year Teen Pregnancy Prevention Program (TPPP) grants awarded by the US Department of Health and Human Services (HHS) to 81 teen pregnancy prevention and research programs in nonprofit organizations, school districts, universities, and public health departments across the nation.

"These programs provide critical, life-changing education to teens about sexual health and avoiding unplanned pregnancies," said Lisa Hollier, MD, MPH, president-elect of the American College of Obstetricians and Gynecologists (ACOG).

The Initiatives

TPPP began as part of a wide-ranging series of evidence-based initiatives established by President Barack Obama in 2010. Current recipients just received their third year of funding for grants awarded in 2015 to run through 2020. Letters informed them in July that funding will not continue for the remaining 2 years.

Teen birth rates have dropped to an all-time low over the past 20 years. From 1991-2014, the birth rate among teens aged 15-19 years dropped by 61% (from 61.8 to 24.2 per 1000 females)—the lowest rate ever recorded. The teen birth rate fell by 29% during the first four years of the TPP program from 2010 to 2014.[3,4] The HHS Office of Adolescent Health conducted 41 evaluations of 2010-2014 TPP programs on the basis of their effectiveness in reducing adolescent pregnancy and births, reducing sexually transmitted infections (STIs), delaying sexual debut, and improving contraceptive use.[5]

"However, these studies were not designed to estimate the overall impact on the local or national teen pregnancy rate," explained Russell Cole, PhD, a senior researcher at Mathematica Policy Research in Princeton, New Jersey, who reviewed the HHS findings. Evidence investigating the role of TPPP in the already declining trend of falling teen pregnancy rates is not available currently, but Dr Cole said research on that question is ongoing.

Ten of the programs HHS evaluated were among 28 programs that the department had already identified as effective in an initial evidence review. Of the 19 evaluations of 10 of those programsevaluations aimed at replicating previous results from those programs—four programs were found effective at changing behavior in a new population or a new setting.

The Office of Adolescent Health also conducted 22 evaluations of programs using new and innovative approaches; 10 of these were entirely new, seven were adapted versions of existing evidence-based programs, and five were existing but untested programs. Eight of these 22 programs were found effective at changing behavior.

"Although there were some studies that did not find significant impacts on these behavioral outcomes, a number of these evaluations showed positive impacts on other variables, such as knowledge about pregnancy and STIs, attitudes toward abstinence or using protection, and self-efficacy," Dr Cole said.

A selection of the evaluation findings were published in a special September 2016 issue of the American Journal of Public Health.[6]

Teen Pregnancy Rates

As a high-risk pregnancy specialist, Dr Hollier said she worries she'll begin seeing more pregnant teens in her practice. Teens have a higher risk for maternal death; pregnancy complications; and poor outcomes, such as premature delivery and newborns with a low birthweight compared with women in their 20s.[7] "ACOG urged the [Trump] administration to support these effective, local efforts and not to turn back the clock on the progress made toward reducing high rates of teen and unintended pregnancy," Dr Hollier said, referencing ACOG's official statement, published in response to the HHS funding cut announcement.

The largest declines in teen pregnancy rates have occurred among adolescents at highest risk for unplanned pregnancy. Rates have dropped 51% among Latinas, for example, and 44% among black adolescents, helping reduce the still substantial disparities in teen pregnancy rates between adolescents of color and white adolescents. Every single US state saw declines of 13% or more in teen pregnancy rates from 2006 to 2014.[3]

Yet the United States still leads the developed world—and much of the developing world—in teen pregnancy rates, even after two decades of declines are accounted for.[8,9] Researchers have called for "further research to identify effective interventions for vulnerable populations"—exactly what TPPP has been doing.[10]

"If we want to keep our children educated, we need to keep them in school, and we need to provide the resources to postpone pregnancy until they're ready to have a family and have the means and support to raise a child in a happy and productive way," said Cora Breuner, MD, MPH, a professor of adolescent medicine at Seattle Children's Hospital and chair of the American Academy of Pediatrics Committee on Adolescence.

Dr Breuner said she sees the funding cuts as a short-sighted attempt to save money. TPPP, she said, saves the US billions of dollars in both the short- and long-term. Costs resulting from teen pregnancy and childbirth total an estimated $9.4 billion a year in the United States—about 90 times the annual cost of the TPPP program.[11,12]

The Future of the Programs

"We're still digesting this news," said Luanne Rohrbach, PhD, an associate professor of preventive medicine at the University of Southern California in Los Angeles and principal investigator of Keeping It Real Together, one of the grantee programs. "I wouldn't say we had no indication, but the way in which this came about was a surprise."

Rumblings in April suggested that TPPP funding might disappear during Congressional budget deliberations, but that concern mostly faded when Congress funded the rest of the fiscal year as usual. Then HHS independently axed the program.

Keeping It Real Together receives just under $2 million a year and serves nearly 15,000 middle school and high school students in Los Angeles and Compton. In addition to school programs, Keeping It Real Together educates parents about how to talk to their children about preventing pregnancy and gives students resource guides listing sexual and reproductive health services in their area.

Dr Rohrbach says she worries that eliminating TPPP will lead STI rates and ethnic/racial disparities in teen pregnancy to grow even greater. Youth accounted for almost two thirds of chlamydia cases and one half of gonorrhea cases in 2015, according to a report by the Centers for Disease Control and Prevention (CDC) that was published last year.[13]

Dr Rohrbach's team planned from the start to make their program sustainable beyond the 5-year grant, but the reality is that few school district and community organizations have the funding for a sustained effort of this magnitude, she said.

Even those that do are scrambling to ensure that data collection over the past 2 years hasn't been in vain. Suddenly slashing grant funding halfway through multiyear projects hamstrings the principal investigators' ability to evaluate the effectiveness of a project.

"We want to be thoughtful and make the best decisions about the data we have, so that we can have some sort of meaningful story to tell about this interventions within the period we have left," said Lisa Masinter, MD, MPH, principal investigator of the grant for the Chicago Healthy Adolescents and Teens (CHAT) program.

CHAT began before TPPP existed in 2009 and reaches over 10,000 youth per year through a collaboration between Chicago public schools and the city's public health department, said Chicago Department of Public Health program director Sarah Parchem, MPH. But TPPP's annual $1 million grant allowed them to partner with Planned Parenthood of Illinois to expand services and track two cohorts of seniors to assess the program's effectiveness. CHAT's sexual education and chlamydia and gonorrhea screenings in Chicago public schools will continue, Parchem said, but the future of the program's evaluation is less certain.

The first cohort of 1100 seniors graduated last spring, with follow-up scheduled 6 and 24 months later to compare seniors who received the intervention with those who didn't. Dr Masinter's team had just recruited the second cohort and was deep into planning parent orientations and informed consent procedures when they received notification of the funding cuts.

"The issue we're facing now is that we don't have time to do the analysis fully on both cohorts because we're still collecting data, and we won't have any 24-month follow-up to assess for pregnancy—the main outcome of interest," Dr Masinter said.

Research has shown that the primary driver of declines in teen pregnancy is improved contraceptive use. For example, improved contraceptive use accounted for 86% of the decreased rates between 1995 and 2002 for teens aged 15-19 years.[14] A more recent study showed no change in sexual activity among teens age 15-19 from 2007 to 2012, but that a 78%-86% increase in use of any contraceptive method occurred alongside a substantial decline in teen pregnancy and birth rates that "was entirely attributable to improvements in contraceptive use."[15] A 2012 study by the CDC found that one half of teens who became pregnant were not using any contraception, and one third of those adolescents didn't think they could get pregnant.[16]

"When you see teen pregnancy rates drop across all socioeconomic, ethnic, and racial [groups], yet the amount of sexually active kids stays the same, then there's only one reason why their pregnancy rates drop, and that's contraception," said Dr Breuner, who authored the American Academy of Pediatrics' 2016 clinical report on sex education for children and adolescents.[17]

TPPP projects aren't limited to improving contraception use, however. Seven of the 2010-2015 programs were abstinence-only programs, with other outcome measures that included reduction of adolescent pregnancy and births, delay of sexual debut, and reduced STI rates.

Because no program can be a one-size-fits-all solution for diverse communities, HHS makes program descriptions and data public for any institutions seeking a program that fits their needs. The TPP Evidence Review includes a study database of more than 600 studies published since 1989 looking at what interventions are most (and least) effective in reducing teen pregnancy and STI rates.

All of the current 2015-2020 programs are designed to assess whether the intervention is effective, and many additionally aim to replicate findings from the 2010-2015 TPP program evaluations.

"We want to fund interventions that will really make a difference, and without such studies as this, we can't do that," Dr Masinter said. "Cutting funding like this limits the ability to show whether any intervention is scientifically proven to reduce teen pregnancy or other sexual health outcomes we're trying to achieve health equity on."

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