Despite declines in the teen birth rate over the past 25 years, there were 209,809 births to teens aged 15–19 years in the U.S. in 2016, of which 17% were non-first births.¹ Repeat teen pregnancy (RTP) and repeat teen birth rates are higher among females within minority and low-income communities,^1–3 and vary by state, as does effective postpartum contraceptive use.⁴ Repeat teen births have a higher preterm and low birthweight risk compared with first teen births.^5–7 Repeat teen births are also at increased risk of adverse social outcomes, such as lower maternal educational attainment⁸ and dependence on government assistance,⁹ exacerbating socioeconomic disadvantages brought on by a first teen birth. Interventions to reduce repeat teen births may differ from those focused on primary prevention of teen pregnancy.^8,10–13 Evidence-based approaches are needed to reduce repeat teen births, including clinic-based interventions, which can be implemented along with other family planning and related reproductive health services.^3,14,15

Previous systematic reviews of RTP prevention programs have not focused exclusively on clinic-based interventions¹⁴ or have been conducted many years ago.^3,16–18 An updated review of clinic-based interventions, which can be integrated into other clinical care services, is needed. Therefore, as part of a broader review related to adolescent family planning services, a systematic review was conducted on the effect of clinic-based RTP programs on short-, medium-, and long-term outcomes among teens, as well as on identifying contextual barriers or facilitators for providing clinic-based RTP programs. This review was conducted in two phases: the first was not published but used to inform the development of Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs¹⁵; the second was recently conducted to update the first review and capture the most recent evidence.

The methods for conducting the first systematic review, covering studies published from January 1, 1985, to February 28, 2011, were based on methodology used by the U.S. Preventive Services Task Force (USPSTF).¹⁹ The updated systematic review, covering studies published from March 1, 2011, to April 30, 2016, followed the same process. The analysis for the initial and updated systematic reviews took place in 2014 and 2017, respectively. Six key questions (KQs) on adolescent-focused family planning services were identified by an expert work group convened to advise the Office of Population Affairs and the Centers for Disease Control and Prevention on the structure and content of the Quality Family Planning recommendations (Table 1), and four priority topic areas were identified for later categorization of studies: youth-friendly services, confidentiality, parental involvement, and RTP prevention. This manuscript focuses on the studies categorized as pertaining to RTP prevention. An analytic framework was developed to show the hypothesized relationships between the provision of adolescent-focused family planning interventions among young people (ages 10–24 years) and key outcomes of interest (Figure 1). Specific outcomes included short-term outcomes (i.e., psychosocial, client experience [KQ3]), medium-term outcomes (i.e., behavioral [KQ2]), and long-term outcomes (i.e., reproductive health, value/cost savings [KQ1]); barriers and facilitators for clinics implementing interventions to strengthen adolescent-focused family planning services (KQ4); unintended consequences associated with adopting or implementing interventions designed to strengthen adolescent-focused family planning services (KQ5); and contextual barriers and facilitators for clients seeking (or clinicians providing) adolescent-focused family planning services (KQ6). Select key outcomes were added to the updated review (Figure 1).

The combined results of the two systematic reviews, covering studies published from January 1, 1985, to April 30, 2016, identified and screened 27,104 unique records by title and abstract. After screening, 26,164 records were excluded because they met at least one exclusion criteria (PRISMA diagram Figure 2), primarily because they were studies conducted outside the relevant countries, unrelated to young people, or unrelated to family planning. Of the 940 full-text articles reviewed, 825 were excluded, primarily because they were studies focused solely on sexually transmitted disease/HIV prevention services without a family planning component, or were conducted outside of a clinic setting. This left 120 studies that met the inclusion criteria for the topic of adolescent-focused family planning services. After categorizing studies by the four priority topic areas previously identified, 17 studies were found to pertain to RTP prevention programs. Of the 17 studies, 12 focused on a diverse set of community-based programs, mostly operated in educational or home visiting settings. Because the aim of this review was to examine clinic-based programs focused on RTP prevention, the aforementioned 12 studies were excluded. The remaining five studies reporting on clinic-based RTP prevention programs comprise the evidence used for this review.

This systematic review identified five studies of clinic-based programs designed to prevent RTP. Four of these studies assessed long-term and medium-term outcomes and one study described facilitators for adolescent clients to remain linked to family planning services. Of the four studies that assessed outcomes,^20–23 two studies found a positive impact on decreasing RTP and unintended pregnancy,^20,22 one study found a positive impact on increasing contraceptive use,²² and two studies found a positive impact on increasing use of family planning services or repeat/follow-up services.²⁰ In addition, two studies showed lower percentages of RTP or repeat teen delivery in their intervention group, but the differences did not reach statistical significance.^21,23 This review uncovered relatively few interventions to prevent RTP in clinic settings and these were studied at least 20 years ago.

More recent literature on RTP includes interventions with a community-based or home visiting focus. A study by Katz and colleagues²⁵ involved randomized cell phone–based counseling to adolescent mothers. Adolescent parents may have difficulty attending appointments or remaining engaged, which may make telephone contact and home visits more effective. However, this intervention was not successful and the authors noted that getting teens to maintain consistent contact with their counselors required persistence.²⁵ A study by Salihu et al.,²⁶ which evaluated a Federal Healthy Start program in Florida that incorporated both home visits and community sessions for teen mothers, was also not successful in reducing RTP. Unlike these two studies, two fairly recent studies of comprehensive interventions did demonstrate positive effects.^27,28 These comprehensive interventions were implemented in community settings and included a school-based program as well as family planning services; both interventions had a positive impact on repeat pregnancy rates through increased contraceptive use and access to services.^27,28

Recent studies of home visiting programs have also shown promising findings on medium- and long-term outcomes. Two recent home visiting studies did not show an effect on RTPs,^29,30 but Cohen and colleagues²⁹ found provision of additional psychosocial support on top of usual midwifery care in clients’ homes resulted in greater use of family planning services. In another study, the Minnesota Visiting Nurse Agency’s Pregnant and Parenting Team Program found teen mothers served by their program were more likely to remain enrolled in, attend regularly, and graduate from school; have full-term pregnancies and babies with healthy birth weights; and obtain adequate prenatal care.³⁰ Nurse home visitation may work through relationship-focused, intensive case management, which Lewis et al.³¹ tested with college-educated case managers to deliver a resiliency-based developmental assets approach to low-income parenting adolescents. This involved a long-term, supportive relationship between the adolescent and case manager, consisting of minimum bimonthly contacts for up to 3 years expected to foster social support and use of birth control.³¹ Intensive case management participants were less likely to have a subsequent birth within 3 years compared with control group participants (WIC recipients attending adolescent health clinics; 16% vs 31%, p=0.09).³¹ Additionally, a series of studies evaluating the effects of comprehensive home visitation services found visits to the mother’s home by a nurse improved birth spacing and reduced subsequent pregnancies,^32–34 and a mentorship program involving home visits was also effective.³⁵

Although the majority of literature on RTP interventions encompasses community-based and home visiting interventions, less is known about RTP prevention interventions implemented in clinic settings. Research on clinic-based RTP prevention interventions may be limited because of the challenges to keep teens connected to and engaged in continuous care.^36–38 Access to effective contraceptive methods has been shown to have the most impact on reducing RTP,³⁹ but clinic staff may also be able to take other steps to help motivate and support teens’ efforts to prevent RTP. A recent RCT of a Motivational Interviewing program called Teen Options to Prevent Pregnancy, published after the time frame of this systematic review, found an 18.1% absolute reduction in self-reported RTP and a 13.7% absolute increase in self-reported long-acting reversible contraception use in the intervention group relative to the control group.⁴⁰ The Teen Options to Prevent Pregnancy program included the following components: (1) personalized contraceptive counseling with nurses trained in Motivational Interviewing; (2) access to a part-time family planning clinic; (3) transportation assistance; and (4) social work assistance.⁴⁰ Clinic-based RTP prevention programs represent a unique opportunity for the provision of contraceptive counseling and methods, sexual health education, and education on healthy parenting behaviors and referrals for social services in the postpartum period.⁴¹ Lewin and colleagues⁴² demonstrated greater contraceptive use among teen parents through a patient-centered medical home intervention that provided family-centered primary care where the teen parents and children saw the same medical provider, usually during the same visit. Addressing family planning and well-child visits together provides an opportunity to reach new mothers and counsel them about contraception and provide contraceptive referrals and prescriptions.^43,44

This systematic review of RTP interventions focusing on clinical settings adds to other comprehensive reviews aimed at identifying effective RTP interventions in various service locations. Akinbami et al.⁴⁵ conducted a systematic review on comprehensive clinical programs for teenage mothers and their children from January 1980 to August 2000, and identified four studies, three of which are included in the current systematic review (Rabin and colleagues,²² Elster et al.,²¹ and O’Sullivan and Jacobsen²⁰). Three of the four studies demonstrated a significant reduction in RTP.⁴⁵

Klerman and colleagues¹⁸ conducted a comprehensive review of evaluated programs aimed at postponing additional pregnancies or births to teen mothers conducted in the U.S. from 1970 to 2002. They found 19 studies, with only four studies describing interventions conducted in medical settings^20–23 and two showed positive results.^20,22 The current systematic review identified these same four studies with the addition of the study by Omar et al.²⁴ Corcoran and Pillai¹⁷ conducted a meta-analysis on 16 intervention studies with control groups that evaluated the effect of teenage pregnancy and parenting programs on subsequent pregnancy rates. They found that interventions produced a 50% reduction in the odds of pregnancy compared with the control groups at the first follow-up period (around 19 months), but by the second follow-up (around 31 months), the effect was no longer significant.

A review by Lachance and colleagues¹⁴ found a number of strategies implemented to reduce RTPs (e.g., case management, home visitation, and clinic-based approaches), but many of these interventions are not rigorously evaluated, making it difficult to reach consensus on the most effective strategies. In 2017, a mixed-methods systematic review of interventions to eliminate repeat conceptions in teenagers identified home-based, community-based, and telephone interventions, but did not report on any clinic-based interventions.^46,47 There was little or no evidence for the effectiveness or cost effectiveness of any of the interventions identified; however, they did find home-based interventions reduced subsequent births.^46,47 They concluded that more theory-based, rigorously evaluated programs need to be developed to reduce unintended repeat pregnancy in female adolescents.^46,47

Finally, a recent systematic review identified 14 high-quality evaluations of interventions specifically designed to prevent rapid repeat pregnancy or birth among adolescents, which included the studies by O’Sullivan and Jacobsen²⁰ and Rabin et al.²² from this review.⁴⁸ Although not all of the interventions were conducted in the U.S. or in clinic-based settings, they found the following to reduce rapid repeat pregnancy: providing contraceptive education and services, monitoring contraceptive use, and involving partners and families; providing postpartum counseling and contraceptive services soon after delivery; helping adolescents plan for a subsequent pregnancy or contraceptive use; helping adolescents understand the role contraceptives can play in determining positive life outcomes; and mentoring, motivating, and goal setting.⁴⁸

RTP interventions often combine multiple strategies into comprehensive programs, which makes it difficult to identify the specific components of these interventions that result in the desired short-, medium-, and long-term outcomes.¹⁴ Additional research is needed to identify the specific components of comprehensive strategies in clinics that are most effective in reducing RTP, as well as an evaluation of their implementation.

This review demonstrates limited evidence regarding effective RTP prevention clinic-based interventions. Two of the five clinic-based studies identified through this systematic review reduced RTPs through comprehensive programs providing prenatal and postpartum care to teenagers using an interdisciplinary team of healthcare professionals. Interdisciplinary teams can provide a supportive environment for adolescents through close and sustained relationships and by connecting them to a range of preventive health services, including quality family planning services. Healthcare systems and organizations should consider implementing comprehensive programs with interdisciplinary teams, and engaging teenagers in a variety of settings, whether in their home, community, or in the clinic setting, to ensure they have access to quality family planning services and support soon after delivery. However, new approaches and research to address contemporary issues of RTPs in populations currently at risk are needed.