Preventing Unintended Teenage Pregnancies With Community Engagement and Quality Improvement

Although many adolescents become pregnant each year in the United States, rates of teenage pregnancies and births have declined to historic lows over the last several decades.¹ This is primarily due to the use of contraception and changes in sexual behavior.^2–4 However, the teenage birth rate in the United States remains higher compared with other developed countries, and most adolescent pregnancies are uninteded.^2,5,6 In Central Ohio’s highly populated Franklin County, that is, the Columbus metropolitan area, teenage birth rate trends have followed national declines over time, but recent teenage birth rates remain higher than the national average, and rates among Black and Hispanic adolescents are higher than those among white adolescents.⁷ Pregnant adolescents face increased risks for preterm birth, infant small-for-gestational age, infant low birth weight, and infant mortality compared with older mothers.^8–10 In Ohio, prematurity is the leading cause of infant mortality, and infants born to teenage mothers experienced the highest infant mortality rate of any age cohort.¹¹ In addition, adolescents experiencing births are less likely to graduate high school and more likely to experience lower earning potential throughout their lifetime.¹² It is important to emphasize that biological and social factors, including poverty and systemic inequalities, contribute significantly to adolescent pregnancy and these outcomes.^13,14 

Approximately 1 in 10 Ohio women experiencing an unintended pregnancy reported barriers to contraception as a contributing factor.¹⁵ Access to contraception and use of contraceptives are evidence-based interventions to reduce unintended pregnancies. Increasing the proportion of adolescents who use effective contraceptives is a national public health objective (Healthy People 2030).¹⁶ There is abundant evidence that innovative programs can successfully challenge existing contraceptive care models and improve outcomes. For example, the Upstream USA organization partners with health systems and public health entities to promote provider and staff training as well as equitable access and a person-centered approach to contraceptive care. Between 2014 and 2017, Title X clinics in Delaware partnered with Upstream USA in a statewide initiative to increase the use of effective contraception. Use of highly effective contraceptives increased, resulting in a 24% decrease in unintended pregnancies among female family planning clients aged 20 to 39 years in Delaware.¹⁷ In 2009, the Colorado Department of Public Health and Environment implemented the Colorado Family Planning Initiative, which supported statewide practices to improve contraceptive access. In the initial postintervention years, Colorado experienced a 50% reduction in teen birth and abortion rates.¹⁸ Subsequently, the intervention was associated with a population-level increase in bachelor’s degree attainment.¹⁹ 

In addition to changes in health care, adolescents need accurate information about sexual health to make informed decisions about their behaviors. Ample evidence supports that group-based comprehensive sexual health education (CSE) programs reduce adolescent sexual risk behaviors and adolescent pregnancies.^20,21 Components of CSE curricula include medically accurate information on normal development, consent, the benefits of delaying sexual activity, and the availability of contraception, along with barrier use and other strategies to prevent sexually transmitted infections. Effective programs are inclusive of diverse youth, foster healthy relationships, and engage educators, parents, and the community.²² CSE is recommended by major medical societies and the Centers for Disease Control and Prevention.^23–26 Of note, the Ohio Revised Code specifies that “venereal disease education” instruction must be abstinence based.²⁷ School districts in Ohio vary widely in the availability of CSE,^28,29 and most adolescents in the Columbus area had not been receiving CSE in their schools.

The NCH Pediatric Vital Signs (PVS) Initiative was launched in May 2018 when the birth rate among female adolescents aged 15 to 19 years (ie, teen birth rate) in Franklin County was 20.9 per 1000 in 2017. Our leadership team comprises a physician leader (Adolescent Medicine, Department of Pediatrics), quality improvement professionals (Center for Clinical Excellence, Partners For Kids), project managers (Department of Community Wellness), a sexual education community worker (Department of Community Wellness), an advanced practice nurse expert trainer (Adolescent Medicine, Department of Pediatrics), an associate medical director of a pediatric accountable care organization (Partners For Kids), and a hospital administrator (Department of Community Wellness). The aim of the PVS Preventing Unintended Teenage Pregnancy initiative has been to leverage internal strengths and collaborate with community partners to accelerate the decline in the teen birth rate in Franklin County, making the rate 14.6 by 2020, 8.6 by 2025, and 6.0 by 2030. Team members optimized existing relationships, partnerships, and activities and sought new opportunities and partnerships to reduce the teenage birth rate in our community.

Central Ohio has been home to committed community partners working to reduce infant mortality and address the connection between infant mortality and unintended teenage births for more than a decade. In 2014 the Greater Columbus Infant Mortality Task Force released a set of recommendations to reduce infant mortality and related racial disparities, resulting in the formation of a cross-sector public-private partnership called CelebrateOne whose mission is to reduce infant mortality and improve health equity in Franklin County.³⁰ CelebrateOne implements the Task Force recommendations by focusing on specific neighborhoods impacted the most by infant mortality. Given higher rates of infant mortality and preterm births among adolescents, the Task Force recommendations from 2014 and the CelebrateOne Strategic Plan of 2021 identified essential strategies to reduce unintended pregnancy, with special emphasis on improving access to and increasing the quality of reproductive health care.³¹ A key partner in this work is Ohio Better Birth Outcomes (OBBO), a collaborative representing Central Ohio’s hospital systems, public health, and federally qualified health centers. OBBO supports health care system–based interventions across the prenatal and perinatal periods and uses a quality improvement (QI) framework to implement CelebrateOne’s overarching strategies to improve reproductive health care.³² We collaborated extensively with CelebrateOne and OBBO to implement adolescent-focused interventions to reduce unintended teenage pregnancy.

In addition to partnering in community-wide efforts, NCH has invested in several internal initiatives to promote the prevention of unintended teenage pregnancies. These include an adolescent-friendly contraception clinic (BC4Teens) and a prenatal care clinic (Teen and Pregnant) that specialize in prenatal care for teens while providing education and contraceptive access to decrease unintended repeat births, both launched in 2014. In September 2018, NCH launched the Contraceptive Access QI Collaborative (CAC) to increase the use of prescription contraceptives among NCH adolescent patients and within NCH’s affiliated accountable care organization, Partners For Kids. Using a QI framework, the CAC supports measurement and shared learning across internal departments to improve access to contraceptive options for patients seen in participating NCH settings and ultimately contribute to the reduction of unintended teenage pregnancy in Franklin County.

Contemporaneous information about the intentionality of pregnancies in populations is unavailable at scale, and the measurement of pregnancies in a specific locality is challenging because many pregnancies do not result in live births and are difficult to count with precision. Accordingly, in this project our primary outcome/metric of focus is the birth rate. The measure’s numerator is births to female adolescents aged 15 to 19. The denominator is the number of female adolescents aged 15 to 19 residing in Franklin County (census data obtained from the Ohio Department of Health’s Population Data for Calculating Rates; National Vital Statistics System). We used QI science methodology to determine the significance of observed changes. To track progress in outcome measures and evaluate the impact of interventions over time, Shewhart control charts were updated monthly for birth rate and prescription contraceptive use. Control chart rules were applied to identify centerline shifts representing special cause variation (defined as performance change outside of what would be normally expected).³³ 

Through a comprehensive review of the literature to identify programs and policies that have effectively tackled unintended pregnancy, multiple interventions were identified as potential strategies to implement in Franklin County. An early (2019) version of this initiative’s Key Driver Diagram is shown in Figure 1. The key factors (ie, drivers) that we focused on between 2018 and 2022 were as follows: Community Partnerships to Design/Implement Solutions; Community Outreach Informs Youth and Adults; Community Agencies Educate Clients and Link to Services; Engaged & Trained Healthcare Providers, Trainees and Staff; Timely & Convenient Access to Reproductive Health Services; and Access to Comprehensive Sexuality Education. NCH follows the Institute for Healthcare Improvement Model for Improvement to monitor and assess QI work. For the PVS initiative and CAC, Shewhart control charts, updated monthly, are used to assess for significant changes in data trends.

In 2017, 64% of Franklin County’s female adolescents aged 15 to 19 years were patients at NCH. In light of this, we pursued a hospital-based intervention as a leading strategy for this initiative because of the potential reach of a hospital-based intervention. Moreover, QI collaboratives have been demonstrated to be an effective approach to improve a targeted medical practice.^34,35 Given the establishment of the NCH CAC just prior to the creation of the PVS initiative, the CAC was a leading intervention.

Another priority intervention focused on developing and promoting quality school-based sexual health education, in conjunction with our community partner CelebrateOne. The Sexual Health Education Partnership (SHEP) was created in 2018 and has worked to establish CSE programming for students in the Columbus City Schools and surrounding school districts. Conceived from a recommendation from the Infant Mortality Taskforce to provide CSE to reduce unintended teenage pregnancies in the Columbus area, SHEP was convened by CelebrateOne and comprised 4 local entities who were stakeholders in teenage pregnancy prevention (hospitals, public health department, and community-based agency). SHEP was tasked with researching best practices and standards for teaching sexual health and deciding which program would have the best outcomes in Franklin County. SHEP reviewed sexual health education curricula that had been evaluated and deemed by the US Department of Health and Human Services to be evidence-based.³⁶ The curriculum “Get Real: Sex Education That Works” had been implemented in more than 30 states, is designed for early adolescents, and had demonstrated effectiveness.^37,38 At 9 sessions per year, Get Real was shorter than most other curriculums and more adaptable to a school setting. In addition, support, training, and technical assistance were offered from its creators and publisher. Get Real had qualities that met the needs of the population that SHEP intended to serve and was selected as its CSE curricula.

The CAC was launched in September 2018 and is a QI collaborative internal to Nationwide Children’s Hospital. The leadership team of the CAC includes an adolescent medicine physician, a community wellness administrator, a quality improvement professional, and a project manager. During the preimplementation phase, the CAC leadership team identified shared decision-making, noncoercive and patient/family-centered care, and an evidence-informed approach as guiding values for this effort. The CAC focuses on promoting access to equitable, reproductive justice–informed, person-centered contraception care.

In this collaborative, a diverse set of internal departments work together to advance a common QI aim through their CAC-related QI projects. The CAC also functions as a place to address challenges common among partners, such as electronic health record modifications and policy barriers, and provides education on reproductive health topics. Initial CAC partners were invited to participate based on data indicating where female adolescent patients were presenting for care, as well as departments having done previous QI work in this area. Initial CAC partners were BC4Teens and Teen and Pregnant clinics, Pediatric and Adolescent Gynecology, Primary Care Pediatrics, Pediatric Hospital Medicine, Partners For Kids, and Pediatric Rheumatology. Pediatric Neurology and Fostering Connections (program for youth in foster care) joined later. In addition to the health care providers and QI professionals representing each partner entity, nursing administrators, a marketing professional, pharmacists, and a health informaticist were invited to participate. Monthly electronic health record extracts are used to measure contraceptive use. The primary aim of the CAC is to increase prescription contraceptive use among female adolescent patients aged 15 to 19 years from 27.1% in 2018 to 35% by 2025. Leading interventions have included increasing the number of hospital divisions that provide or refer for contraceptive counseling, advocacy for and technical support to operationalize changes to the NCH confidential contraception care to minors’ policy, and availability of contraceptive implant procedural training. To date, no QI projects within the CAC have moved into sustainment phase. Sustainment phase is a phase of implementation during which external implementation supports are removed and measurement continues. The work of the CAC is to integrate access to contraception counseling and contraceptives into routine adolescent health care. It is anticipated that projects, once having achieved their aim, will move into sustainment phase and receive less surveillance. Ideally, enhanced contraceptive access across the institution will become accepted as an updated standard of care.

In 2020, CelebrateOne and the City of Columbus signed an agreement for SHEP to provide Get Real to seventh- and eighth-grade students in Columbus City Schools. NCH provides project management and in-kind staff support and works to secure external funding to support these efforts. Implementation of Get Real began in January of 2020 with 5 schools and has since expanded to 21 middle schools and several charter schools, with the help of the existing partners and the funding support of a Department of Health and Human Services Office of Population Affairs Preventing Teenage Pregnancy grant.

Additional programmatic activities that this PVS initiative led or contributed to between 2018 and 2022 are listed in Table 1. We sought and received funding from community foundations (eg, Women’s Fund Central Ohio) and federal government (eg, Coronavirus Aid, Relief, and Economic Security Act), engaged diverse partners (eg, OBBO, CelebrateOne, local community college and federally qualified health centers, Partners For Kids) and engaged in numerous activities.

Given NCH’s commitment to family-centered care, NCH strongly values parental involvement in adolescents’ decisions about contraceptive use and actively engages parents and guardians in reproductive health decisions. In some cases, minor adolescents require access to confidential services, and lack of access to confidential care can be a barrier to adolescents’ use of contraceptives. When this initiative started, adolescents in the Columbus area could receive confidential contraception counseling and contraceptives at Title X–funded sites and at one large health system that allowed mature minors aged 15 years and older to consent to contraceptives. In November 2020, in dialogue with leaders of this PVS initiative, NCH aligned its confidential protected minor policy with other hospitals in the area to allow mature minor adolescents aged 15 years and older to consent to contraception (excluding intrauterine devices). In practice, use of this policy has not been common. Health care providers within NCH carefully assess the maturity of minor adolescents requesting confidential contraception care and encourage parent or guardian involvement when it is safe and appropriate.

Ohio is the only state without health education content standards for primary and secondary school students,³⁹ and schools that are interested in including sexual health as part of their curricula face unique challenges. Ohio legislation on “venereal disease education” requires instruction to emphasize sexual abstinence until marriage—an approach that has been found to be harmful and ineffective.^27,40 Columbus City Schools and the SHEP agreed on a plan to implement sexual health education in alignment with the best practices in the field.

Another policy aimed at reducing teen pregnancy is increasing the availability of intrauterine devices and contraceptive implants, also known as long-acting reversible contraceptives (LARCs). Cost concerns are a major barrier for adolescents’ utilization of these methods,⁴¹ and removing the cost barrier is associated with increased LARC use in adolescents.⁴² One state policy to reduce the cost burden of these methods for a subpopulation of women is to provide health insurance coverage of postpartum LARC insertion. For adolescents, this strategy is aimed at reducing the number of repeat teen births, which account for approximately 1 in 5 births to teens between the ages of 15 and 19 years.² In 2017, ORC 3727.20 was passed, requiring hospitals with a maternity unit to have the option for women to have LARC placement after delivery and the costs covered by Medicaid.⁴³ Although the policy does not directly impact those with private insurance, a study of Cleveland women found that once access was mandated by state law, there was an increase in immediate postpartum period LARC use among both privately and publicly insured women.⁴⁴ 

In July 2019, the Franklin County teen birth rate (births per 1000 female adolescents aged 15 to 19 years) demonstrated a centerline shift downward from 17.7/1000 to 15.4/1000 and remained at that rate through 2022 (Figure 2). Franklin County’s teen birth rate has seen a higher average percent decrease from 2015 to 2022 compared with 2 counties in Ohio with large metropolitan areas and similar demographics, Hamilton and Cuyahoga (Table 2; Figure 3).

The CAC has diligently implemented QI initiatives across multiple departments^45,46 and in 2022 saw a statistically significant improvement in the percentage of female adolescent patients who are prescribed contraceptives (Figure 4). In January 2019, there was a centerline shift from 27.1% to 29.1% of female patients aged 15 to 19 years using or prescribed a contraceptive at the time of their last visit at NCH. At the time of this centerline shift, more than 5000 eligible patients a month had visits at NCH. Immediately after Franklin County’s COVID-related stay-at-home order in March 2020, there was a dramatic decline in the number of eligible patient visits, with an associated increase in contraceptive coverage among those still attending medical appointments during this time. In April 2021, there was a centerline shift downward in contraceptive use among eligible patients from 29.1% to 26.5%, as most hospital departments and affiliated clinics resumed normal operations, resulting in a sustained increase in eligible patients to more than 6100 per month. Recently, there has been a centerline shift upward from 26.1% to 31.1% that occurred in March 2022. This increase is above the prepandemic percentage of female patients with contraceptive coverage and represents improvements in access to contraceptives within NCH.

During the 2019–2020 academic year, Get Real was implemented for seventh-grade students in 3 Columbus City School middle schools. In spring 2020, the curriculum was adapted to be administered virtually due to schools transitioning to 100% online because of the COVID-19 pandemic. Five schools implemented virtually during spring 2020 and 7 implemented virtually during fall 2020. During the 2021–2022 academic year, the program returned to in-person sessions in 19 middle schools for both seventh- and eighth-grade students. In the 2020–2021 academic year, 2837 students participated, and in the 2021–2022 academic year, 5338 students participated, an 88% increase from the previous year. Parents and guardians were able to opt out of having their children participate in the Get Real sessions; the opt-out portion for the 2020–2021 year was 2.0% and was 1.3% in 2021–2022. By the 2022–2023 academic year, 20 schools were implementing Get Real sessions. An evaluation of this intervention is in progress, and additional outcome data are not presently available.

An interdisciplinary team, in collaboration with community partners, engaged in evidence-based programmatic activities within a QI framework to reduce unintended teenage pregnancies in Franklin County, Ohio. The teenage birth rate in Franklin County has declined significantly since 2018 when the initiative began, and the percentage decline since 2015 is greater compared with other Ohio counties with large metropolitan areas and similar demographics. We have seen changes that support this decline in teenage births in our 2 primary program interventions: the percentage of female adolescent patients at Nationwide Children’s Hospital being prescribed or using a contraceptive has increased significantly through the efforts of the CAC, and students in 20 middle schools received CSE programming. The next steps for this initiative are to focus on reducing racial and ethnic disparities in teenage births in Franklin County, to expand evidence-based sexual health education programming to high school students, and to extend our work to rural counties. This expansion will need to be sensitive to diverse stakeholder needs and preferences, be informed by best available evidence about effective interventions, and engage community members. In addition, we will employ Implementation Facilitation, an approach rooted in the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) theoretical framework, as an implementation strategy.⁴⁸ Through a unique partnership of health care providers and systems, local and regional community partners, and government representatives, we hope to achieve demonstrable and sustained progress in reducing unintended pregnancies for adolescents living throughout Ohio.

CAC

Contraceptive Access Quality Improvement Collaborative

CSE

comprehensive sexual health education

LARC

long-acting reversible contraceptive method

NCH

Nationwide Children’s Hospital

OBBO

Ohio Better Birth Outcomes

PVS

Pediatric Vital Signs

QI

quality improvement

SHEP

Sexual Health Education Partnership