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Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20

Evaluation of an Integrated Services Program to Prevent Subsequent Pregnancy and Birth Among Urban Teen Mothers a

b

Loral Patchen CNM , Kathryn LeTourneau MSW MSPH & Erica Berggren MD

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a

Teen Alliance for Prepared Parenting Program , Center for Adolescent Women, MedStar Washington Hospital Center , Washington , DC , USA b

RTI International, Research Triangle Park , North Carolina , USA

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Department of Obstetrics and Gynecology, Division of MaternalFetal Medicine , Jefferson Medical College of Thomas Jefferson University , Philadelphia , Pennsylvania , USA Published online: 15 Aug 2013.

To cite this article: Loral Patchen CNM , Kathryn LeTourneau MSW MSPH & Erica Berggren MD (2013) Evaluation of an Integrated Services Program to Prevent Subsequent Pregnancy and Birth Among Urban Teen Mothers, Social Work in Health Care, 52:7, 642-655, DOI: 10.1080/00981389.2013.797538 To link to this article: http://dx.doi.org/10.1080/00981389.2013.797538

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Social Work in Health Care, 52:642–655, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2013.797538

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Evaluation of an Integrated Services Program to Prevent Subsequent Pregnancy and Birth Among Urban Teen Mothers LORAL PATCHEN, CNM Teen Alliance for Prepared Parenting Program, Center for Adolescent Women, MedStar Washington Hospital Center, Washington, DC, USA

KATHRYN LETOURNEAU, MSW, MSPH RTI International, Research Triangle Park, North Carolina, USA

ERICA BERGGREN, MD Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA

This article details the evaluation of a clinical services program for teen mothers in the District of Columbia. The program’s primary objectives are to prevent unintended subsequent pregnancy and to promote contraceptive utilization. We calculated contraceptive utilization at 6, 12, 18, and 24 months after delivery, as well as occurrence of subsequent pregnancy and birth. Nearly seven in ten (69.5%) teen mothers used contraception at 24 months after delivery, and 57.1% of contraceptive users elected long-acting reversible contraception. In the 24-month follow-up period, 19.3% experienced at least one subsequent pregnancy and 8.0% experienced a subsequent birth. These results suggest that an integrated clinical services model may contribute to sustained contraceptive use and may prove beneficial in preventing subsequent teen pregnancy and birth. Received December 29, 2012; accepted April 16, 2013. RTI International is a trade name of Research Triangle Institute. At the time the evaluation was conducted, Barbara W. Sugland was affiliated with the Center for Applied Research and Technical Assistance, Inc., in Baltimore, MD. The author passed away before this article was completed. Address correspondence to Loral Patchen, CNM, Director, Teen Alliance for Prepared Parenting Program, Center for Adolescent Women, MedStar Washington Hospital Center, 110 Irving Street, NW, East Building G-105, Washington, DC 20010. E-mail: [email protected] Medstar.net 642

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KEYWORDS adolescence, maternal, psychosocial intervention

INTRODUCTION

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Interventions to Prevent Subsequent Pregnancy and Birth Among Teen Mothers Pregnancy and childbirth among teen mothers represents a serious economic, social, and public health challenge. Subsequent teen childbearing further compounds the challenges that often ensue after a first teen birth (Klerman, 2004). Teen mothers with a second child are more likely to live in poverty and they complete fewer years of schooling than teen mothers who have only one child before reaching age 20 (Hoffman, 2006). Subsequent teen birth is also associated with delayed initiation of prenatal care, early birth, and delivering a low birth weight baby (Akinbami, Schoendorf, & Kiely, 2000; Chandra, Schiavello, Ravi, Weinstein, & Hook, 2002; Hueston, Geesey, & Diaz, 2008). Nationally, about 20% of all teen births among youth age 15 to 19 years represent second or higher order births (Schelar, Franzetta, & Manlove, 2007). Preventing subsequent pregnancy and birth is an emerging intervention focus for pregnant and parenting teens. Several factors have been identified that may be important for successful programming to reduce subsequent teen pregnancy: they should begin during the prenatal period and continue for at least 24 months, promote a strong relationship between the teen and her service providers, and provide individualized attention for the teen (Barnet et al., 2009; Kan et al., 2012; Klerman, 2004). Programs that provide tailored, individualized attention are more effective at reducing subsequent pregnancy than programs that implement standardized messages or services (Corcoran & Pillai, 2007; Barnet et al., 2009; Klerman, 2004), possibly because tailored programs are able to address teens’ personal ambivalence toward preventing subsequent pregnancy. Nonetheless, impacts on reducing subsequent pregnancy and birth rates have generally been modest. A meta-analysis including 16 evaluations of teen parenting programs found moderate effects on subsequent pregnancy over approximately 18 months of follow-up, but those effects disappeared at later follow-up time points (Corcoran & Pillai, 2007). A recent multi-site evaluation of federally funded demonstration projects found short-term reductions in repeat pregnancy (Kan et al., 2012). Recently, policies and programs serving pregnant and parenting teens have focused primarily on home visiting services for pregnant and parenting teens (Barnet, Liu, DeVoe, Alperovitz-Bichell, & Duggan, 2007; Barnet et al., 2009; Black et al., 2006; Koniak-Griffin et al., 2003; McDonell, Limber, & Connor-Godbey, 2007; Olds et al., 2004). Considerably less is understood about the effectiveness of service programs for teen parents in other settings

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(Klerman, 2004); however, there is emerging evidence that an integrated clinic-based approach can address adolescent parents’ complex needs (Cox, Buman, Woods, Famakinwa, & Harris, 2012) and are an important program setting for pregnant and parenting teens that merits further evaluation. Teen parents demonstrate improved outcomes when integrated and comprehensive care is delivered in a health care setting (Barnet, Duggan, & Devoe, 2003; Cox et al., 2012, Sarri & Phillips, 2004). Clinicians working in collaboration with social service providers using in integrated approach to care may be well-positioned to mitigate barriers to access and more fully serve the needs of this population (Woolf et al., 2005). Teen mothers need an array of health and community services, and they face multiple barriers to accessing services, such as obtaining transportation to multiple service locations, not knowing which providers to contact for services, and lack of coordinated communication among multiple providers (Hueston et al., 2008). Social workers and health care providers may be best-positioned to address these barriers when they work in collaboration and provide closely integrated services within the framework of a single program services model. Social workers may play a key role in fostering collaboration between clinical and community-based settings. Barnet et al. (2007) calls for evaluation of programs using innovative strategies to promote collaboration between health care and social service professionals. The present evaluation involves a program with both a hospital- and clinic-based site that targeted subsequent pregnancy and birth among teen mothers by providing integrated care and fostering multidisciplinary provider communication among health care and social service providers. Program services were informed by the principles of positive youth development. Community-based youth development programs aimed at preventing teen pregnancy typically develop specific youth competencies, use youth assets rather than deficits as a program starting point, mobilize the community to create positive goals related to youth, develop specific opportunities to promote youth strengths, and encourage youth to avoid risky behaviors (Gallagher, Stanley, Shearer, & Mosca, 2005). Increasing participants’ exposure to supportive and empowering environments creates myriad opportunities for a range of skill-building experiences (Roth & Brooks-Gunn, 2003). The positive youth development approach offers potential for building resiliency and social competencies as a means to reduce the behaviors that result in teen pregnancy (Gavin, Catalano, David-Ferdon, Gloppen, & Markham, 2010; Resnick, 2000) and it has been used in primary prevention efforts (Catalano, Hawkins, Berglund, Pollard, & Arthur, 2002). A comparison of effective and ineffective programs has demonstrated that teen parenting programs focusing on perceived deficits are less successful than programs focusing on health and well-being (Seitz & Apfel, 1999). Such an approach also may improve outcomes for pregnant and parenting teens.

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Program Services Clients at a hospital and a community-based health center participated in a teen program to prevent subsequent pregnancy and birth among teen mothers in the District of Columbia (DC). The pregnancy and birth rates among 15- to 17-year-olds in DC are among the highest in the nation (Guttmacher Institute, 2010). The program utilizes an integrated and comprehensive approach to preventing subsequent teen pregnancy and birth that relies upon the expertise of both health care providers and social workers. While located in a health care setting, this program ensures teens’ access to an array of qualified service providers across disciplines including social workers, youth development specialists, nurse health educators, nurse-midwives, and physicians; promotes strong relationships with program staff; and draws upon a youth development theoretical framework to promote developmental competencies through program activities. The model is intended to increase teen mothers’ motivation and ability to prevent subsequent pregnancy and birth. Program services are designed to address the teen mothers’ immediate need for medical care, while augmenting these services with activities to provide psychological, social, and emotional supports, as well as opportunities to assist with education continuation and completion and job skills development (Figure 1). Social workers provide care coordination through a case management approach, offer life skills support in individual and group settings, and work with the integrated team to identify and strengthen socialbehavioral supports for the teen parents. Social workers also coordinate services to ensure education continuation and completion as well as referrals for workforce development. A nurse educator also provides health education, including childbirth classes, breastfeeding and lactation support, and family planning education, in individual and group settings. These services are integrated with medical prenatal services. This model offers teens multiple points of access to an integrated array of services and providers. Rather than a linear service relationship, where the teen mother may first meet with a case worker and subsequently be referred to the next provider or service, it offers an integrated constellation of service partners through which the teen mother can obtain services. Program services may be provided in hospital-based outpatient health centers and community-based health centers. Participants enroll during pregnancy and receive prenatal care and labor and delivery services, followed by family planning services for at least 24 months after delivery. The program staff provides individualized services that identify and coordinate a mix of medical, social service, education, and employment supports through direct service provision and referrals for additional services as indicated. Participants have access to both individual supports and group-based activities to build developmental competencies that increase

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TAPP Theory of Change

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Reduced Subsequent Fertility for Teens

Attitudes Supportive of Avoiding Pregnancy

Increased Social Support and Self-efficacy

Developmental Competencies, Supports, and Opportunities

Avoidance of Sex Contraception and Condom Use

Access to High Quality Services: Maternal and Child Medical Services, Youth Development Services, Multidisciplinary Intensive Case Management FIGURE 1 Theory of change model for integrated services program.

motivation and ability to prevent subsequent pregnancies. At program intake, a staff member completes an individual needs assessment for each participant, which is updated every 3 months to ensure that support services are coordinated for the duration of program enrollment. Participants work with a medical provider (either a midwife or physician), a licensed social worker, and at least one other staff member whose professional training may include counseling, youth asset building, or health education. Staff members meet weekly during case conference to review the individual service plans. Individual service plans recognize participant goals, identify service needs, and track progress. The program aims to reduce subsequent pregnancy and birth through the development of personal competencies and increased access to social support.

METHODS Design and Sample The program’s goals were (1) to prevent subsequent pregnancy and birth among participants and (2) to promote contraceptive utilization after delivery. Outcomes were measured using medical record data from pregnancy tests, birth information, and contraceptive information at 6-month, 12-month, 18-month and 24-month follow-up. The rate of subsequent birth

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after delivery was compared to aggregated data for DC. The evaluation was approved by the Institutional Review Board of the participating hospital. All participants in the program between February 2003 and April 2005 with no more than 4 months of prior program participation were eligible to enroll in the evaluation. To enroll in the evaluation, participants had to complete a social work intake assessment, an initial medical evaluation, and have at least one follow-up visit with complete medical record information after intake. Out of 329 eligible program participants, 232 (70.5%) participated in the evaluation and completed the intake assessment. Among participants, 12 teens did not meet the inclusion criteria, 13 transferred their care prior to delivery, 14 did not continue participation after delivery, and 6 had incomplete medical record data about subsequent pregnancy and birth by 24-month follow-up. These participants were excluded from the analysis, yielding a sample of 187 teens. Follow-up data were available for 70% of participants at 18 months after delivery and 56% of participants at 24 months after delivery. Participants’ average age of first intercourse was 14.6 years, and they averaged one sexual partner within the year prior to intake, although the number of past-year partners ranged from 0 to 20 (Table 1). Just under one quarter (23.5%) of the participants had been previously diagnosed with one or more sexually transmitted infections at the time of intake. Approximately one fifth (19.8%) had been pregnant at least once prior to the pregnancy at intake, and 5.9% already had at least one child at enrollment. TABLE 1 Evaluation Participants’ Sexual, Birth, and Pregnancy History, Overall and by Site Overall Characteristic Average age at first intercourse (years) (range = 9–18 years) Average number of current sexual partners (range = 0–20 partners) Average number of sexual partners in past year (range = 1–20) Sexually transmitted infection (STI) history Never diagnosed with an STI Diagnosed with 1 STI Diagnosed with 2 or more STIs One or more prior births Pregnancy history 1 pregnancy 2 or more pregnancies Sexual trauma history—reported sex against her will, rape, or sexual abuse

CHC

N

%

Mean

n

177



14.6

180 180

%

HHC

Mean

n

%

69

15.0

108

14.3

1.0

68

0.9

112

1.1

1.6

70

1.4

110

1.7

187 76.5 187 19.8 187 3.7 187 5.9

73 87.7 73 11.0 73 1.4 73 8.2

114 114 114 114

69.3 25.4 5.3 4.4

187 80.2 187 19.8 181 19.3

73 84.9 73 15.1 70 11.2

114 114 111

77.2 22.8 24.3

CHC = community-based health center, HHC = hospital-based outpatient health center.

Mean

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Nearly two thirds of the participants were enrolled at the hospital-based health center (HHC), with the remainder being enrolled at the communitybased health center (CHC). Overall, the majority of participants (61.3%) were African American (Table 2). On average, participants were 16.2 years old at enrollment, with ages ranging from 12 to 18, and 36.9% were from families receiving public assistance. Over half (56.1%) lived in a single parent home. About half had a mother who was a teen parent (52.4%), and 40.1% reported having a sibling who was a teen parent. Several participant characteristics differed by program site. Participants who received services from the community-based health center (CHC) were predominantly Hispanic, whereas participants at the HHC were TABLE 2 Demographic Characteristics of Evaluation Participants, Overall and by Site Overall Characteristic Race/Ethnicity Black or African American Hispanic White (non-Hispanic) Other Age (range = 12–18) Family Receives Public Assistance Educational Attainment (last grade completed)

Evaluation of an integrated services program to prevent subsequent pregnancy and birth among urban teen mothers.

This article details the evaluation of a clinical services program for teen mothers in the District of Columbia. The program's primary objectives are ...
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