Intensive case management for pregnant & parenting teens

There is some evidence that intensive case management reduces repeat pregnancies among teen mothers who are Black and/or Hispanic while they participate in the intervention (Tolma 2014, Blank 2010, Kan 2012, Lewis 2012, McDonell 2007). Additional evidence is needed to confirm longer term effects and determine which aspects of case management are most effective.

Case management services provided by culturally matched, school-based social workers, combined with comprehensive health services and education by peers has been shown to reduce repeat pregnancies among adolescents who are Black and live in urban areas (Blank 2010). Case management programs may also strengthen support networks, improve academic outcomes, and increase high school completion rates among teenage mothers who are Black and live in rural areas (McDonell 2007). Multi-component school-based programs which include case management may increase attendance, credits earned, and graduation rates among pregnant and parenting teen mothers, particularly those who are Black (US DHHS-Asheer 2017), though impacts on teen fathers have not been studied (Asheer 2020). Elements of one such program suggest that successful school-based programs should be well-defined but flexible to meet the needs of both the students and the school, work with partners in the community to provide services, hire committed staff, and build a collaborative culture with program and school staff (Asheer 2020).

Effective programs usually provide intense one-on-one support (Harding 2020); less intensive case management services may not have the same effect on repeat pregnancy rates (Finigan-Carr 2015). Efforts to shift existing programs to more intensive, structured formats should account for participants’ goals, ensure case managers have sufficient training and allow for flexibility in implementing the new program version in order to meet participants’ needs (Asheer 2020a).

Programs can serve teenage fathers as well as mothers but face unique challenges. Teenage fathers, as non-birthing parents, are harder to identify, and societal pressure to be employed to support their child or family may interfere with finishing their own education or restrict the time they have available to participate in programs. To increase participation, experts suggest hiring male staff, developing a welcoming environment for fathers, offering father-specific services, and recruiting from places teen fathers frequent (Niland 2020). Research suggests that programs to reduce repeat pregnancy among pregnant and parenting teens are more likely to be effective when they include easy access to services, contraceptive education (Rowlands 2010), home visiting (Cochrane-Lopez 2015, Rowlands 2010), and tailored messages (Kan 2012), and when programming is offered individually rather than in group formats (Klerman 2004). For case management programs that include home visits, more frequent visits appear to reduce repeat pregnancy more effectively than usual care (Kan 2012, Blank 2010) and can also increase use of long-acting reversible contraception (LARCs) (Kan 2012).

Engagement and retention strategies may include supportive relationships with staff, social activities, and peer support groups; concrete supports such as child care and transportation; and having one point of contact coordinate services for each family (Egan 2020). A pilot study in Philadelphia suggests the inclusion of phone, text, video calling, and social media in a case management framework has the potential to help connect with difficult to reach clients, increasing responsiveness and flexibility, but may add challenges regarding boundary setting, rapport building, and pose data security concerns (Kang 2020).

Comprehensive clinic-based programs have the potential to decrease disparities in rapid repeat birth rates between teenage parents who are from systematically disadvantaged backgrounds, including those who are Black, low income, or from rural areas, and those who are from more advantaged backgrounds based on the intervention design.

Approximately 1 in 6 births to 15 to 19-year-olds are repeat births (Margolis 2020). While the rate of repeat births among teens decreased from 2004 to 2015 (CDC MMWR-Dee 2017), rates of repeat pregnancy are higher among teens from low income or minoritized populations (Frederiksen 2018), with higher rates of repeat births in rural counties than in urban ones (CDC MMWR-Hamilton 2018). Rates also vary by state (Frederiksen 2018, CDC MMWR-Dee 2017), along with effective postpartum contraceptive use (Frederiksen 2018). Available evidence suggests some programs may not be as effective for adolescents from lower income backgrounds as for those from higher income backgrounds (Corcoran 2007).

Pregnancy rates are also higher among teens in foster care (King 2022) and among teens with special needs (Mathematica-Goesling 2020). Programs often underserve these populations, with multiple barriers to service use. A study among pregnant and parenting teens with foster experience suggests the need for navigation services, information and data sharing across systems and programs, and increased diversity in the workforce, whose members should be trained on both diverse communities and implicit bias against teen parents (Villagrana 2023, Villagrana 2022). Teen parents from minoritized groups may also have trouble trusting providers, due to past efforts by institutions to reduce or eliminate births in those populations, as well as perceived stigmatization and judgement based on stereotypes around teen pregnancies and births (Hubel 2020).

Research should better address the changing context of adolescent pregnancy and births, including availability of highly effective contraceptives in the form of LARCs, Medicaid expansion and insurance changes increasing access to birth control, and shifting abortion policies. While increased availability and increased effectiveness of contraceptives have the potential to reduce repeat pregnancy and birth among teens, abortion restrictions could increase these rates (SmithBattle 2017).

Teenage pregnancy was not regarded as a major problem until the mid-1960s (Vinovskis 2003), when early marriage rates began declining, particularly among teenagers who were Black or from other racially minoritized groups (Furstenberg 2007), leading to an increase in out-of-wedlock births (Vinovskis 2003). In the late 1970s, policymakers framed these teen birthrates as an “epidemic,” even though teen birth rates were in decline (Vinovskis 2003). Programs for pregnant and parenting teens began emerging in the U.S. in the 1970s, to reduce taxpayer costs and improve maternal and child outcomes (SmithBattle 2017), as young single mothers were viewed as a social problem, along with political concerns about rising welfare costs (Vinovskis 2003).

Teen pregnancy rates have been declining in the U.S. since 1991 but are still higher than in other high-income countries. Racial and geographic disparities also exist within the U.S. (CDC-About teen pregnancy): pregnancy rates are three times higher among Black and Hispanic teens than whites in some states (Mathematica-Goesling 2020), and birth rates remain higher for young women of color nationwide (KFF-Hill 2022, Fuller 2018, CDC-About teen pregnancy), particularly in the South and Southwest (Fuller 2018). Teen pregnancy rates among those who have been in foster care have also not declined at the same rate (King 2022).

Teen mothers today continue to experience disadvantages, often coming from backgrounds characterized by childhood adversity, including poverty, instability, violence, chronic stress, and trauma (SmithBattle 2017). Adolescent mothers are more likely to suffer maternal complications (CDC-Woodall 2020), drop out of school, have more limited job prospects, and live in poverty ((Harding 2020), SmithBattle 2017), and repeat births can increase these disadvantages (Frederiksen 2018). However, some experts suggest studies of teen parents’ poor outcomes do not account for the context of many teen parents’ lives, and that the same factors that increase the risk of teen pregnancy are largely responsible for these outcomes (SmithBattle 2017).

Teen pregnancies are associated with higher rates of neonatal and infant mortality, with the highest rates among infants born to Black teens (CDC-Woodall 2020). While the risk of infant mortality declined between 1996 and 2019 for most racialized groups and geographies, it has not changed significantly for infants born to teens who are Black or Hispanic in rural counties (Woodall 2023). Teen pregnancies also have a higher risk of complications including preterm birth and low birthweight (CDC-Woodall 2020). These risks are higher for infants born to teens who are already parents (Woodall 2023, Frederiksen 2018). Children born to teenage parents are also more likely to have academic and behavioral issues when they are older (Klerman 2004).

Global initiatives, such as the United Nations’ Sustainable Development Goals, advocate for individuals to access their preferred contraceptive methods as part of their human rights. Such initiatives note the health and other related benefits, such as education and expanded opportunities for women, that come with access to comprehensive sexual and reproductive health services (WHO-SDG 3.7).

• Where can adolescents in your community access the necessary knowledge and resources to prevent repeat pregnancy?
• How are existing programs trying to be culturally and linguistically appropriate, and inclusive of all gender identities and sexual orientations? Are there any systematic barriers to accessibility?
• Who can you partner with in the community to determine what type of programming may be useful and accepted?
• How do your programs address both clinical and non-clinical needs within your patient community?

Case management programs are available at locations across the country. Some programs are at the state level, such as the Massachusetts Pregnant and Parenting Teen Initiative, which provides services in 13 different communities (MPPTI). In New Mexico, the school-based Graduation Reality and Dual-role Skills (GRADS) program is a multi-component program that can include case management, connections to health and child care, classroom intervention, and support for teen fathers (NM PED-GRADS).

The New Heights program, based in 12 Washington, D.C. high schools (New Heights) where approximately 10% of female students may be parenting (Asheer 2020), provides supports to expectant and parenting students of all genders through case management, educational workshops, and an incentive program to earn things for their children (New Heights).

Lifeworks’ Teen Parent Services and the Tandem Teen Prenatal and Parenting Program provide comprehensive case management services for teenage parents in Austin, Texas. Lifeworks is a nonprofit offering comprehensive social services for youth and families; their Teen Parent Service offers case management, connections to community resources, parenting groups, and support in school and community settings (Lifeworks-TPS). Tandem is an interagency collaboration led by People’s Community Clinic that provides pregnant and parenting teens and their children with medical, mental health, education, vocational, and social support (PCC-Tandem).

Healthy Teen Network - Healthy Teen Network (HTN). Making a difference in the lives of teens and young families.

MCH Journal-PAF - Harding JF, Zief S, Farb A, Margolis A, eds. Supporting expectant and parenting teens: The pregnancy assistance fund. Maternal and Child Health Journal. 2020;24(2 Suppl):S57-242.

* Journal subscription may be required for access.

Asheer 2020 - Asheer S, Zief S, Neild R. Roadmap for effective school-based practices to support expectant and parenting youth: Lessons from the New Heights program in Washington, D.C. Maternal and Child Health Journal. 2020;24(Suppl 2):S125-S131.

Asheer 2020a - Asheer S, Keating B, Crowley J, Zief S. Implementing case management with positive youth development to empower young mothers in California. Maternal and Child Health Journal. 2020;24(Suppl 2):S141-S151.

Blank 2010* - Blank L, Baxter SK, Payne N, Guillaume LR, Pilgrim H. Systematic review and narrative synthesis of the effectiveness of contraceptive service interventions for young people, delivered in educational settings. Journal of Pediatric and Adolescent Gynecology. 2010;23(6):341-351.

CDC MMWR-Dee 2017 - Dee DL, Pazol K, Cox S, et al. Trends in repeat births and use of postpartum contraception among teens — United States, 2004–2015. Morbidity and Mortality Weekly Report (MMWR). 2017;66(16):422-426.

CDC MMWR-Hamilton 2018 - Hamilton BE, Ely DM. Repeat birth rates for teens, by urbanization level of county — National Vital Statistics System, 2007–2016. Morbidity and Mortality Weekly Report (MMWR). 2018;67(35):998.

CDC-About teen pregnancy - Centers for Disease Control and Prevention (CDC). About teen pregnancy.

CDC-Woodall 2020 - Woodall AM, Driscoll AK. Racial and ethnic differences in mortality rate of infants born to teen mothers: United States, 2017-2018. Data Brief no. 3761. Centers of Disease Control and Prevention (CDC), National Center for Health Statistics. 2020.

Cochrane-Lopez 2015* - Lopez LM, Grey TW, Hiller JE, Chen M. Education for contraceptive use by women after childbirth. Cochrane Database of Systematic Reviews. 2015;(7):CD001863.

Corcoran 2007* - Corcoran J, Pillai VK. Effectiveness of secondary pregnancy prevention programs: A meta-analysis. Research on Social Work Practice. 2007;17(1):5-18.

Egan 2020 - Egan J, Bhuiya N, Gil-Sanchez L, Campbell S, Clark J. Engaging expectant and parenting adolescents: Lessons from the Massachusetts Pregnant and Parenting Teen Initiative. Maternal and Child Health Journal. 2020;24(Suppl 2):S191-S199.

Finigan-Carr 2015* - Finigan-Carr NM, Murray KW, O’Connor JM, et al. Preventing rapid repeat pregnancy and promoting positive parenting among young mothers in foster care. Social Work in Public Health. 2015;30(1):1-17.

Frederiksen 2018 - Frederiksen BN, Rivera MI, Ahrens KA, et al. Clinic-based programs to prevent repeat teen pregnancy: A systematic review. American Journal of Preventive Medicine. 2018;55(5):736-746.

Fuller 2018* - Fuller TR, White CP, Chu J, et al. Social determinants and teen pregnancy prevention: Exploring the role of nontraditional partnerships. Health Promotion Practice. 2018;19(1):23-30.

Furstenberg 2007 - Furstenberg FF. Chapter 1: The history of teenage childbearing as a social problem. In: Destinies of the Disadvantaged: The Politics of Teen Childbearing. New York: Russell Sage Foundation; 2007.

Harding 2020 - Harding JF, Knab J, Zief S, Kelly K, McCallum D. A systematic review of programs to promote aspects of teen parents’ self-sufficiency: Supporting educational outcomes and healthy birth spacing. Maternal and Child Health Journal. 2020;24(Suppl 2):S84-S104.

Hubel 2020* - Hubel GS, Moreland AD. What do adolescent parents need to prevent repeat pregnancy? A qualitative investigation. Vulnerable Children and Youth Studies. 2020;15(1):21-31.

Kan 2012* - Kan ML, Ashley OS, LeTourneau KL, et al. The adolescent family life program: A multisite evaluation of federally funded projects serving pregnant and parenting adolescents. American Journal of Public Health. 2012;102(10):1872-8.

Kang 2020 - Kang N, Patrick M, Williams F, et al. Using technology to support expectant and parenting youth through case management: Lessons learned in the field. Maternal and Child Health Journal. 2020;24(Suppl 2):S200-S206.

KFF-Hill 2022 - Hill L, Artiga S, Ranji U. Racial disparities in maternal and infant health: Current status and efforts to address them. KFF. 2022.

King 2022 - King B, Shpiegel S, Grinnell-Davis C, Smith R. The importance of resources and relationships: An introduction to the special issue on expectant and parenting youth in foster care. Child and Adolescent Social Work Journal. 2022;39(6):651-656.

Klerman 2004 - Klerman LV. Another chance: Preventing additional births to teen mothers. Washington, D.C.: The National Campaign to Prevent Teen Pregnancy. 2004:1-58.

Lewis 2012* - Lewis CM, Faulkner M, Scarborough M, Berkeley B. Preventing subsequent births for low-income adolescent mothers: An exploratory investigation of mediating factors in intensive case management. American Journal of Public Health. 2012;102(10):1862-5.

Lifeworks-TPS - Lifeworks Youth & Family Alliance. Teen Parent Service (TPS).

Margolis 2020 - Margolis A, Rice T, Banikya-Leaseburg M, et al. Meeting the multifaceted needs of expectant and parenting young families through the Pregnancy Assistance Fund. Maternal and Child Health Journal. 2020;24(Suppl 2):S76-S83.

Mathematica-Goesling 2020 - Goesling B, Wood RG. Promoting lasting, equitable change by reaching youth in need. Princeton: Mathematica Policy Research (MPR); 2020.

McDonell 2007* - McDonell JR, Limber SP, Connor-Godbey J. Pathways teen mother support project: Longitudinal findings. Child and Youth Services Review. 2007;29(7):840-55.

MPPTI - The Massachusetts Pregnant and Parenting Teen Initiative (MPPTI). MPPTI aims to increase life opportunities and enhance family stability among young families.

New Heights - District of Columbia Public Schools. New Heights Program for expectant and parenting students.

Niland 2020 - Niland K, Selekman R. Challenges and successes of Pregnancy Assistance Fund programs supporting young fathers. Maternal and Child Health Journal. 2020;24(Suppl 2):S178-S182.

NM PED-GRADS - New Mexico Public Education Department (NM PED). Expecting and parenting youth: New Mexico GRADS (Graduation, Reality, And Dual-role Skills).

PCC-Tandem - People's Community Clinic (PCC). Tandem Teen Prenatal and Parenting Program.

Rowlands 2010* - Rowlands S. Social predictors of repeat adolescent pregnancy and focused strategies. Best Practice & Research Clinical Obstetrics Gynecology. 2010;24(5):605-616.

SmithBattle 2017* - SmithBattle L, Loman DG, Chantamit-o-pas C, Schneider JK. An umbrella review of meta-analyses of interventions to improve maternal outcomes for teen mothers. Journal of Adolescence. 2017;59(1):97-111.

Tolma 2014* - Tolma EL, Stoner JA, McCumber M, et al. Longitudinal evaluation of a teenage pregnancy case management program in Oklahoma. Journal of Family Social Work. 2014;17(5):457-479.

US DHHS-Asheer 2017 - Ahseer S, Bukander P, Deke J, Worthington J, Zief S. Raising the bar: Impacts and implementation of the New Heights program for expectant and parenting teens in Washington D.C. Washington, D.C.: U.S. Department of Health and Human Services (US DHHS), Office of Adolescent Health; 2017.

Villagrana 2022 - Villagrana KM, Carver AT, Holley LC, et al. ‘You have to go hunting for information’: Barriers to service utilization among expectant and parenting youth with experience in foster care. Child and Family Social Work. 2023;29:571-583.

Villagrana 2023 - Villagrana KM, Carver AT, Holley LC, et al. "You have to go hunting for information": Barriers to service utilization among expectant and parenting youth with experience in foster care. Child and Family Social Work. 2023;29(2):571-583.

Vinovskis 2003* - Vinovskis MA. Historical perspectives on adolescent pregnancy and education in the United States. The History of the Family. 2003;8(3):399-421

WHO-SDG 3.7 - World Health Organization. (2024, December 13). SDG target 3.7: Sexual and reproductive health. The Global Health Observatory. Retrieved December 17, 2024.

Woodall 2023* - Woodall AM, Driscoll AK, Mirzazadeh A, Branum AM. Disparities in mortality trends for infants of teenagers: 1996 to 2019. Pediatrics. 2023;151(5):e2022060512.