Evidence-based commissioning

Monetary incentives increased participation by adolescent mothers in peer support groups, but had no effect on repeat pregnancy rates

Stevens-Simon C, Dolgan J E, Kelly L, Singer D. The effect of monetary bzcentires atzdpeer support groups on repeat adolescent pregnancies. JAMA 1997; 277:977-982

Objective

To evaluate the effect of financial incentives on the incidence of repeat pregnancy.

Setting

Denver, CO, USA.

Method

Randomised controlled trial

Literature review

No explicit strategy; 37 references, seven on repeat pregnancy prevention.

Intervention

286 females younger than 18 years, were randomized to four interventions: t) Monetary incentive and peer support group; 2) Peer support group only; 3) Monetary

incentive only; 4) No intervention. The 'Dollar-a-Day Program' provided an incentive for teenage mothers to meet and converse informally about their present and future concerns in an adult-led peer group. The advantages of delaying further childbearing and the costs of not doing so were emphasized during every meeting, although not explicitly. Guest speakers were invited and special outings to restaurants and parks were arranged with free contraceptive services and information about jobs and preparation for work training.

Outcome measures

1 Participation in peer group activity 2. Repeat pregnancy.

Results

The monetary incentive increased

© Fl~court Brace and Company Ltd 1998

participation in the program with 50% of those offered an incentive participating compared with 9% in the control group. Those attending the peer support group had a rate of second pregnancies which was not sigtdficantly different from the rate of those who did not attend.

Authors' conclusions

The authors conclude that 'like prior investigators who have used more conventional intervention strategies,' they had no significant effect on repeat conception. In the group sessions, they had tried to promote 'future-orientated career planning' to support the benefits of delaying additional pregnancies, but without success, and the 'distant hope of financial and marital security,' which they had tried to foster in the group appeared to be insignifcant beside the perceived benefits of repeat childbearing. They do, however, cite other studies in which one-to-one training and home-based mentoring provide encouraging results.

The authors believe that peer support groups and incentive programs have benefits although the impact of these interventions may be overwhelmed by realities of the daily life of the young people, and 'speculate' that if this type of support program is not accompanied by substantial changes in the environment that make early and repeated childbearing an attractive option, the rate of adolescent pregnancy is likely to continue to increase.

:OMMENTAR~

Adolescent pregnancy presents a significant problem for adolescent parents, the child and society in general. In addition, a growing number of pregnant teenagers are choosing to keep their babies rather than giving them up for adoption or seeking abortions. Adolescent mothers are at risk of physical complications during pregnancy. They are also less likely to complete school, have reduced opportunit ies for employment and, increased reliance on state welfare. The children born to teenage mothers are at increased risk of sudden infant death syndrome, prematurity, injuries, abuse, developmental delays, poverty, poor housing and nutri t ion. At a societal level, teenage childbearing has enormous social and financial costs. It is important to design and evaluate interventions to reduce the risk of a repeat

pregnancy andlor to improve parenting skills.

That this was a randomized-control led tr ial which demonstrated an ineffective intervention in relation to its primary goal of pregnancy prevention is useful information for care providers, payers and purchasers, even w i thou t cost-analysis. However, for those agencies which are pursuing the goal of preventing repeat teenage pregnancies, there are some tantal izing effects such as the increased rate of participation in the group setting. Coupled wi th the authors' interpretat ion that this contact could provide the setting for other types of interventions directed at social determinants, one would look for evidence of this type in other studies. In the final analysis, however, the broader population-based interventions around social issues of education, employment and housing need a further look.

Evaluation of the information provided in a structured abstract wil l l ikely vary according to perspective. Policy-makers are not only concerned wi th effectiveness of a program, they also need to consider safety, acceptability and appropriateness for their community. I was concerned that this abstract did not give socio-economic characteristics of the participants, but the inference would be that this was a disadvantaged group. As a public health policy-maker, this raised some concerns in relation to equitable t reatment and acceptability which would also concern pat ient representatives.

Dr Marilyn James Medical Officer of Health

Regional Municpafity of Hamilton-Wentworth Ontario, Canada

MARCH 1998 EVIDENCE-BASED HEALTH POLICY AND MANAGEMENT 17