Beth Barnet, MD1, Adrienne Williams, PhD1, Margo DeVoe, MS1, Ed Pecukonis, Ph.D.2,

Melanie A. Gold, DO3 Anne K. Duggan, ScD4

1 University of Maryland Department of Family & Community Medicine2 University of Maryland School of Social Work

3 University of Pittsburgh Department of Pediatrics, Pittsburgh PA4 Johns Hopkins Department of Pediatrics

Motivational Intervention toMotivational Intervention toReduce Rapid Repeat Births in Reduce Rapid Repeat Births in

Adolescent Mothers: Adolescent Mothers: A Community-based Randomized TrialA Community-based Randomized Trial

Project Funding Project Funding

• Grant APRPA006010 from the Department of Health and Human Services, Office of Population Affairs, Office of Adolescent Pregnancy Programs

• Cooperative Agreement MM-0452-03/03 from the Centers for Disease Control/Association of American Medical Colleges

Teenage Births in U.S.

•Births to teens increased in 2006 & 2007

•435,436 births in 2006 to 15-19 year olds

•>1/4 have another birth within 2 years

•Adverse outcomes increase with a 2nd birth• Greater school dropout• Long term poverty, welfare dependence• Higher levels of stress & poor mental health • Cognitive and behavioral problems in the kids• Substantial public sector costs

Factors Associated with Rapid Factors Associated with Rapid Repeat Pregnancy/BirthRepeat Pregnancy/Birth

• Age (mixed findings)

• Race (African-American & Hispanic > White)

• Partner relationships– married, living with partner > non-married

• Low cognitive ability

• Type/use of contraception

• Depression?

Many well designed interventions to reduce 2nd and higher order teen births

• Settings: clinic and community

• Service providers: broad range

• Interventions: – health education– birth control– home visiting– social support, family support – service coordination– life skills– employment training – monetary incentives

modest impact

…perhaps because of insufficient attention to

motivation and support for

behavior change

Motivational Interviewing

• Empirically-validated counseling style

• Effective helping people change negative behaviors

• Employs empathy and reflection to raise awareness of discrepancies between stated goals and actual behaviors– Facilitates the individual’s own motivation

to change

Can MI be used to facilitate motivation and behavior

change for repeat pregnancy prevention in teens?

Research Question

ObjectivesObjectives

• To conduct an intervention aimed at reducing adolescent repeat birth

– Grounded in theory – Explicit focus on motivation– Address malleable proximate risk factors– Informed by our prior home visiting experience – Rigorously evaluated

• To examine effectiveness in real world setting

– Baltimore’s teen birth rates among highest in U.S.

CAMICAMIComputer Assisted Motivational InterventionIntervention

• Customized software - algorithms based on the Transtheoretical Model

• Questions measure reproductive health risks & behaviors– Computes readiness to use

contraception and condoms– Summary printout of pregnancy and

STI risk

• 20-minute stage-matched motivational interviewing– begins after delivery – repeated every 3 months until index

child turns 2 years

BRIDGES Intervention Timing and Components

• Prenatal (enrollment) through 2 years postpartum (completion)

• Biweekly to monthly home visits– Parenting curriculum with child age-&-

developmentally- specific modules

– Case management

– Teen and family support

– Outreach to fathers

• CAMI conducted every 4th home visit

Target Population

Intervention Component / Service Use Proximal Outcomes Distal Outcomes Objective

Pregnant and mothering teenage girls < 18 years at enrollment Baby’s fathers – if teen mother agrees

Computer Assisted Motivational Intervention Assess risk for repeat pregnancy & STIs Assess motivation to avoid repeat pregnancy &

STIs Assess stage of change for consistent

contraception and condom use Use MI to promote use of effective

contraception and condoms

Care Management – Teen Mother Connect teen & child to primary care medical

home Track & promote primary care appointment-

keeping Provide information to primary care provider(s)

(e.g. teen’s contraception use, depression) Coordinate the involvement with community

mental health, if needed

Social Support via a Caring Continuity Relationship

Teen Mother consistent use of

effective contraception

consistent condom use

Reduce repeat

pregnancy and

repeat birth

within 2 years of

index birth

Baby’s Father support for

partner’s contraception use

consistent condom use Baby’s Father

Increase perceived risk & costs of rapid repeat fathering

Improve communication and reduce conflict with partner

Teen Mother Improve motivation to

use contraception & condoms

Forward movement along stage of change continuum for contraception and condom us

Improve communication & reduce conflict with partner

Logic Model for CAMI Intervention

Compare 2 Interventions

CAMI-Only

CAMI+

Enhanced Home Visiting

1. Does a CAMI-only intervention or a CAMI+ intervention (enhanced home visiting) reduce repeat pregnancy in teen mothers?

2. Do they differ in effectiveness?

Secondary Objective

• To investigate risk factors along the causal pathway to adolescent repeat pregnancy – i.e. - is depression is a risk factor?

Intervention Staff & CAMI Training

• African American women from local communities

• Equivalent caseloads for CAMI+ and CAMI-only home visitors

• 2 ½ days initial interactive training– Motivational interviewing– Use of CAMI program

• Rating of videotaped CAMI session with standardized patient

• Proficiency maintenance - audio-taped sessions

Participants and Setting

• Eligibility– Pregnant teen, > 24 wks, < 18 years– Informed consent from teen and parent/guardian– Teen completed baseline assessment– Random assignment

• Recruitment – from 5 Baltimore clinics providing prenatal

care to low income women

• Home & community-based intervention

Design & Study FlowRecruitment between February 2003 and April 2005

Intervention Phase completed October, 2007

Outcome MeasurementTiming and Sources

• Data collected at 1-and-2 years postpartum

• Two data sources:– Structured interview assessing rpt preg. & birth – Birth certificates (baseline consent from teen)

• Successful match for entire cohort of 235

• Main Outcome – % with a repeat birth by 24 months

• Overall and by group– Cox proportional hazards ratios for time (months) to repeat birth

AnalysisAnalysis

• Intention to Treat (ITT)

• Complier Average Causal Effect (CACE )– Most interventions do not achieve full participant

adherence

– With variable adherence, ITT may produce biased estimates of intervention causal effects

•Adherence is measured only in the intervention group

•Control group participants who would have adheredwho would have adhered if assigned to the experimental group are not identified

•As a result, treatment effects are under-estimated

CACE AnalysisCACE Analysis2-step iterative procedure

1. Define intervention adherence “receipt > 2 CAMIs”

• Identify baseline characteristics of intervention adherers and assign a weight of 1

• Use these adherence characteristics to compute the probability of adherence for individuals in the control group

2. Outcomes for adherers in the intervention group are compared with outcomes for the weighted controls “supposed adherers”

CACE models enable comparison of outcomes between actual intervention adherers and the subpopulation of

controls who meet criterion for adherence

Baseline Assessment

  

Overall CAMI+ CAMI-Only UCC p valuen=235 n=80 n=87 n=68

Maternal age (12-19), mean years (SD)

17.0(1.2)

17.2 (1.1)

17.0 (1.2)

16.9 (1.4)

.24

African American, % 97 99 95 99 .39

Medicaid insurance, % 86 80 89 90 .18

Continuous health insurance, past 12 months, %

61 53 66 63 .25

Dropped out of school, % 42 39 43 46 .69

Married (n=2), living together, going with baby’s father, %

74 78 72 72 .66

Age of baby’s father (14-39), mean years (SD)

19.8 (3.2)

20.4 (3.4)

19.3 (2.6)

19.7 (3.6)

.11

Characteristics of Adolescent Mothers at Baseline

Teen Mothers’ Pregnancy History at Baseline, by group

38

1614 14

30

5

18

12

24

13

710

0

5

10

15

20

25

30

35

40

PriorPregnancy

Prior Birth Prior Abortion PriorMiscarriage

Per

cent

CAMI+ CAMI-Only Usual Care Control

p=.19

p=.04p=.14

p=.85

Teen Mothers’ Contraceptive & Condom Practices, Plans, and STI History at Baseline,

by Groupp=.76

p=.76

p=.14

p=.003

p=.02

p=.54

Results

Follow-up Outcome Data

• DHMH Vital Statistics Administration matched 100% of our index birth cohort followed by search for subsequent birth records

• 80% of cohort completed a 2-year follow-up interview– 85% CAMI+– 77% CAMI-Only– 79% usual care control

% of Teens with a Repeat Birth by Groupn=235

25

1714

0

5

10

15

20

25

30

Control CAMI-only CAMI+

Re

pea

t B

irth

, %

p=.08

CAMI=Computer Assisted Motivational Intervention

Results

Months between index birth and repeat birth

Cu

mu

lati

ve H

azar

d o

f R

epea

t B

irth

252015105

0.20

0.15

0.10

0.05

0.00

Control

CAMI-only

CAMI+

Risk of Subsequent Birth, by groupIntent to Treat Model

Hazard Ratio 0.45

p<.05

Results

Proportion of Teen Mothers Reporting a Repeat Pregnancy Between Index Birth and 2 Years Postpartum

Interview Data n=190

53

55

49

56

44

46

48

50

52

54

56

58

Per

cent

p=.74

Overall CAMI + Home

Visiting

CAMI -Only

Usual Care

Control

Proportion of Teen Mothers Reporting they Had an Abortion Between Index Birth and 2 Years Postpartum

Interview Data n=190

21 2119

24

0

5

10

15

20

25

30

Per

cent

p=.81

Usual Care

Control

CAMI -Only

CAMI + Home

Visiting

Overall

Process Data Collected by CAMI Counselors

• Session attempts

• Completed sessions

• Content of sessions

Variation in CAMI Session Adherence among Intervention Participants

Total Possible = 7 CAMI sessions

CAMI Sessions Completed

CAMI + CAMI-Only

Mean # (SD) 4.3 (3.6) 2.2 (2.6)

7 39% 11%

> 5 50% 32%

> 2 66% 41%

0 25% 49%

Differences Between CAMI Adherers and Non-adherers

No Differences• School dropout• Depressive symptoms• Substance use• Household violence• Prior birth• Condom use• Intention to use

contraception after delivery

Adherer Differences

• Younger

• Insured by Medicaid

• Greater social support

• Less likely to have been diagnosed with STI

GroupHazard Ratio

95% Confidence Interval

Control ref --

CAMI + 0.40‡ 0.16-0.98

CAMI-Only 0.19‡ 0.05-0.69

CACE Model* of the Risk of Subsequent Birth, by Group

‡p<.05 *compares outcomes between actual intervention adherers (received > 2 CAMIs) and

the subpopulation of controls who meet criterion for adherence

(i.e. who would have received > 2 CAMIs if they had been assigned to the intervention group)

Conclusions

• Receipt of > 2 CAMI sessions, either alone or in the context of a multi-component home-based intervention, reduced the risk of rapid repeat birth to adolescent mothers

• Earlier and more frequent contact in the CAMI + group facilitated participant engagement

Limitations

• Lack of follow-up interview data for the entire sample– Reduces ability to examine intervention impact on

behavioral mediators (e.g. use of contraception)

• MI quality ratings not systematically collected – Not able to determine moderating effects of quality

on outcomes

• 2-year follow-up observation period– Do reductions in repeat birth continue throughout

the teen’s adolescence?

Implications

• Findings support the use of motivational interviewing paired with interactive behavior change technology to reduce rapid subsequent birth in adolescent mothers

• A CAMI initiative within or closely linked with primary care might have broader reach to impact unintended and teen pregnancy

• Evaluation of CAMI in primary care settings should be considered

Secondary Findings

Months Between Index Birth & 1 stRepeat Pregnancy

25.020.015.010.05.00.0

Cu

mu

lati

ve H

azar

d o

f

Rep

eat

Pre

gn

ancy

1.0

0.8

0.6

0.4

0.2

0.0

Depressive Symptoms

No Depressive Symptoms

Risk of Repeat Pregnancy among those with and without Preceding Depressive Symptoms

p<.05

Months Between Index Birth & 1st Repeat Pregnancy

25.020.015.010.05.00.0

Cu

mu

lati

ve H

azar

d o

f

Rep

eat

Pre

gn

ancy

1.0

0.8

0.6

0.4

0.2

0.0

Depressive Symptoms

No Depressive Symptoms

Risk of Repeat Pregnancy among those with and without Preceding Depressive Symptoms

p<.05

Barnet et. al., Archives of Pediatrics and Adolescent Medicine, 2008.

Cost Effectiveness Analysis

Costs of Computer Assisted Motivational Intervention With and Without Enhanced Home Visiting, 2009 US$

CAMI+ CAMI-Only

Average cost per teenager $2,735 $1,449

Cost per prevented repeat birth, (95% Confidence Intervals)

$19,247(15,085-26,072)

$15,078(11,546-21,092)

Lessons Learned

• Need functional, user-friendly data management system

• Weekly review of process data– Individual participants– Summary views– Feedback to front line staff

• Measure intervention progress by predetermined benchmarks…

• …but be flexible - listen to staff input

• Quality control systems to increase fidelity