1. Beth Barnet, MD 1, Adrienne Williams, PhD 1, Margo DeVoe, MS 1, Ed Pecukonis, Ph.D. 2, Melanie A. Gold, DO 3 Anne K. Duggan, ScD 4 1 University of Maryland Department of Family & Community Medicine 2 University of Maryland School of Social Work 3 University of Pittsburgh Department of Pediatrics, Pittsburgh PA 4 Johns Hopkins Department of Pediatrics Motivational Intervention to Reduce Rapid Repeat Births in Adolescent Mothers: A Community-based Randomized Trial

2. 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

3. 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 2 nd 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

4. Factors Associated with Rapid Repeat 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?

5. Many well designed interventions to reduce 2 nd 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

6. 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

7. Can MI be used to facilitate motivation and behavior change for repeat pregnancy prevention in teens? Research Question

8. Objectives 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.

9. CAMI Intervention CAMI Computer Assisted Motivational Intervention 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

11. 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 4 th home visit

12. Logic Model for CAMI Intervention

13. 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?

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

15. 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

16. 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

17. Design & Study Flow Recruitment between February 2003 and April 2005 Intervention Phase completed October, 2007

18. Outcome Measurement Timing 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

19. Analysis 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 who would have adheredControl group participants who would have adhered if assigned to the experimental group are not identified As a result, treatment effects are under-estimated

20. CACE Analysis CACE Analysis 2-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

21. Baseline Assessment

22. OverallCAMI+CAMI-OnlyUCC p value n=235n=80n=87n=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, %97999599.39 Medicaid insurance, %86808990.18 Continuous health insurance, past 12 months, % 61536663.25 Dropped out of school, %42394346.69 Married (n=2), living together, going with baby’s father, % 747872.66 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

23. Teen Mothers’ Pregnancy History at Baseline, by group p=.19 p=.04 p=.14 p=.85

24. Teen Mothers’ Contraceptive & Condom Practices, Plans, and STI History at Baseline, by Group p=.76 p=.14 p=.003 p=.02 p=.54

25. Results

26. 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

27. Repeat Birth, % p=.08 CAMI=Computer Assisted Motivational Intervention Results

28. Months between index birth and repeat birth Cumulative Hazard of Repeat Birth 252015105 0.20 0.15 0.10 0.05 0.00 Control CAMI-only CAMI+ Risk of Subsequent Birth, by group Intent to Treat Model Hazard Ratio 0.45 p<.05 Results

29. Proportion of Teen Mothers Reporting a Repeat Pregnancy Between Index Birth and 2 Years Postpartum Interview Data n=190 p=.74 Overall CAMI + Home Visiting CAMI - Only Usual Care Control

30. Proportion of Teen Mothers Reporting they Had an Abortion Between Index Birth and 2 Years Postpartum Interview Data n=190 p=.81 Usual Care Control CAMI - Only CAMI + Home Visiting Overall

31. Process Data Collected by CAMI Counselors Session attempts Completed sessions Content of sessions

33. 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) 739%11% > 550%32% > 266%41% 025%49%

34. 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

35. Group Hazard Ratio 95% Confidence Interval Controlref-- CAMI +0.40 ‡ 0.16-0.98 CAMI-Only0.19 ‡ 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)

36. 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

37. 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?

38. 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

39. Secondary Findings

40. Months Between Index Birth & 1 st Repeat Pregnancy 25.020.015.010.05.00.0 Cumulative Hazard of Repeat Pregnancy 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 & 1 st Repeat Pregnancy 25.020.015.010.05.00.0 Cumulative Hazard of Repeat Pregnancy 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.

41. 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)

42. 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