A Public-Private Partnership to Reduce Unintended Pregnancy Rates and Improve Economic Mobility

A recent economic mobility study from Harvard University ranked Charlotte, North Carolina, 50th out of 50 metropolitan areas in terms of intergenerational mobility. This suggests it is particularly difficult for people in our community to rise out of poverty [1]. In response to this study, Charlotte/Mecklenburg County convened an Opportunity Task Force in late 2015 to study economic mobility and to make recommendations on how it can be improved.

The task force has considered a wide range of factors that impact mobility including family stability, school quality, race, and residential segregation. One area discussed in detail is unintended pregnancy, and it is anticipated that this will emerge as a priority when the task force issues its recommendations in late 2016. Unintended pregnancy has a profound impact on family stability and is a strong predictor of economic mobility [2]. Fortunately, reducing the rates of unintended pregnancy is feasible because new contraceptive technologies are now available that are highly effective, safe, and convenient.

Recently, a number of communities have dramatically reduced unintended pregnancy rates by making long-acting reversible contraception more widely available and by educating the public about its effectiveness [3, 4]. Interest in these outcomes and in the work of the Opportunity Task Force has led a group of local funders to plan a community campaign to reduce unintended pregnancy in Mecklenburg County. Three features distinguish this campaign: it will focus on unintended pregnancy in women up to age 29 years; it will be a public-private partnership; and it will be closely tied to community efforts to improve economic mobility.

Traditionally, public health interventions to reduce unintended pregnancies focused on adolescents, and teen pregnancy rates across the United States have fallen. While adolescent pregnancy rates continue to decline in Mecklenburg County and in other communities, there were still 662 teen births in 2014. Of these, 15% were repeat births, and significant disparities remain between different racial and ethnic groups [5]. In addition, local data show that 1,058 births (12%) in Mecklenburg County were to women who conceived 6 months or less after a previous birth. Only 42 of these especially short pregnancy intervals occurred among teens aged 12–19 years [5]. Greater access to new contraceptive technologies may be particularly important among low-income women, since local Medicaid data show that only 9% of women who have just given birth in Mecklenburg County are currently using long-acting reversible contraception, compared to 15% statewide (unpublished data).

In 2016, the Mecklenburg County and Union County health departments received competitive funding from the North Carolina Department of Health and Human Services to implement regional interventions to reduce infant mortality. One intervention targets clinical settings to specifically increase the availability and use of long-acting reversible contraception. While still in the early stages of development, the community campaign will build on these efforts through a public-private partnership. It will include a planning and mobilization component designed to develop community awareness and participation in the goals and components of this multiyear project. Community engagement was considered to be particularly important given North Carolina's historical experience with involuntary sterilization; at one time, Mecklenburg County had the highest rates of sterilization in the state.

The multiyear community campaign will be supported by a coalition of local funders. It will tap into local and national expertise in community-based approaches to reduce unintended pregnancy. It will be based on existing evidence-based interventions from other communities, as well as on the needs and assets identified in the planning component. The campaign will focus on several key activities: a public education/communications campaign, community and institutional policy changes to improve access to contraceptives, training and quality improvement efforts in clinical settings, collaboration with community institutions engaged in supporting families and developing skills and educational opportunities, and evaluation of the intervention in terms of reductions in unintended pregnancy.

In addition to the medical and public health implications of this project, a prioritized goal is to create greater opportunity for economic mobility through strengthened family structures. Possible approaches include increasing access to family planning, encouraging marriage and active fathership, expanding home ownership, and improving access to affordable, high-quality child care. A community intervention to reduce unintended pregnancy is attractive because much of the needed capacity and long-term funding mechanisms are in place, meaningful intermediate results can be attained in a relatively short period, and early success can help drive other more difficult community changes. However, changes in economic mobility will ultimately require attention to other core issues. Whether the pregnancy is intended or not, each child born in our community must be nurtured. It is imperative that we also address other key determinants for economic mobility such as early childhood development, K–12 school quality, housing, college and workforce readiness, and mentorships—as well as efforts to foster a sense of hope and aspiration—to ensure that every child is on a path to achieve his or her version of the American Dream.

• ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.