Teen Pregnancy Prevention That Actually Works: The Data From Mississippi to Manhattan

There is a number buried in the CDC’s annual vital statistics that represents one of the most dramatic public health victories in modern American history, and almost nobody talks about it. Between 1991 and 2023, the teen birth rate among Black adolescents in the United States fell by approximately 70 percent. Seventy percent. In a country where public health outcomes for Black Americans almost universally trend in the wrong direction — where diabetes is up, maternal mortality is up, life expectancy gaps are widening — this single metric plunged with the consistency and slope of a boulder rolling downhill. The Black teen birth rate, which stood at 118.2 per 1,000 girls aged 15–19 in 1991, dropped to roughly 25 per 1,000 by 2022. This is not a marginal improvement. It is a transformation, and the fact that it happened while the national conversation about Black youth remained fixated on failure should tell you something about how poorly we understand what actually works.

But before we celebrate, and we should celebrate, we must confront the other number: Black teen girls still give birth at approximately twice the rate of their white peers. The gap persists even as both rates have fallen, which means the structural and cultural factors driving early pregnancy among Black adolescents have been battered but not broken by whatever combination of interventions produced that 70 percent decline. The question that matters now — the only question that has ever mattered in this space — is what worked, what didn’t, and whether we have the courage to fund the things that work even when they make us uncomfortable.

The Abstinence-Only Catastrophe

Let us begin with what did not work, because the United States spent approximately $2 billion on it over two decades, and its failure is not merely well-documented but should be considered one of the great wastes of public money in the history of American social policy. Abstinence-only-until-marriage education, which was federally funded beginning in 1981 under the Adolescent Family Life Act and massively expanded under Title V of the 1996 welfare reform, told teenagers not to have sex and provided no information about contraception, sexually transmitted infections, or reproductive health. It was, in essence, a policy built on the assumption that if you told teenagers something forcefully enough, they would do it.

They did not. A rigorous evaluation commissioned by the Department of Health and Human Services itself, conducted by Mathematica Policy Research and published in 2007, followed more than 2,000 youth across four abstinence-only programs for up to six years and found that participants were no more likely to abstain from sex than those who received no intervention at all. The age of first intercourse was identical. The number of sexual partners was identical. The rate of unprotected sex was identical. Two billion dollars, and the needle did not move.

The states that leaned hardest into abstinence-only education — Mississippi, Texas, Arkansas — consistently had among the highest teen pregnancy rates in the nation. Mississippi, which in 2012 passed a law requiring abstinence-only instruction in schools, had the highest teen birth rate in the country. This was not a coincidence. It was the entirely predictable result of a policy that confused moral aspiration with public health strategy. You can believe that teenagers should abstain from sex. You can preach it from every pulpit. But when you build policy on the assumption that they will, and you withhold from them the tools they need when they don’t, you are not protecting them. You are abandoning them to consequences that you had the power to prevent.

What Actually Worked: The Carrera Model

In 1984, in East Harlem, a man named Dr. Michael Carrera started a program at the Children’s Aid Society that would eventually become the gold standard for teen pregnancy prevention — not because it talked about sex more effectively, but because it understood that teen pregnancy is not primarily a sex problem. It is a hope problem. The Carrera Adolescent Pregnancy Prevention Program did not begin with reproductive health. It began with jobs. It began with academic tutoring. It began with banking — each participant opened a savings account and learned to manage money. It included comprehensive family life and sexuality education, yes, but that was one component of a program that fundamentally sought to give young people a reason to delay parenthood by giving them something to delay it for.

The evaluation, conducted by Philliber Research Associates and published in 2002, was among the most rigorous in the field: a randomized controlled trial with a three-year follow-up. The results for young women were extraordinary. Girls in the Carrera program were 50 percent less likely to become pregnant and significantly more likely to use contraception consistently. They had higher rates of college attendance. They had bank accounts. They could see a future, and they chose to protect it.

What Carrera understood, and what decades of failed abstinence programs refused to acknowledge, was that a fifteen-year-old girl in East Harlem who cannot see a path to college, who has no savings, no job prospects, no adults investing in her intellectual development, has no economic reason to avoid pregnancy. A baby, in that context, is not a mistake. It is the most meaningful thing available. It is identity. It is purpose. It is someone who will love you unconditionally in a world that has offered nothing of the sort. You cannot compete with that by handing out pamphlets about abstinence. You can only compete with it by offering something better — a future worth waiting for.

The LARC Revolution and What the Data Shows

If the Carrera model represented the holistic, long-term approach to teen pregnancy prevention, the introduction and widespread adoption of Long-Acting Reversible Contraception — IUDs and implants, collectively known as LARCs — represented the single most impactful clinical intervention. The Colorado Family Planning Initiative, launched in 2009, offered free LARCs to low-income women and teens through Title X clinics across the state. The result was a 54 percent decline in the teen birth rate and a 64 percent decline in the teen abortion rate over six years. Among the populations served, which were disproportionately low-income and included significant numbers of Black and Hispanic women, the effects were transformative.

The reason LARCs work is brutally simple: they remove the daily decision. A teenage girl using birth control pills must remember to take a pill every day. She must have access to refills. She must navigate the logistics of a pharmacy, a prescription, and insurance coverage, all while managing the chaos of adolescent life. Failure rates for the pill among typical teenage users run between 7 and 9 percent annually. An IUD, once placed, is effective for three to twelve years depending on type, with a failure rate under 1 percent. It does not require daily compliance. It does not require a trip to the pharmacy. It simply works.

The economists Melissa Kearney and Phillip Levine, in their rigorous analysis of the teen birth rate decline, found that approximately one-third of the reduction could be attributed to increased access to contraception, with another significant portion attributable to the influence of media — specifically, they found that MTV’s 16 and Pregnant and Teen Mom led to measurable decreases in teen births in the months following new episodes, likely by making the reality of teen motherhood visible and unglamorous. This finding was controversial, but the methodology was sound and the effect sizes were statistically significant.

Comprehensive Sex Education: The Evidence Is Not Debatable

The Guttmacher Institute, which has tracked reproductive health data with more rigor and less ideology than any organization in the field, has documented a simple and consistent finding across decades of research: comprehensive sex education that includes information about both abstinence and contraception delays the initiation of sexual activity, reduces the number of sexual partners, and increases contraceptive use among those who do become sexually active. It accomplishes, in other words, everything that abstinence-only education promised and failed to deliver, while also providing the tools that prevent pregnancy when abstinence fails.

The states with the most comprehensive sex education requirements — New Jersey, California, Oregon — consistently rank among those with the lowest teen birth rates. The states with the most restrictive, abstinence-focused requirements — Mississippi, Arkansas, Louisiana — consistently rank among the highest. This is a natural experiment running across fifty states and several decades, and it produces the same result every time. The correlation is not perfect, because other factors — poverty, urbanization, access to healthcare — also matter. But the pattern is unmistakable, and the refusal to acknowledge it is not a matter of intellectual disagreement. It is a matter of choosing ideology over children.

The Economics of Teen Motherhood

The National Campaign to Prevent Teen and Unplanned Pregnancy estimated that teen childbearing costs American taxpayers approximately $9.4 billion annually in direct costs — healthcare, foster care, incarceration, and lost tax revenue. Other analyses, using broader measures of economic impact including lost lifetime earnings for both mothers and children, have placed the figure closer to $29 billion. These numbers are large enough to be abstract, so let us make them concrete.

A teenage mother is significantly less likely to finish high school. Without a high school diploma, her lifetime earnings are roughly $200,000 less than a graduate’s. Her children are more likely to experience poverty, more likely to have behavioral and academic problems, and more likely to become teen parents themselves. The intergenerational transfer of disadvantage is not a metaphor. It is a measurable, documented pipeline that begins at the moment a teenager gives birth and extends, with cruel efficiency, through the next twenty years of two lives.

Mississippi: A Case Study in What Happens When You Change Course

Mississippi’s story is instructive because it demonstrates both the depth of the failure and the possibility of recovery. For years, the state had the highest teen birth rate in the nation, a distinction it earned through a combination of poverty, limited healthcare access, and an education policy that treated honest discussion of contraception as morally unacceptable. The state’s 2011 sex education law required that abstinence be the primary message and permitted but did not require instruction about contraception.

But community-based organizations, operating outside the constraints of the school system, began implementing evidence-based programs in the state’s poorest communities. The Mississippi First initiative pushed for policy reform. Community health centers expanded access to contraception, including LARCs. And the teen birth rate, which had seemed immovable, began to fall. Between 2007 and 2022, Mississippi’s teen birth rate dropped by more than 60 percent. The state still ranks among the worst, but the trajectory has changed, and it changed not because Mississippi suddenly became progressive, but because evidence-based interventions work even in the most resistant environments when they are actually implemented.

What Scandinavia Proves

The Nordic countries — Denmark, Sweden, Norway, Finland — have teen birth rates that are a fraction of America’s. Sweden’s teen birth rate is approximately 5 per 1,000, compared to America’s roughly 15 per 1,000 overall and approximately 25 per 1,000 for Black teens. The Scandinavian model combines universal comprehensive sex education beginning in early adolescence, free access to contraception including LARCs, destigmatized reproductive healthcare, and a social safety net that reduces the economic desperation that often drives early childbearing.

The lesson from Scandinavia is not that Americans should become Scandinavians. It is that teen pregnancy is not an intractable feature of human nature. It is a policy outcome. Countries that treat it as a public health problem and apply evidence-based solutions achieve rates so low that they barely register as a social concern. Countries that treat it as a moral failing and respond with lectures and shame achieve rates that devastate communities. The choice between these approaches is not a choice between conservative and liberal values. It is a choice between what works and what doesn’t.

“Children learn more from what you are than what you teach.”
— W.E.B. Du Bois

The Path Forward: What Black Communities Can Do Now

The data from the past three decades tells us, with unusual clarity, what reduces teen pregnancy in Black communities. It is not one thing. It is a combination of interventions that operate at different levels, and the communities that have deployed them comprehensively have seen the most dramatic results.

First, comprehensive sex education that begins before sexual debut — typically by age twelve or thirteen — and that includes honest information about anatomy, contraception, consent, and relationships. Second, free and confidential access to the full range of contraceptive methods, with particular emphasis on making LARCs available to teens who want them, without requiring parental consent in states where that is legally permissible. Third, holistic youth development programs that build academic skills, financial literacy, and career pathways — programs modeled on the Carrera approach that understand teen pregnancy as a symptom of hopelessness and treat hopelessness directly. Fourth, culturally competent healthcare providers who can discuss reproductive health with Black adolescents without judgment, without condescension, and without the particular brand of discomfort that white-dominated medical institutions have historically brought to conversations with Black patients about their bodies.

And fifth — the intervention that no program can provide but that the data says matters more than any other — the presence of engaged adults in the lives of young people. Parents who talk to their children about sex. Fathers who are present. Mothers who set expectations and enforce them. Churches that provide guidance without shame. Communities that surround their young people with enough love, enough supervision, and enough belief in their futures that the question of early parenthood answers itself.

The 70 percent decline is proof that this problem yields to effort. The remaining gap is proof that the effort is not yet sufficient. Black teen girls deserve the same rates of early pregnancy as their peers in any other community, and the tools to achieve that exist, have been tested, and have been proven effective. The only question is whether we will fund them, implement them, and sustain them long enough for the next generation of Black girls to inherit a future that was chosen rather than one that was defaulted into. The data says we can. The only remaining variable is whether we will.