Interventions for preventing unintended pregnancies among adolescents

Chioma Oringanje; Martin M Meremikwu; Hokehe Eko; Ekpereonne Esu; Anne Meremikwu; John E Ehiri

doi:10.1002/14651858.CD005215.pub3

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Figure 1

Risk of bias summary: review authors' judgments about each risk of bias item for each included study.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 Multiple interventions, Outcome 1 Unintended pregnancy [individually randomised trials].

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Analysis 1.2

Comparison 1 Multiple interventions, Outcome 2 Unintended pregnancy [cluster‐randomised trials].

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Analysis 1.3

Comparison 1 Multiple interventions, Outcome 3 Initiation of sexual intercourse ‐ individually RCT.

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Analysis 1.4

Comparison 1 Multiple interventions, Outcome 4 Initiation of sexual intercourse ‐ cluster RCT.

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Analysis 1.5

Comparison 1 Multiple interventions, Outcome 5 Use of birth control methods ‐ individually RCT.

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Analysis 1.6

Comparison 1 Multiple interventions, Outcome 6 Use of birth control methods ‐ cluster RCT.

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Analysis 1.7

Comparison 1 Multiple interventions, Outcome 7 Sexually Transmitted Diseases ‐ individually RCT.

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Analysis 1.8

Comparison 1 Multiple interventions, Outcome 8 Sexually Transmitted Diseases ‐ cluster RCT.

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Analysis 1.9

Comparison 1 Multiple interventions, Outcome 9 Childbirth ‐ cluster RCT.

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Analysis 1.10

Comparison 1 Multiple interventions, Outcome 10 Childbirth ‐ individually RCT.

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Analysis 1.11

Comparison 1 Multiple interventions, Outcome 11 Second unintended pregnancy ‐ individually RCT.

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Analysis 1.12

Comparison 1 Multiple interventions, Outcome 12 Abortion (cluster RCT).

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Analysis 2.1

Comparison 2 Sensitivity analysis [Multiple interventions]: Unintended pregnancy, Outcome 1 Unintended pregnancy ‐ cluster‐randomi sed trials .

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Analysis 2.2

Comparison 2 Sensitivity analysis [Multiple interventions]: Unintended pregnancy, Outcome 2 Unintended pregnancy ‐ individually‐randomi sed trials .

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Analysis 2.3

Comparison 2 Sensitivity analysis [Multiple interventions]: Unintended pregnancy, Outcome 3 Unintended pregnancy ‐ cluster‐adjusted + individual .

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Analysis 3.1

Comparison 3 Sensitivity analysis [Multiple interventions]: Initiation of intercourse, Outcome 1 Initiation of sexual intercourse ‐ individually RCT.

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Analysis 3.2

Comparison 3 Sensitivity analysis [Multiple interventions]: Initiation of intercourse, Outcome 2 Initiation of sexual intercourse ‐ cluster RCT.

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Analysis 3.3

Comparison 3 Sensitivity analysis [Multiple interventions]: Initiation of intercourse, Outcome 3 Initiation of sexual intercourse ‐ cluster‐adjusted + individual.

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Analysis 4.1

Comparison 4 Educational interventions , Outcome 1 Initiation of sexual intercourse ‐ cluster RCT.

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Analysis 4.2

Comparison 4 Educational interventions , Outcome 2 Use of birth control methods ‐ cluster RCT.

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Analysis 4.3

Comparison 4 Educational interventions , Outcome 3 Use of contraceptives ‐ individually RCT.

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Analysis 5.1

Comparison 5 Contraceptive‐promoting interventions, Outcome 1 Unintended pregnancy ‐ individually RCT.

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Analysis 5.2

Comparison 5 Contraceptive‐promoting interventions, Outcome 2 Initiation of sexual intercourse ‐ cluster RCT.

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Analysis 5.3

Comparison 5 Contraceptive‐promoting interventions, Outcome 3 Use of birth control methods ‐ cluster RCT.

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Analysis 5.4

Comparison 5 Contraceptive‐promoting interventions, Outcome 4 Use of birth control methods ‐ individually RCT.

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Analysis 5.5

Comparison 5 Contraceptive‐promoting interventions, Outcome 5 Sexually Transmitted Diseases ‐ individually RCT.

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Contraceptive‐promoting interventions (individual RCTs)
Patient or population: Male and female adolescents aged 10 years to 19 years Setting: All settings Intervention: Contraceptive‐ promoting interventions Comparison: No additional activity/intervention to existing conventional population‐wide activities
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)
	Risk with No intervention/standard curriculum	Risk with Contraception Intervention
Unintended pregnancy follow up: range 6 months to 12 months	Study population		RR 1.01 (0.81 to 1.26)	3440 (2 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	83 per 1000	84 per 1000 (67 to 105)
	Moderate
	85 per 1000	86 per 1000 (69 to 107)
Use of birth control methods (condom use in last sex) follow up: range 6 months to 12 months	Study population		RR 0.95 (0.87 to 1.04)	3091 (2 RCTs)	⊕⊕⊕⊕ HIGH
	367 per 1000	348 per 1000 (319 to 381)
	Moderate
	312 per 1000	296 per 1000 (271 to 324)
Use of birth control methods (hormonal contraceptives) follow up: range 6 months to 12 months	Study population		RR 2.22 (1.07 to 4.62)	3091 (2 RCTs)	⊕⊕⊕⊕ HIGH
	165 per 1000	365 per 1000 (176 to 760)
	Moderate
	131 per 1000	292 per 1000 (141 to 607)
Sexually Transmitted Diseases follow up: range 6 months to 12 months	Study population		RR 0.92 (0.75 to 1.13)	3440 (2 RCTs)	⊕⊕⊕⊕ HIGH
	103 per 1000	95 per 1000 (77 to 117)
	Moderate
	98 per 1000	90 per 1000 (73 to 111)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹ Downgraded by 1 for imprecision: confidence interval fail to appreciable harm and included the null value

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Educational interventions (cluster RCTs)
Patient or population: Male and female adolescents aged 10 years to 19 years Setting: All settings Intervention: Educational interventions Comparison: No additional activity/intervention to existing conventional population‐wide activities
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)
	Risk with No intervention/Standard curriculum	Risk with Educational intervention
Use of birth control methods (condom use at last sex) follow up: range 5 months to 24 months	Study population		RR 1.18 (1.06 to 1.32)	1431 (2 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	261 per 1000	308 per 1000 (277 to 345)
	Moderate
	534 per 1000	630 per 1000 (566 to 704)
Initiation of sexual intercourse (mixed gender) follow up: range 12 months to 24 months	Study population		RR 0.95 (0.71 to 1.27)	672 (2 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}
	227 per 1000	215 per 1000 (161 to 288)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹ Several risk of bias assessment were unclear (not provided in the text) ² Low number of events and confidence interval includes the null value

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Multiple interventions (cluster RCTs)
Patient or population: Male and female adolescents aged 10 years to 19 years Setting: All settings Intervention: Multiple interventions Comparison: No additional activity/intervention to existing conventional population‐wide activities
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)
	Risk with No Intervention/Standard curriculum	Risk with Multiple interventions
Unintended pregnancy follow up: range 3 months to 48 months	Study population		RR 0.50 (0.23 to 1.09)	3149 (5 RCTs)	⊕⊕⊝⊝ LOW ^{1 2 3}
	67 per 1000	33 per 1000 (15 to 73)
	Moderate
	25 per 1000	13 per 1000 (6 to 27)
Initiation of sexual intercourse (mixed gender) follow up: range 3 months to 36 months	Study population		RR 0.84 (0.68 to 1.04)	8608 (7 RCTs)	⊕⊝⊝⊝ VERY LOW ^{1 4 5}
	253 per 1000	212 per 1000 (172 to 263)
	Moderate
	212 per 1000	178 per 1000 (144 to 220)
Use of birth control methods (condom use at last sex) follow up: range 6 months to 17 months	Study population		RR 1.01 (0.93 to 1.09)	2620 (4 RCTs)	⊕⊕⊕⊝ MODERATE ^{1 6}
	585 per 1000	591 per 1000 (544 to 637)
	Moderate
	565 per 1000	570 per 1000 (525 to 615)
Use of birth control methods (consistent condom use) follow up: range 6 months to 36 months	Study population		RR 1.95 (0.70 to 5.44)	826 (3 RCTs)	⊕⊕⊝⊝ LOW ^{1 7}
	353 per 1000	689 per 1000 (247 to 1000)
	Moderate
	133 per 1000	259 per 1000 (93 to 722)
Use of birth control methods (hormonal contraceptives) follow up: range 16 months to 24 months	Study population		RR 1.01 (0.72 to 1.43)	3987 (3 RCTs)	⊕⊝⊝⊝ VERY LOW ^{1 5 7}
	244 per 1000	246 per 1000 (176 to 349)
	Moderate
	251 per 1000	254 per 1000 (181 to 360)
Sexually Transmitted Diseases follow up: range 6 months to 17 months	Study population		RR 0.76 (0.27 to 2.14)	420 (2 RCTs)	⊕⊕⊝⊝ LOW ^{1 8}
	37 per 1000	28 per 1000 (10 to 80)
	Moderate
	31 per 1000	24 per 1000 (8 to 66)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹ Downgraded by 1 for risk of bias; several assessments were unclear due to no information provided. Such potential limitations are likely to lower confidence in the estimate of effect ² Downgraded by 1 for imprecision; low number of events, confidence interval includes appreciable benefit and null value ³ Heterogeneity could be explained (difference in comparison intervention and length of follow up) ⁴ Downgraded by 1 for imprecision: confidence interval includes appreciable benefit ⁵ Downgraded by 1 for inconsistency: unexplained large variations in effect ⁶ Confidence interval includes the null value, however, the sample size and number of events are fairly large and confidence interval is relatively narrow ⁷ Downgraded by 1 for imprecision: confidence interval includes appreciable benefit and harm ⁸ Downgraded by 1 for imprecision; low number of events, confidence interval includes appreciable benefit and harm

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Multiple interventions ( individual RCTs)
Patient or population: Male and female adolescents aged 10 years to 9 years Setting: All settings Intervention: Multiple interventions Comparison: No additional activity/intervention to existing conventional population‐wide activities
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)
	Risk with No Intervention/Standard curriculum	Risk with Multiple interventions
Unintended pregnancy follow up: range 12 months to 36 months	Study population		RR 0.66 (0.50 to 0.87)	1905 (4 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	116 per 1000	76 per 1000 (58 to 101)
	Moderate
	149 per 1000	98 per 1000 (74 to 129)
Initiation of sexual intercourse (mixed gender) follow up: range 9 months to 36 months	Study population		RR 0.99 (0.74 to 1.32)	1796 (4 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	410 per 1000	406 per 1000 (304 to 542)
	Moderate
	236 per 1000	234 per 1000 (175 to 312)
Use of birth control methods (condom use in last sex) follow up: range 12 months to 24 months	Study population		RR 1.00 (0.95 to 1.06)	796 (3 RCTs)	⊕⊕⊕⊝ MODERATE ^{1 6}
	840 per 1000	840 per 1000 (798 to 891)
	Moderate
	837 per 1000	837 per 1000 (795 to 887)
Use of birth control methods (consistent condom use) follow up: range 12 months to 24 months	Study population		RR 1.21 (0.95 to 1.54)	1681 (5 RCTs)	⊕⊕⊝⊝ LOW ^{1 5 6}
	353 per 1000	427 per 1000 (335 to 544)
	Moderate
	476 per 1000	575 per 1000 (452 to 732)
Sexually Transmitted Diseases follow up: mean 12 months	Study population		RR 0.89 (0.65 to 1.22)	699 (2 RCTs)	⊕⊝⊝⊝ VERY LOW ^{1 5 8}
	191 per 1000	170 per 1000 (124 to 233)
	Moderate
	270 per 1000	241 per 1000 (176 to 330)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹ Downgraded by 1 for risk of bias; several assessments were unclear due to no information provided. Such potential limitations are likely to lower confidence in the estimate of effect ² Downgraded by 1 for imprecision; low number of events, confidence interval includes appreciable benefit and null value ³ Heterogeneity could be explained (difference in comparison intervention and length of follow up) ⁴ Downgraded by 1 for imprecision: confidence interval includes appreciable benefit ⁵ Downgraded by 1 for inconsistency: unexplained large variations in effect ⁶ Confidence interval includes the null value, however, the sample size and number of events are fairly large and confidence interval is relatively narrow ⁷ Downgraded by 1 for imprecision: confidence interval includes appreciable benefit and harm ⁸ Downgraded by 1 for imprecision; low number of events, confidence interval includes appreciable benefit and harm

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Table 1. Studies that Could not be included in meta‐analysis

Intervention	Outcome	Study ID	Number Assessed	Case affected	Control affected	Test Statistics	95% CI	p‐value
Educational intervention	Pregnancy	Mitchell‐DiCenso 1997	1701	‐	‐	OR: 0.97	0.93 to 1.0	0.04

	Initiation of intercourse	Clark 2005	156	‐	‐	Beta: 1.604 and SE: 1.00	‐	< 0.11
		Aarons 2000 (females)	139			Adj. OR: 1.88	1.02 to 3.47	0.04
		Aarons 2000 (males)	123			Adj. OR: 1.18	0.61 to 2.29	0.62
		Perskin 2015	1079	‐	‐	OR: 1.00	0.70 to 1.41
	Changes in knowledge and attitudes about the risk of unintended pregnancy	Blake 2001	351	92.9%	91.8%	ns
	Use of birth control at last sex	Mitchell‐DiCenso 1997 (females)	109	42.2%	46.7%	OR: 1.03	1.00 to 1.07	0.03
		Mitchell‐DiCenso 1997 (males)	214	39.3%	35.9%	OR: 1.06	1.02 to 1.77	0.005
		Aarons 2000 (females)	135			Adj. OR: 3.39	1.16 to 9.95	0.025
		Aarons 2000 (males)	125			Adj. OR: 1.53	0.55 yo 4.26	0.42
	Use of condom at last sex	Okonofua 2003	1896	39.1%	31.9%	OR: 1.41	1.12 to 1.77	‐
		Clark 2005	221	77%	73%
	Unprotected intercourse in the past 3 months^a	Kogan 2012	502			Beta: ‐0.375 and SE: 0.32		>0.05
	Ever had sex without condoms	Dilorio 2007		Mean: 0.23	Mean: 0.57		‐0.61 to ‐0.06	0.03
Multiple interventions	Pregnancy	Coyle 2006	308	‐	‐	OR; 0.84	‐	0.61
		Diclemente 2004	460	‐	‐	OR: 0.53	0.27 to 1.03	0.06
		Stephenson 2004^b	1172	2.3%	3.3%	‐	‐	0.07
		Kirby 2004	2145	‐	‐	OR: 1.34	0.98 to 1.84	0.07
		Coyle 2006	417	‐	‐	OR: 0.77	0.49 to 1.23	0.28
		Smith 1994	95	‐	‐	‐	‐	< 0.05
		O'Donnell 2002	195	6.8%	18.5%
		Morrison‐Beedy 2013	323			B=‐.823 OR: 0.44		0.009
		Allen 1997	560	‐	‐	OR: 0.41	‐	‐
	Initiation of sexual intercourse (mixed gender)	Coyle 2006	94	‐	‐	OR: 1.23	0.51 to 2.97	0.65
		Smith 1994	95	.Mean: 1.19	.Mean: 2.74
		Basen‐Engquist 2001	8326	‐	‐	OR: 1.03	0.88 to 1.21	0.69
		Markham 2012	627			AOR:0.65	0.54,0.77	<.01
		O'Donnell 2002	195	40.1%	66.1%	OR: 0.39	0.20 to 0.76	0.005
		Markham 2012	735			AOR:0.82	0.51,1.34	>0.05
		Coyle 1999	2565			OR:1.13 SE: 0.24	0.71 to 1.82	0.60
	Initiation of sexual intercourse (male)	Coyle 2004	1412	19.3%	27.7%	model R²: 0.118	‐	0.02
		Kirby 2004	809	‐	‐	OR: 1.08	0.80 to 1.46	0.63
		Stephenson 2004	8156	32.7%	31.1%	OR: 0.90	0.65 to 1.23	0.35
		Eisen 1990	408	36%	44%	‐	‐	‐
	Initiation of sexual intercourse (female)	Coyle 2004	1417	20.3%	22.1%	model R²: 0.145	‐	0.53
		Kirby 2004	1220	‐	‐	OR: 0.88	0.59 to 1.31	0.54
		Stephenson 2004	8156	34.7%	40.8%	OR: 0.80	0.66 to 0.97	0.008
		Eisen 1990	480	27%	22%	‐	‐	‐
	Use of condoms at last sex	Kirby 2004	2145	‐	‐	OR: 1.38	1.06 to 1.79	0.02
		Coyle 2006	359	‐	‐	OR: 1.00	0.49 to 1.23	0.99
		Diclemente 2004	460	‐	‐	OR: 3.94	2.58 to 6.03	< .001
		Downs 2004	258	‐	‐	OR: 2.13	‐	0.15
		Norton 2012	198			OR: 0.93	‐0.75,0.62	0.85
		Coyle 1999	1018			OR:191 SE:0.27	1.13 to 3.21	0.02
	Childbirth	Henderson 2007	4196	300/1000	274/1000	OR: 14.6		0.32
	Abortion	Henderson 2007	4196	127/1000	112/1000	OR: 26.4		0.40
	Consistent condom use at 12 months	Sieving 2011	253	Mean: 0.96 (116/126)	Mean: 0.66 (81/127)	ARR:145	1.26 to 1.67	0.00
	Consistent condom use at 24 months	Sieving 2011	204	Mean:1.53	Mean: 0.93	ARR: 1.57	1.28,1.94
	Consistent hormonal contraceptive use at 12 months	Sieving 2011	253	Mean: 4.27 (74/126)	Mean: 2.91 (51/127)	ARR:1.46	1.13 to 1.89	0.00
	Consistent hormonal contraceptive use at 24 months	Sieving 2011	203	Mean: 3.29	Mean: 2.34	ARR: 1.30	1.06,1.58

		Minnis 2014	162			OR:0.42		0.12
	Use of condoms at first sex	Coyle 1999	285			OR:0.68 SE:0.48	0.26 to 1.75	0.42
	Protected against pregnancy at last sex	Coyle 1999	998			OR:1.62 SE:0.22	1.05 to 2.50	0.03
	Sexually Transmitted Infections	Morrison‐Beedy 2013	323			B=‐0.067 OR: ‐0.94		0.77
		Jemmott 2005^c		Mean:10.5 SE: 2.9	Mean:18.2 SE:2.8			0.05
Baird 2010: The following listed outcomes were reported. However, the method of reporting made difficult to extract correct estimates. 1. Pregnancy School girls and dropouts among the treatment group are 1.1 percentage points less likely to have become pregnant over the past year. Not statistically significant. 2. Onset of sexual intercourse There was a 46.6% reduction in the onset of sexual activity among initial dropouts (P < 0.01) and a 31.3% reduction in the onset of sexual activity among initial schoolgirls (P = 0.112). 3.Condom use The intervention had no impact on self‐reported condom use.
a ‐ Binary outcome (did unprotected intercourse occur or not?) b ‐ Study (Stephenson 2008) same as Stephenson 2004, but with an extended follow up (7yrs) c ‐ Data comparing skills‐based intervention versus health‐promotion intervention Analyses assessing impact on delay of sexual initiation excluded individuals who reported any type of sexual intercourse at baseline Analyses assessing impact on other on sexual behaviours are limited to individuals that are sexually active ns ‐ non‐significant

Table 1. Studies that Could not be included in meta‐analysis

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Comparison 1. Multiple interventions

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Unintended pregnancy [individually randomised trials] Show forest plot	4	1905	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.50, 0.87]

2 Unintended pregnancy [cluster‐randomised trials] Show forest plot	5	3149	Risk Ratio (M‐H, Random, 95% CI)	0.50 [0.23, 1.09]

3 Initiation of sexual intercourse ‐ individually RCT Show forest plot	4	1796	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.74, 1.32]

4 Initiation of sexual intercourse ‐ cluster RCT Show forest plot	7	8608	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.68, 1.04]

5 Use of birth control methods ‐ individually RCT Show forest plot	8		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

5.1 Condom use in last sex	3	796	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.95, 1.06]
5.2 Consistent condom use	5	1681	Risk Ratio (M‐H, Random, 95% CI)	1.21 [0.95, 1.54]
5.3 Contraceptive use at last sex	1	408	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.95, 1.03]
5.4 Consistent contraceptive use	1	253	Risk Ratio (M‐H, Random, 95% CI)	1.29 [1.06, 1.59]
6 Use of birth control methods ‐ cluster RCT Show forest plot	6		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 Condom use at last sex	4	2620	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.93, 1.09]
6.2 Consistent condom use	3	826	Risk Ratio (M‐H, Random, 95% CI)	1.95 [0.70, 5.44]
6.3 Hormonal contraceptives	3	3987	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.72, 1.43]
7 Sexually Transmitted Diseases ‐ individually RCT Show forest plot	2	699	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.65, 1.22]

8 Sexually Transmitted Diseases ‐ cluster RCT Show forest plot	2	420	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.27, 2.14]

9 Childbirth ‐ cluster RCT Show forest plot	1	4776	Odds Ratio (M‐H, Fixed, 95% CI)	0.64 [0.52, 0.79]

10 Childbirth ‐ individually RCT Show forest plot	1	484	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.31, 1.45]

11 Second unintended pregnancy ‐ individually RCT Show forest plot	1	149	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.22, 1.02]

12 Abortion (cluster RCT) Show forest plot	1	4776	Odds Ratio (M‐H, Fixed, 95% CI)	0.93 [0.72, 1.21]

Comparison 1. Multiple interventions

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Comparison 2. Sensitivity analysis [Multiple interventions]: Unintended pregnancy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Unintended pregnancy ‐ cluster‐randomi sed trials Show forest plot	2	497	Risk Ratio (M‐H, Random, 95% CI)	0.20 [0.10, 0.39]

2 Unintended pregnancy ‐ individually‐randomi sed trials Show forest plot	3	1421	Odds Ratio (M‐H, Fixed, 95% CI)	0.68 [0.46, 1.00]

3 Unintended pregnancy ‐ cluster‐adjusted + individual Show forest plot	5	1918	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.39, 0.72]

Comparison 2. Sensitivity analysis [Multiple interventions]: Unintended pregnancy

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Comparison 3. Sensitivity analysis [Multiple interventions]: Initiation of intercourse

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Initiation of sexual intercourse ‐ individually RCT Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Gender mixed or not specified	3	1312	Risk Ratio (M‐H, Random, 95% CI)	1.18 [0.67, 2.09]
2 Initiation of sexual intercourse ‐ cluster RCT Show forest plot	4	1687	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.57, 1.25]

2.1 Gender mixed or not specified	4	1687	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.57, 1.25]
3 Initiation of sexual intercourse ‐ cluster‐adjusted + individual Show forest plot	7	2999	Odds Ratio (M‐H, Fixed, 95% CI)	0.88 [0.74, 1.05]

3.1 Gender mixed or not specified	7	2999	Odds Ratio (M‐H, Fixed, 95% CI)	0.88 [0.74, 1.05]

Comparison 3. Sensitivity analysis [Multiple interventions]: Initiation of intercourse

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Comparison 4. Educational interventions

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Initiation of sexual intercourse ‐ cluster RCT Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Gender mixed or not specified	2	672	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.71, 1.27]
2 Use of birth control methods ‐ cluster RCT Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 condom use at last sex	2	1431	Risk Ratio (M‐H, Random, 95% CI)	1.18 [1.06, 1.32]
3 Use of contraceptives ‐ individually RCT Show forest plot	1	360	Risk Ratio (M‐H, Fixed, 95% CI)	2.5 [1.39, 4.48]

Comparison 4. Educational interventions

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Comparison 5. Contraceptive‐promoting interventions

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Unintended pregnancy ‐ individually RCT Show forest plot	2	3440	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.81, 1.26]

2 Initiation of sexual intercourse ‐ cluster RCT Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Female	1	1446	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.76, 1.04]
2.2 Male	1	1560	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.87, 1.21]
3 Use of birth control methods ‐ cluster RCT Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Hormonal contraceptives	1	415	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.69, 1.18]
4 Use of birth control methods ‐ individually RCT Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

4.1 Condom use in last sex	2	3091	Risk Ratio (M‐H, Random, 95% CI)	0.95 [0.87, 1.04]
4.2 Consistent condom use	1	1950	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.71, 1.15]
4.3 Hormonal contraceptives	2	3091	Risk Ratio (M‐H, Random, 95% CI)	2.22 [1.07, 4.62]
5 Sexually Transmitted Diseases ‐ individually RCT Show forest plot	2	3440	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.75, 1.13]

Comparison 5. Contraceptive‐promoting interventions

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