At 8:30 a.m. on a bright Monday morning on the Upper West Side of Manhattan, a dozen students line up at the front of their morning class, debating how much communication between sexual partners is required to use a diaphragm, that dome-shaped contraceptive of yesteryear that covers the cervix. The students, each holding a different birth control device (the female condom, the patch, the vaginal ring), are ninth graders at Opportunity Charter School, where 84 percent of kids are eligible for free or reduced-price lunch.
Their teacher, Shanda Holt, had asked them to create a spectrum across the classroom, from the contraceptive that requires the least amount of communication between partners to the one that requires the most. They are now fidgeting with their assigned safeguards, waiting to explain their case.
“If you put tape on the patch, does it do anything?” asks a girl on the far right. Holt holds up a sample patch, showing how it sticks tightly to the body, smacking her hands together to demonstrate. “So water doesn’t affect it at all?” another girl asks, nearly joking, but with clear interest. “What if you shower?” someone shouts out.
“I beg you to take a shower,” Holt teases, and then she goes on to explain that water does not, in fact, alter the efficacy of the patch.
The back-and-forth is lighthearted, but in fact much is riding on the students’ informal questions and Holt’s easy responses. The curriculum is part of the Carrera Adolescent Pregnancy Prevention Program, a long-term intervention intended to reduce pregnancy among the most marginalized kids in the United States.
Birth control access, public funding for prenatal and postnatal care, and data-driven programs like Carrera are easily overlooked as political controversies come and go. But these topics form the core of reproductive health in this country. With that in mind, I went to see this unorthodox pregnancy prevention program in action. By coupling interactive sex education with a host of social services, the program has successfully cut teen pregnancy by 40 percent in the communities it serves. And for a country that spends at least $9.4 billion a year on costs associated with teen pregnancy, that’s a big deal.
In the last 25 years, the national teen birth rate has fallen by 61 percent, but it varies widely by class and race. The teen birth rate among black and Hispanic teens, for example, was more than twice that of white teens in 2014. Public health experts often talk about teen pregnancy as a shorthand for poverty.
“Reducing unplanned pregnancy helps improve other important issues facing our nation,” argues Ginny Ehrlich, the CEO of The National Campaign to Prevent Teen and Unplanned Pregnancy. She notes that lower teen pregnancy rates lead to “less poverty, more economic opportunity, better educational attainment, healthier children and families, and the empowerment of women and girls.”
But the question of how to lower teen pregnancy rates, for the general population but also for the most marginalized kids in society, has remained knotty. Abstinence-only education doesn’t work, but what does? Distributing condoms in school? Funding comprehensive sex ed classes? Making it easier for minors to obtain emergency contraception?
Michael Carrera, who has a doctorate in education with a specialization in adolescent sexuality, has an answer. He founded his namesake program after teaching a sex ed class at the Children’s Aid Society in the 1970s, and seeing discouraging results.
“I was talking to them about sexuality and sexual expression and decision making and acquiring services. And they were walking in with earaches, headaches, toothaches, asthma, obesity, mental health problems, family fragmentation, abuse, neglect,” Carrera told me one morning in his office in Harlem. “So it was a thud. My alignment was off.”
Still a project of the Children’s Aid Society, the Carrera program grew in response to that misalignment. Made up of seven components, the program teaches kids how to use birth control, but also addresses the earaches, the toothaches, the mental health problems, and the neglect that Carrera saw early on. Students get assigned social workers; work with tutors outside of class; get vision screening and glasses at no cost, as well as medical care and dental services; write resumes; and set up bank accounts.
The key insight behind the program is that it’s not enough to give kids the devices that prevent pregnancy; they must also have a stake in the future, a compelling alternative to getting pregnant. The whole thing makes traditional sex ed classes, and their condom-on-banana demonstrations, look feeble in comparison.
Data shows that the Carrera program is remarkably effective at achieving its goal. After three years in the program, girls were 40 percent less likely to have ever been pregnant and 50 percent less likely to have given birth, according to a multi-site, randomized controlled trial of the program in six states between 1997 and 2004. (On the other hand, while the program has a significant effect on female participants, it had no measurable effect on decreasing the likelihood that a male participant would cause a pregnancy or father a child.) Participants were also 16 percent more likely than the control group to have had some work experience. After seven years in the program, a follow-up report at the six New York City sites showed that participants were 30 percent more likely to have graduated from high school or obtained a GED. For every dollar spent, Carrera calculates that nearly $10 are saved down the line.
The main drawback to the program is that it requires a lot of time and money upfront. The cost per child is $3,200 in the first year for an incoming sixth grade class of 100 students, and Carrera puts the cost at $2,400 to $2,600 per child when the program is at scale in a particular school.
“I would say to critics that this is where money is best spent,” reports Leonard Goldberg, the founder of Opportunity Charter School, which partnered with Carrera in 2008. “It’s best spent in the schools. It’s best spent when children are young.” He cited the money that must be spent at the other end of pregnancy, to fund the foster care system, the prisons and jails, and the emergency rooms that spring up when young people have children but no opportunities.
Allison Mutzel, the middle school principal who started as a teacher at the school, says she depends on the Carrera program’s additional support, especially to “teach boys in the heat of spring,” as she puts it. She’s seen students get braces and eyeglasses, medical help for diabetes, in-class tutors, emergency counselors. As an educator of kids aged 10 to 14, I asked her if she ever thought the program, or at least the sex ed component, began too soon. “Oh no,” she said. “It could start much earlier.”