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Impact of social service and public health spending on teenage birth rates across the USA: an ecological study
  1. Heather L Sipsma1,2,
  2. Maureen Canavan1,
  3. Melissa Gilliam2,
  4. Elizabeth Bradley1
  1. 1 Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
  2. 2 Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health, University of Chicago, Chicago, Illinois, USA
  1. Correspondence to Dr Heather L Sipsma; hsipsma{at}


Objective To examine whether greater state-level spending on social and public health services such as income, education and public safety is associated with lower rates of teenage births in USA.

Design Ecological study.

Setting USA.

Participants 50 states.

Primary outcome measure Our primary outcome measure was teenage birth rates. For analyses, we constructed marginal models using repeated measures to test the effect of social spending on teenage birth rates, accounting for several potential confounders.

Results The unadjusted and adjusted models across all years demonstrated significant effects of spending and suggested that higher spending rates were associated with lower rates of teenage birth, with effects slightly diminishing with each increase in spending (linear effect: B=−0.20; 95% CI −0.31 to 0.08; p<0.001 and quadratic effect: B=0.003; 95% CI 0.002 to 0.005; p<0.001).

Conclusion Higher state spending on social and public health services is associated with lower rates of teenage births. As states seek ways to limit healthcare costs associated with teenage birth rates, our findings suggest that protecting existing social service investments will be critical.

  • teenage birth
  • United States
  • social determinants
  • spending

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors HLS, MC, and EB conceptualised the design of the study and gathered the data. HLS and MC conducted the analyses, and HLS wrote the first draft. All authors contributed to the interpretation of results, revising the paper and approve the final version for submission.

  • Funding This work was funded by grants from the Robert Wood Johnson Foundation (grant no 71531) and Blue Cross Blue Shield of Massachusetts Foundation, Inc.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data used in this analysis are publicly available; no unpublished data were used.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with 'BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.

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