Paying Teens Not to Have Sex: What Mississippi Can Learn From Malawi

A high childhood poverty rate and religious opposition to sex education leave Mississippi with the country’s highest teen pregnancy rate. Cash transfers solved similar problems in Malawi.

The State of Mississippi holds the dubious distinction of having the highest rate of teenage births in the United States (55 per 1,000 births compared to a national average of 34 per 1,000). Its most recent effort to curb these numbers is a controversial bill that requires the collection of umbilical cord blood for paternity testing in situations legislators say show red flags for abuse. This is supposed to discourage men from getting teen girls pregnant in the first place. But in a state known for abstinence-only, condom-free sex education, it’s unclear if this will help.

Meanwhile, in Malawi, the teenage birth rate is much higher still, 177 per 1,000 births. That rate is especially sobering given that many of these teenagers are having sex with adults. And one in ten Malawian adults is HIV positive.

Paying people has been proven to be a successful method of encouraging positive behavior.
A 2010 study in Malawi, supported by the Bill and Melinda Gates Foundation, shows a promising tactic to combat teen pregnancy and the risk of STIs. In this study, conditional cash transfers successfully reduced sexual activity amongst teenagers. In other words, teenage girls in Malawi stopped having sex in exchange for money.

This approach sounds troubling on its face. Surely teenagers should be making healthy decisions without being paid to do so? But paying people has been proven to be a successful method of encouraging positive behavior.

In Brazil and Mexico, multi-billion dollar state-run social welfare programs, Bolsa Familia and Opportunidades pay poor families to achieve a threshold rate of school and health clinic attendance. In South Asia, municipal and state governments contribute to savings accounts for secondary-school girls to stem their otherwise high drop-out rate. A 2009 World Bank global review of conditional cash transfers (CCT) concluded that they have successfully “reduced poverty and encouraged parents to invest in the health and education of their children”.

What’s more, there seems to be a correlation between teenage sexual behavior and poverty. A review in Guttmacher Institute’s journal, International Family Planning Perspectives reported that “female adolescents from poor households are more likely than their wealthiest counterparts to have had sex, according to an analysis of nationally representative data from four countries in Sub-Saharan Africa.” In a 2006 study reported in AIDS Education and Prevention, interviews with more than 600 South African adolescents showed that poor adolescents were more likely to have unhealthy parent-child relationships which made them more vulnerable to risky sexual behavior.

Clearly, something about having money prevents teenagers from having sex. However, until recently, no one had directly examined the effects of cash transfers on sexual behavior.

In 2009, the Bill and Melinda Gates Foundation funded a two year randomized control trial in Malawi that examined the effects of cash transfers on schoolgirls’ (self-reported) sexual activity. Roughly 4,000 12-22 year old girls were randomly assigned to a treatment or control group where they either did or did not receive money in exchange for attending school 80 percent of the time and reporting on their sexual activity, among other behaviors. The payment, which covered about 15 percent of monthly household expenses, was split between the girl and her family. The researchers monitored school attendance and the girls reported on their sexual activity at the start of the trial and annually thereafter.

The results became obvious by end of the first year. The onset of sexual activity was 38 percent later for girls in the treatment group than for girls in the control group. The increase in number of lifetime sexual partners was 25 percent less for treatment group girls than control group girls. The probability of becoming pregnant reduced by 40 percent for schoolgirls who had been dropouts before the study (compared to their counterparts in the control group). A World Bank review of the study concluded that the cash led to declines in the onset of the girls’ sexual activity and declines in risky behavior among those girls who were already sexually active.

As in Malawi, poverty and poor sex education combine to lead to risky sexual behavior among Mississippi teenagers.
Mississippi is better off than Malawi. It has higher incomes, less disease, better schools. But where it does resemble Malawi is in its high rate of teenage sex and pregnancy. According to the Center for Disease Control’s High School Youth Risk Behavior Survey Data, in 2012, 58 percent of high school students in Mississippi were sexually active and 35 percent did not use condoms. We can partly attribute this to the fact that sex education in Mississippi is oriented around abstinence, with half of its 82 school districts adopting an abstinence-only health education program. But it is also partly due to the state’s high poverty rate. Children in Mississippi are poorer than children anywhere else in the U.S. As in Malawi, poverty and poor sex education combine to lead to risky sexual behavior among Mississippi teenagers. So, can we pay Mississippi teenagers to have less sex?

We already know that paying American children to change other behaviors can work. In a pilot program in New York City, NYC Opportunity, conditional cash transfers resulted in a subset of poor students improving both school attendance and educational outcomes. The program also reduced teenagers’ aggressive behavior and substance abuse.

Both Malawi and Mississippi have a surfeit of teenage pregnancy. The typical American antidote for reducing sexual behavior amongst teenagers—sex education—cannot work in Mississippi because of religious opposition by school boards. Meanwhile, conditional cash transfers reduced sexual behavior in a well-received randomized control trial in Malawi. Finally, we know that conditional cash transfers have successfully increased positive behavior among poor students in New York City.

Can we pay Mississippi teenagers to stop having sex? To abstain until they are older? And to have safe sex if they do have sex? Teenage pregnancies cost Mississippi $155 million a year, according to a study by the Women’s Fund of Mississippi. There is an opportunity here to try a new tactic that can reduce the rate of teen pregnancies without upsetting religious leaders.

To start, a randomized control trial could test the viability of using cash transfers to reach, teach and engage Mississippi teenagers in healthy sexual behavior. This trial could test proof of concept by paying at-risk students to attend non-school based teen programs like Delta Health Partners Healthy Initiatives, Operation Shoestring, and Talking Parents/Healthy Teens, programs that use non-school funding to teach sexual education. If paid students reduce sexual behavior and have fewer pregnancies, then a larger program could be piloted.

The U.S. has some of the most disadvantaged communities in the developed world. Their circumstances and needs are so diverse that all they seem to have in common is the country’s inability to help them without spending trillions of dollars on hotly contested programs. Adapting and trying out tactics from developing countries could achieve specific goals in specific circumstances without getting mired in the politics and bureaucracy of the endless welfare debate.