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Playing with dolls


With a new baby in the house parents can look forward to sleepless nights and sleepless days, beholden to a creature whose whims they have very little control over.  Life revolves around sleeping, eating and changing nappies with seemingly no respite.  As you queue up in the supermarket to buy another packet of newborn nappies, your eyes meet with another new parent and you wonder if you look as tired as they do. Do you have the same posset stains on your crumpled t-shirt? A nod recognizing the shared suffering and you both shuffle out – the living dead – into the car park.

Being a new parent can be hard, even if you are prepared for it, it can be even harder if you are still at school.  With the number of teenage pregnancies in Australia unchanging a number of strategies have been tried to reduce the incidence.  Perhaps one of the most well know is the introduction of realistic infant simulators (or dolls) into the classroom. But how effective are they? This randomized control trial from Western Australia tries to provide the answer.

Brinkman SA, Johnson SE, Codde JP, Hart MB, Straton JA, Mittinty MN, Silburn SR. Efficacy of infant simulator programmes to prevent teenage pregnancy: a school-based cluster randomised controlled trial in Western Australia. The Lancet. 2016 Aug 25.

What was the premise of the study?

The investigators wanted to know if a Virtual Infant Parenting (VIP) program reduced the incidence of teenage pregnancies. According to the Australian Bureau of Statistics, Australia has a rate of 16 births per 1,000 girls aged 15-19. This has fallen from a rate of 55.5 per 1,000 in 1971.  This is likely due to the ease of access to effective contraception rather than a drop in sexual activity.


The teenage pregnancy rate in Aboriginal and Torres Strait Islanders has only been reported since 1997. Currently, it has a rate similar to the general population in the 1970s – 57 per 1,000 girls.

How was it carried out?

The study took place in Perth, Western Australia between 2003 and 2006.  All 66 high schools (excluding the Catholic ones) in the region were included in the trial and randomized on a 1:1 basis using a table of random numbers. With a limited number of infant simulators available only five students per week could be enrolled in the program. Once a school had been designated as a VIP or non-VIP school the tricky task of obtaining informed consent took place.  With incentives to enrol including a chocolate frog for the children and a tea bag for the parents one might wonder at the low level of participation.  Only 45% of the control group and 58% of the intervention group consented

What did the program involve?

These high-end dolls are designed to replicate a baby’s usual feeding and sleeping habits. They were part of a combined package that the school health nurses delivered over six days.  This included four small group discussions, a reference workbook, watching a documentary of teenage mothers talking about their own lives and finally, the homework.  This meant the children had to ‘care’ for their infant charges from the end of the school day on Friday to recommencement on Monday morning.

What end-points were the researchers looking at?

The girls were followed up until the age of 20 using data linkage to hospital and specialist clinic records looking for the following outcome measures:-

  • Live birth
  • Stillbirth
  • Termination of pregnancy

They were unable to collect data with regard to miscarriages and their is no mention of students that may have moved out of state.  Sample size calculations (to detect a 25% reduction in pregnancy rates) worked out as 1300 per arm of the trial.

Were the two study groups equal?

A number of baseline variables were looked at including:-

  • Socio-economic status
  • Family type (original parents/step parents/blended families)
  • Level of psycho-social distress
  • Smoking status
  • Whether they had ever drunk alcohol
  • Whether they have looked after young children before
  • Were they sexually active?

If you compare the control group with the intervention group it is clear that the two groups are not identical when it comes to these baseline variables.  The intervention group contained girls of a lower socioeconomic status and who were less likely to be living in a traditional (two original) parent family unit.

What were the surprising results of this study?

8% of girls in the intervention group (97 out of 1267) recorded one or more pregnancy.

4% of girls in the control group (67 out of 1567) recorded one or more pregnancy.

In other words, one could suggest that playing with the dolls made the girls more comfortable with having their own children.  Of course, correlation does not equal causation. There were low levels of participation at an individual level in the study (45% in the control schools and 58% in the intervention schools).

So why didn’t this expensive intervention work? One commentator came up with four possible reasons.

  1. The intervention  targeted only teenage girls and not the potential fathers.
  2. Teenage pregnancy might be a result of a subconscious evolutionary desire to escape from adversity.
  3. Teenage girls might idealise adulthood because of the positive feedback and attention they get from their peers because of the simulators.
  4. Socioeconomic factors are associated with teenage pregnancy.

Does these findings fit in with previous research on the topic?

A recently updated Cochrane review looked at 53 randomised controlled trials comparing various interventions against standard (if there is such a thing) sex education classes.  The only interventions that appeared to be of benefit were those that combined education and the promotion of contraceptive use.

Teenagers at risk of unintended pregnancy

Other studies have also suggested that infant simulators have minimal impact on teens perceptions of early pregnancy.

Does the media have a role to play?

Vicky Pollard aside, several popular television programmes have depicted young mums. 16 and Pregnant and Teen Moms may have some influence on behaviour. Examination of Google and Twitter analytics around the time of new episodes showed a significant upswing of interest around the terms “birth control” and “abortion”. Again, correlation does not equal causation, but this corresponded with a US-wide reduction in teenage mothers of around 5.7%.

How else can we reduce the rate of teenage pregnancy?

It’s worth reading the UK’s Teenage Pregnancy Strategy in full to look at an example of a successful programme that combines education, improving access to effective contraception (especially LARC’s), and targeted interventions to at risk groups. Or perhaps they should just watch this…


Brinkman SA, Johnson SE, Codde JP, Hart MB, Straton JA, Mittinty MN, Silburn SR. Efficacy of infant simulator programmes to prevent teenage pregnancy: a school-based cluster randomised controlled trial in Western Australia. The Lancet. 2016 Aug 25.

Hadley A, Ingham R, Chandra-Mouli V. Teenage Pregnancy Strategy for England. The Lancet. 2016 May 24.

Herrman JW, Waterhouse JK, Chiquoine J. Evaluation of an infant simulator intervention for teen pregnancy prevention. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2011 May 1;40(3):322-8.

Kearney MS, Levine PB. Media influences on social outcomes: the impact of MTV’s 16 and pregnant on teen childbearing. The American Economic Review. 2015 Dec 1;105(12):3597-632.

Marino JL, Lewis LN, Bateson D, Hickey M, Skinner S. Teenage mothers. Australian Family Physician. 2016 Oct;45(10):712.

Oringanje C, Meremikwu MM, Eko H, Esu E, Meremikwu A, Ehiri JE. Interventions for preventing unintended pregnancies among adolescents. The Cochrane Library. 2016 Jan 1.

Quinlivan JA. Magic dolls: no quick fix for teenage pregnancy. The Lancet. 2016 Aug 25.

Taylor D, James EA. An evidence‐based guideline for unintended pregnancy prevention. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2011 Nov 1;40(6):782-93.

Whitaker R, Hendry M, Rabeea’h Aslam AB, Carter B, Charles JM, Craine N, Edwards RT, Noyes J, Ntambwe LI, Pasterfield D, Rycroft-Malone J. Intervention Now to Eliminate Repeat Unintended Pregnancy in Teenagers (INTERUPT): a systematic review of intervention effectiveness and cost-effectiveness, and qualitative and realist synthesis of implementation factors and user engagement. Health technology assessment (Winchester, England). 2016 Feb;20(16):1.



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