Teenage pregnancy: a multi-factorial problem that needs a joined-up action plan
Teenage pregnancy: a multi-factorial problem that needs a joined-up action plan |
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Key words: sexually transmitted infections, young people, pregnancies
Introduction
Teenage pregnancies are an important public health issue because of the short
and long term problems associated with them. Rate of teenage pregnancy in the
UK has been estimated to be 30 per 1000 women aged 15-191. Teenage pregnancy
rates in the UK are relatively higher than most of the other European countries
where there has been a steady decline over the past 20 or so years. The rates
for the USA are 55/1000.
The average age at which young people start having sex has been getting younger.
It is now 17 in the UK; forty years ago it was 21 for women and 20 for men.2
The use of contraception by sexually active teenagers is lower in the UK compared
with other European countries.3
Most of the pregnancies are not planned4 and happen through not using contraception
or failure of the contraception method. Around 50% of conceptions in under 16s
end up being terminated. A significant number of these teenage girls conceive
again in their teens.
Why it matters
Teenage mothers are more likely to have obstetric risks such as anaemia, toxaemia,
eclampsia, hypertension, prolonged and difficult labour and small for gestational
age babies. The perinatal mortality rate of their infants is 60% higher than
for babies of older women5. Early motherhood is also strongly associated with
adverse outcomes in later life, for example long periods on state benefits,
lower income and being more likely to remain a lone parent and be in semi-skilled
or unskilled manual occupations.6 The personal and social costs of significant
numbers of teenagers who drop out of education and economic cycle are significant.
Risk factors for teenage pregnancy
Research in the UK and in the other countries has shown that low socio-economic
class, poor educational opportunities and dropping out of school are significant
risk factors for teenage pregnancy. There are associations with teenage parenthood
and not being in education, training or work and with a history of sexual abuse,
mental health problems and involvement in crime. Multiple risk factors also
lead to a geographical distribution of teenage pregnancy, with the highest rates
in the poorest areas7. Some ethnic populations are at high risk of higher teenage
pregnancy.8
There are many reasons put forward by teenagers for not using contraception.
These include fears regarding confidentiality, sheer ignorance (lack of adequate
sexual health education in schools), youth-unfriendly environment of family
planning clinics. Location and opening hours of family planning clinics may
not be suitable for teenagers who may be tied to a school timetable and rely
on public transport. A recent study suggests a lower rate of teenage pregnancy
in general practices with a female doctor than those without a female doctor.9
There is a high rate of failure of contraception among teenagers principally
with condoms and the pill. When a regular contraceptive method fails, or is
missed, access to emergency contraception may provide a last chance against
an unwanted pregnancy, but this option is underused by teenagers.
Factors responsible for teenage pregnancies.
Individual’s reasons for sex and parenthood are never simple to understand
but 3 factors stand out;
The first is low expectations. Throughout the developed world teenage pregnancy
is more common amongst young people who have been disadvantaged in childhood
and have poor expectations of education of getting a job. They see ‘no
reason not to get pregnant’.
The second is ignorance. Young people lack accurate knowledge about contraception,
sexually transmitted diseases, what to expect in relationships and what it means
to be a parent. Only around half of under 16’s and two third of 16-19’s
use contraception when they start to have sex, compared with around 80% in the
Netherlands, Denmark or the US.
The third is mixed messages. The society and media are more open towards sex
than in the past and give the implied message to a teenager that sexual activity
is the norm. On the other hand most parents and public institutions are reluctant
to talk about sex and there is an expectation that sexual activity should be
delayed. One teenager quoted "it sometimes seems as if sex is compulsory
but contraception is illegal".
How to tackle the problem
Due to the variety of factors contributing to the problem of high teenage pregnancy,
the prevention strategies should address these factors individually, to break
the chain of events at several points.
National Campaign.
There is a desperate need to raise awareness of the issue in the society, among
parents, professionals and the teenagers themselves to change the culture around
the issue. A new structure is being put in place for coordination of action
between national and local plans with clear accountability arrangements. The
Department of Health in UK has set out an action plan (The National Teenage
Pregnancy Strategy)1, to achieve the target goal of halving the pregnancy rate
of under-18s by 2010. An independent national advisory group on teenage pregnancy
has been set up to advise government and monitor the success of the whole strategy.
At a local level, named coordinators are identified. Coordination of genito-urinary,
contraceptive and psychosexual services should improve the sexual health and
use of contraception. Advertisement of these integrated services in the local
media is recommended. Areas of high teenage pregnancy should be identified and
specific local campaigns organized for these.
There is encouraging evidence that success is possible. In Stovner, Oslo, teenagers
abortion rates halved from 1988 levels after the introduction of an integrated
package, including young people's clinics and age-appropriate sex education.
These results have been rolled out across Oslo, and the initial cohorts continue
to have low abortion rates aged 20-24.10
Sex and Relationship Education (SRE) To reduce the teenage pregnancy rates
at all ages, young people have to be prepared far more effectively for sex and
relationships. SRE does not make young people more likely to start sex. Indeed
it can help them delay starting sex and make them more likely to use contraception
when they do.11 In a survey of 19000 people, two thirds thought they should
have been better informed about sex when they started being sexually active.
Research shows that ignorance about sex is a risk factor for teenage pregnancy
and that good sex education helps to delay rather than accelerate young people
start sex. Sex education at schools in generally not considered adequate.1
Despite the recent emphasis on sex education, few controlled studies have addressed
the effectiveness of such education in preventing adolescent pregnancy, perhaps
because of the multifactorial nature of the problem. A study conducted in low
income African Americans on HIV risk reduction12, compared the abstinence interventions,
with delaying sexual intercourse or reducing its frequency, and the safer sex
intervention with condom use. Follow up was done at 3, 6, and 12 months. Compared
with controls, abstinence intervention participants were less likely to report
having had sexual intercourse at 3 months but not at 6 and 12 months. Among
participants who were sexually experienced at baseline, those receiving the
safer sex intervention reported having less sexual intercourse, and less unprotected
sex than did the control or abstinence- intervention groups. The authors concluded
that safer-sex interventions are more effective than the abstinence interventions.
Targetting high risk groups.
There is a need to identify groups of teenagers with a high risk of parenthood.
These groups include children under care, children excluded from schools and
young men linked to young offenders institutes. The social services need to
give priority to preventing teenage pregnancy for the children in their care.
Young offenders institutes should offer parenting and sexual health classes.
There should be arrangement in place for sex education for children excluded
from schools. The overall framework should be improved for 16-18 years olds
not benefiting from education, training or employment.
Once a teenager has had one baby, she is at increased risk of having another.13
Young mothers should be educated about contraceptives, counselled about vocational
and educational options and supported in their efforts to pursue a career in
addition to motherhood.
Access and information regarding contraceptive services There should be better access, effective advertising and signposting of services. All services should review their opening hours to match the local population needs. Clear and credible guidance should be available for health professionals on the prescription, supply and administration of contraceptives to under 16s, including a duty to counsel them when they seek advice on contraception.
Emergency contraception
Many reproductive health care workers believe that the number of unplanned pregnancies
and abortions could drop with widespread access to emergency contraceptive pills.
Most teenagers are simply unaware of this option.4 All Health Authorities should
ensure an effective advertising and easy availability without prescription.
Health care professionals could take a more proactive role by telling their
teenager patients about the pills and providing them both in advance of and
in response to emergency situations.14
Teenagers may be encouraged to use contraceptive methods that are less user
dependent and more reliable e.g. Injection Depo-Provera and Implanon, alongside
the use of condoms to protect against sexually transmitted infections.
Access to Abortion services
As most of the teenage pregnancies are unplanned4, hence a significant proportion
of these end up in abortions. Access to abortion services varies greatly from
place to place and from doctor to doctor.1 In the report by the social exclusion
unit, young women reported a disapproving staff attitude and inadequate counselling
in some abortion clinics. Little opportunity was taken when women presented
for abortion for future contraception information and supply to prevent a repeat
unplanned pregnancy.
Uniform provision and timely access to the abortion procedure is one of the
key recommendations of the Unit. From 2005 Women who meet the legal requirement
for abortion should have access to an abortion within 3 weeks of the first appointment
with the GP or other referring doctor.
Better support
Teenagers who become parents should not lose on opportunities for the future.
Young people should have the chance to complete their education and prepare
to support themselves and their family. Housing policies that take account of
young parents needs (not a lone tenancy), child care to complete their education
and help to find a job should be provided. The child support agency (CSA) should
target the fathers of children of under 18 mothers for early child support action.
National Strategy for Sexual Health and HIV (July 2001)15 is the first national
strategy to prevent and manage sexual ill-health. The consequences of poor sexual
health, unintended pregnancies and STIs can have a long lasting impact on people’s
lives. With unprotected intercourse, there is a 90% risk of conceiving within
one year. In a single act of unprotected sex with an infected partner the risk
of acquiring genital herpes is 30%, gonorrhoea and chlamydia 30-50% and 1% risk
of acquiring HIV.4 This national strategy addresses the rising prevalence of
sexually transmitted infections and of HIV and aims to reduce the transmission
and prevalence of HIV, STIs and unintended pregnancy rates.
Conclusion
Teenage pregnancy is not an easy issue to tackle for any Government. With carefully
considered and consistently implemented policies, a step-wise change can be
made that brings benefit in fewer unwanted pregnancies and consequently young
people having better chances for future.
References
©2004 Sexual Health Matters. Published Quarterly by Express
Print Works, Middlesbrough, UK
ISSN 1469-7556
http://www.sexualhealthmatters.com