Despite improvements in sexual health education and services for young people, pregnancy rates and sexually transmitted infections among this group remain high
The under-18 conception rate in England is at a 40-year low but a further reduction is needed to reach levels in comparable western European countries. Sexually transmitted infections are common among young people, with chlamydia the most prevalent STI in the UK.
To challenge this, a multi-agency approach is needed, with high-quality sex and relationships education, easy access to contraception and sexual health services and an open culture around relationships and sexual health. Nurses play a crucial role in supporting young people within both contraception and sexual health services and as trusted practitioners in a range of settings.
Citation: Hadley A, Evans DT (2013) Teenage pregnancy and sexual health. Nursing Times; 109: 46, 22-27.
Authors: Alison Hadley OBE is director of the Teenage Pregnancy Knowledge Exchange, University of Bedfordshire; David T Evans is senior lecturer in sexual health, University of Greenwich.
- This article has been double-blind peer reviewed
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In a recent public opinion poll, teenage pregnancy rates were estimated to be 25 times higher than official government statistics (Ipsos Mori, 2013). In fact, rates in England are at the lowest level since 1969. As a result of the previous government’s Teenage Pregnancy Strategy (Social Exclusion Unit, 1999) and concerted efforts by individual services and practitioners between 1998 and 2011 the under-18 conception rate fell by 34% (Office for National Statistics, 2013). Nurses have played a major role in this success.
However, we are only two-thirds of the way towards the original goal of a 50% reduction. The majority of teenage pregnancies remain unplanned, with at least 50% ending in a termination. Outcomes for young parents and their children, although improving, remain disproportionately poor.
In addition, despite improvements in rapid access to sexually transmitted infection screening and treatment, STIs are common among young people, with chlamydia being the most prevalent sexual infection in the UK (Public Health England, 2013).
A continuing priority
These statistics explain why teenage pregnancy and sexual health continue to be prioritised in new policy of the coalition government.
The Public Health Outcomes Framework 2013-16 (Department of Health, 2013a), against which national and local government will monitor improvements in public health, includes reducing under-18 conception rates and late diagnosis of HIV, and increasing chlamydia diagnoses among 15-24-year-olds as key sexual health indicators. Alongside this, the Framework for Sexual Health Improvement in England highlights reducing rates of under-18 conceptions and STIs as two of the five priority areas for improvement (DH, 2013b).
The teenage pregnancy (SEU, 1999) and sexual health and HIV strategies (DH, 2001) were based on the best international evidence on what helps young people both to prevent early pregnancy and to look after their sexual health.
High-quality sex and relationships education (SRE) is essential. This should be regular and continuous, not a one-off condom teaching session or single day at the end of year 11, and should be delivered by trained educators, building knowledge and skills to help young people develop healthy and safe relationships (Kirby, 2007). Comprehensive SRE also needs to be combined with easy access to free youth-friendly contraceptive and sexual health services and free condoms (Santelli et al, 2007). There is no good evidence that “abstinence only” programmes or cutting social welfare for teenage parents are effective methods of reducing rates of teenage pregnancy or STIs.
To be effective, prevention needs to reach all young people, with more intensive prevention for those at greatest risk. By the age of 20, around 90% of young people will be sexually active so they all need effective SRE and access to contraceptive and sexual health services to help them look after their sexual health.
Nurses and other practitioners, such as SRE teachers, need to be alert to identify young people who are at increased risk of unprotected sex and who may need extra support. A recent study found the girls most at risk of pregnancy before 18 were:
- Eligible for free school meals;
- Persistently absent from school;
- Making slower than expected academic progress between key stages 2 and 3 (ages 11-14) (Crawford et al, 2013).
Other risk factors are:
- Being in care or a care leaver;
- Experiencing sexual abuse and exploitation;
- Alcohol use and misuse;
- Having had a previous pregnancy.
In England, an estimated 20% of births conceived to under-18-year-olds are to young women who already have a baby, and 11% of terminations to under-19s are young women who have had one or more terminations before.
Although data on boys and young fathers is not routinely collected, individual studies have found similar vulnerabilities (Fatherhood Institute, 2013).
The risk factors for unplanned and teenage pregnancies also affect the motivation and sense of self-worth young people need to consistently use condoms to prevent STIs.
With all young people, but particularly those with risk factors, nurses need to be vigilant for signs of sexual exploitation and abuse. Brook, a sexual health charity for under-25s, has an online traffic light tool that provides a helpful guide to assessing sexual behaviours (Brook, 2012).
Sexual health improvement framework
The sexual health improvement framework (DH, 2013b) builds on the evidence from the teenage pregnancy and sexual health and HIV strategies. It sets out clear ambitions across a person’s “life-course” that require local authorities and clinical commissioning groups to make further progress.
A main objective of the framework is to build an open and honest culture around relationships and sexual health, something that is common in comparable countries with low teenage pregnancy rates. Despite strong evidence that effective SRE delays sexual activity and protects children and young people, a fear of open discussion continues to be a barrier for some schools to providing even the basic foundations of SRE as well as new challenges such as pornography and social media. Embarrassment deters many parents and their children from discussing sex and relationships, and many teenagers still report a sense of stigma and disapproval if they ask for sexual health advice.
For lesbian, gay, bisexual and transgender (LGBT) young people and other marginalised groups, the silence and stigma around sexual health can be even more acute (Burrows, 2011). This may lead to homophobic bullying, from schools and institutions as well as individuals, which ultimately contributes to higher levels of mental health problems, unprotected sex and suicide risk in these groups.
For many young LGBT people, the “invisibility” of their lifestyles and needs is another barrier that prevents them from accessing sexual health services (especially, for example, if such services are perceived to be for “family planning”). Some nurses and professional carers may have unwelcoming beliefs about non-heterosexual people or may be unaware of the sexual health needs of young LGBT people, especially safer sex for STI and HIV prevention (Evans, 2013; Royal College of Nursing, 2012).
The wider health workforce
Because teenage pregnancy and sexual health are complex lifestyle issues, the sexual health framework asks local authorities to include the preventive role of the wider health and non-health workforce in commissioning and to join up sexual health services with other local support services. These can include drugs and alcohol, mental health and sexual violence services.
Making every contact between a young person and a professional count and creating a seamless care pathway helps to ensure that young people access help early and reduces healthcare costs (Brook and fpa, 2013).
How can nurses help?
Nurses have been essential to achieving a significant reduction in the UK’s teenage pregnancy rate and improving access to sexual health services.
Their contributions include the following:
- Nurse-led contraceptive and sexual health services;
- Sexual health outreach nurses providing targeted support for at-risk young people;
- School nurses working as part of multi-agency school and college-based clinics (Box 2);
- Postnatal and post-termination contraception nurses helping young women prevent repeat pregnancies (Box 3);
- Practice nurses offering drop-in services in primary care and contributing to SRE programmes.
However, even without formal courses in aspects of contraception and sexual health, nurses can still make a valuable contribution. Table 1 outlines a few key areas to consider.
As part of the school nurse development programme (DH, 2012), the Department of Health England is planning to publish a Sexual Health Professional Pathway to help school nursing teams, college and sexual health nurses provide high-quality teenage pregnancy prevention and sexual health promotion for young people. The DH will also produce a new practice nursing model that will include suggestions on how practice nurses can support young people in looking after their sexual health. In spring 2014, the DH will publish a compendium of school nurse good practice examples in order to help share effective local work, including examples of male school nurses.
This discussion article has taken a broad approach to preventing teenage pregnancy, contraception and the sexual health of young people and how nurses in various fields of practice can support young people.
The aim has been to raise awareness of some of the key issues involved in sexual health for young people and to point you to further resources if you wish to continue your personal and professional development. The article is based on a study day developed for health and non-health professionals working with young people and delivered in local areas by Alison Hadley and David Evans.
- The under-18 conception rate in England is at its lowest level since 1969
- Rapid access to sexually transmitted infection screening has improved significantly
- Continuing to reduce teenage pregnancy and improve young people’s sexual health remains a government public health priority
- A fear of open discussion about sexual health continues to be a barrier to providing young people with accurate information
- Nurses in all settings have a role in supporting young people to prevent pregnancy and STIs
For more information, contact firstname.lastname@example.org
Brook (2012) Sexual Behaviours Traffic Light Tool. A Guide to Identifying Sexual Behaviours. Brook: London.
Brook and fpa (2013) Unprotected Nation: the Financial and Economic Impacts of Restricted Contraception and Sexual Health Services. London, Brook and fpa.
Burrows G (2011) Lesbian, gay, bisexual and transgender health: part 1 - sexual orientation; Practice Nurse; 41: 3, 23-25.
Crawford C et al (2013) Teenage Pregnancy in England. Centre for Analysis of Youth Transitions Impact Study 6. Sheffield, Institute for Fiscal Studies.
Evans DT (2013) Promoting sexual health and wellbeing: the role of the nurse. Nursing Standard; 28: 10, 51-58.
Department of Health (2001) National Strategy for Sexual Health and HIV. London: Department of Health.
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Department of Health (2013b) A Framework for Sexual Health Improvement in England. London: DH.
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Fatherhood Institute (2013) Fatherhood Institute Research Summary: Young Fathers. Savernake: Fatherhood Institute.
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Office for National Statistics (2013) Conceptions in England and Wales 2011. London: Office for National Statistics.
Public Health England (2013) Sexually Transmitted Infections Annual Data. London: PHE.
Royal College of Nursing (2012) The Nursing Care of Lesbian, Gay and Bisexual Clients - Guidance for Nursing Staff. London: Royal College of Nursing.
Santelli J et al (2007) Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. American Journal of Public Health; 97; 1, 150-156.
Social Exclusion Unit (1999) Teenage Pregnancy Report. London: Social Exclusion Unit.