VOL: 98, ISSUE: 04, PAGE NO: 36
Mary Kiddy, BSc, RGN, RSCN, is a teenage pregnancy coordinator at Calderdale and Huddersfield NHS Trust, West Yorkshire
Teenage pregnancy is perceived as a problem in the UK and has negative connotations. It is associated with health inequalities and attracts a great deal of media attention. The issues of access to housing, benefits and declining morals dominate the headlines, perpetuating the myth that young women have babies for material gain. What is not addressed, however, is how young women become pregnant in the first place.
Research shows that for most young women discovering they are pregnant is a shock (Tabberer et al, 2000). Early pregnancy can have a negative effect on the health of mother and child (Irvine et al, 1997) as well as having long-term adverse effects on education, employment and economic status (Acheson, 1998). But it is important to remember that teenage pregnancy is not always a disaster and is sometimes planned. Indeed, 10% of teenage pregnancies occur within marriage. So whose problem is teenage pregnancy?
Quantifying the problem
Teenage pregnancy is a complex issue that is poorly understood even by teenage parents themselves. ‘Teenage pregnancy’ is, in itself, an emotive term that covers a whole array of conception issues, including miscarriage, termination and live birth.
The Social Exclusion Unit (SEU) report on teenage pregnancy in England (1999) quotes a figure of 90,000 teenage conceptions for 1997. Of these, 56,000 resulted in live births. Some of these conceptions may have been second pregnancies and many occurred among teenagers at high risk of social exclusion, including those in the care of local authorities. Those who run away from local authority care are over-represented in teenage conception rates.
The actual rate of conception varies widely across the UK with the average being 30 per 1,000 women aged 15-19, but there is a direct correlation between high teenage pregnancy rates and areas of high deprivation (SEU, 1999).
Overall, teenage birth rates in the UK have not changed during the past 20 years, in marked contrast to the rest of western Europe. The Netherlands and France, in particular, have significantly reduced live birth rates among this age group during the same time period. In the UK, the pattern of teenage births more closely resembles that of other English-speaking nations - the USA has the highest rate of such births in the developed world (SEU, 1999).
Adolescence is a transitional phase of life (McRae and Rote, 1997) concerned with the development of maturity and independence. Rosenbaum and Carty (1996) refer to the ‘sub-culture of adolescence’ as markedly different to childhood or adulthood and culturally less well defined. This is particularly true in the developed world, where teenagers are often dependent on the family unit for an extended period of time because they are in full-time education. Adolescents constitute approximately 15% of the population in the developed world (Sawyer and Bowes, 1999). However, within this group, there are variations in aspirations, achievement and education, as well as differing socio-economic factors and cultural issues, all of which impact on the health and health-related behaviour of young people (Glendinning et al, 1995; Wiley et al, 1997; Mitchell and Wellings, 1998; Pavis et al, 1998). All these research studies agree that adolescence is a time of experimentation and is strongly associated with the development of risk-taking in activities, such as smoking, drinking alcohol, drug abuse and sexual health.
It can safely be assumed that adolescence is a confusing time. The physical and emotional changes that result in a changed self-concept (King, 1997) may be compounded by the pressure of taking exams and lifestyle choices that occur after primary school.
Sexually speaking, young people receive mixed messages from the world around them. These messages come via ‘teen’ magazines, which are usually targeted at girls, newspapers, advertising and the internet. In contrast to this easily accessible information are the difficulties parents often have in talking to young people about sex (Rosenthal et al, 1998). Kenny (2000) has claimed that schools are also reluctant to timetable sex and relationship education (SRE). Young people’s concerns around confidentiality in sexual health clinics compound the problem (Davies and Casey, 1999; Wellings and Kane, 1999).
It is not surprising that many young people feel poorly equipped to deal with sexual relationships and unable to access contraceptive services. Both are factors in the high teenage conception rates.
High teenage pregnancy rates in the UK are often attributed to poor or non-existent SRE programmes in schools (Fullerton, 1997). The perception that teaching children and young people about sex and relationships will lead to earlier sexual experiences still persists, despite evidence to the contrary (Wellings et al, 1995).
Until recently, this ambivalence has been underpinned by a lack of support at national level. However, since the publication of Sex and Relationship Education Guidance (Department for Education and Employment, 2000), all schools are now obliged to have a policy for SRE, which must reflect the wishes of parents, teachers and governors and take account of the local community setting. Despite this, teaching SRE is non-statutory - apart from human growth and reproduction, which is taught as part of the science curriculum - and parents still have the right to remove their children from sessions.
Another criticism levelled at SRE is that it comes too late for many adolescents. Much SRE takes place in year 10 when adolescents are 14 and 15 years old. The evidence suggests that some young people have already started sexual relationships by this time (Few et al, 1996; Mackereth and Forder, 1996). Given that the rise in the live birth rate increases significantly at 15, this would seem a fair assumption.
A further challenge is how to include boys and young men - teenage pregnancy and SRE are often seen as female issues. But boys are less easy to engage than girls (Measor et al, 1999) and are more likely to be excluded from classes because of anti-social behaviour. There are also few male ‘sex educators’ available in most areas and this can be a significant factor in depriving boys of the necessary lessons.
Community-based SRE can offer a viable alternative and should bring together parents, young people, faith groups and the wider community to address the issues of teenage pregnancy and sexual health. Part of the Netherlands’ success in reducing the teenage birth rate is attributed to what is seen as a more open culture surrounding teenage sexuality, which allows schools and parents to talk about issues without embarrassment.
Every teenage pregnancy is the result of unprotected sex - either when a contraceptive fails or when none is used. Mackereth and Forder (1996) found that adolescents had widely differing levels of knowledge; some had an accurate understanding of contraception and some had none at all. The understanding of emergency contraception was found to be generally low.
Barriers to accessing services also exist. Pearson et al (1995) found that teenagers with unplanned pregnancies were less confident about using family planning services. Almost 30% of the interviewees had not used any method of contraception.
Lastly, and probably most importantly, there is a real issue about communication and contraception. A survey of teenagers’ first sexual experience (Mitchell and Wellings, 1998) found that they felt unable to discuss sexual intercourse with their partner, even when it was taking place. This scenario left no opportunity for negotiations about contraception and was particularly characteristic of younger teenagers.
The government has recognised that teenage pregnancy is a complex public health concern encompassing a broad range of issues ranging from poverty and deprivation to lack of knowledge and poor communication skills. The target of halving the number of conceptions by under 18s by 2010 is ambitious, but is well supported with resources and cross-departmental strategies.
A national cross-departmental teenage pregnancy unit is spearheading a multifaceted approach to the problem. Each area of England now has a local teenage pregnancy strategy linked to a local implementation fund, with regional and local teenage pregnancy coordinators already in place. Local strategies cover four key areas:
- Media campaigns;
- Sex and relationship education;
- Sexual health services;
- Support for teenage parents.
The coordinator’s role is to ensure that partnerships between young people, health care professionals and concerned organisations (youth services, health promotion agencies, housing, social services, leisure services, Sure Start, Health Action Zones and voluntary agencies) are developed locally and have common ownership of a specific aim. The intention is to provide a variety of preventive and support services that young people can access.
This means developing coherent SRE policies that reach all young people - not just those at school, particularly as some of the most ‘at-risk’ young people attend irregularly or not at all.
What stands out is the fact that pregnancy is a choice for only a very few. For most sexually active teenagers, a lack of knowledge and communication skills ensure that the odds are stacked against them. For the first time, however, national targets to reduce teenage pregnancy have resources attached to them.
Change is achievable only by giving consistent messages to young people. Developing SRE policies in schools and providing sexual health services that young people feel confident to use are vital, as is ensuring teenage parents are fully supported to give themselves the best chance in life.
Teenage parents and their children are among the most vulnerable members of society and this has now been formally recognised by public health strategy. Rather than labelling young people, we have been given a chance to work with them to tackle the causes of teenage pregnancy and to ensure that they can at least make informed choices about when to become parents.
- See next week’s issue for a report on sexual health roadshows for teenagers. For more information on the cross-government Teenage Pregnancy Unit’s strategy, see www.teenagepregnancyunit.gov.uk