Adolescents are becoming sexually active at an increasingly younger age.
VOL: 99, ISSUE: 12, PAGE NO: 32
Suzanne J. Hughes, BSc, RGN, is senior staff nurse, main theatres, Llandough Hospital, Cardiff
The Family Planning Association reports that nearly one in five young women say they have had sex before the age of 16 (Maner and Rees, 1998). Much of this activity is risky, contraceptive use is often erratic and may result in unwanted pregnancies. In a few instances, sexual activity is forced (World Health Organization, 2000).
Within Western Europe, the UK stands out as having the highest teenage birth rate (Fig 1). It is twice that of Germany, three times that of France and six times that of The Netherlands (Brennan, 2002). The National Assembly for Wales (2003) has published statistics showing that Wales has a consistently higher teenage birth rates than England. In 2000, the conception rate in Wales for under-18s was 47.3 per 1,000 females. Although the rate fluctuates from year to year, the latest figures are below the peak 1998 level.
Unwanted teenage pregnancy is clearly a health problem for Wales. Tables 1 and 2 illustrate the number of abortions performed in Wales by age and area of residence during 2000.
Abortion remains a common approach to handling unwanted pregnancies, which is ideally performed in the first trimester, when an abortion is considered less traumatic. Perioperative nurses are frequently involved in caring for teenagers undergoing surgical termination of pregnancy. At the time of writing, I am a senior staff nurse working in the education department of a busy operating theatre suite comprising 11 theatres, which includes a day surgical unit and obstetric unit.
In 1946, the WHO (2002) defined health as ‘a state of physical, mental and social well-being and not merely the absence of disease or infirmity’. In other words, health is not simply about physiological parameters but also about how the person feels.
Medical practice is largely guided by a biomedical model of disease, which assumes that the condition can be fully accounted for by deviations from the norm of measurable biologic variables. Novack (1981) suggests that this model has outlived its usefulness and that a biopsychosocial model offers greater understanding of the illness process.
Most disease prevention focuses on the physiological aspects of health as illustrated by the biomedical model, but Engel (1981) developed a biopsychosocial model of health and illness integrating the psychological and social aspects of health into the more traditional biomedical model (Ogden, 2000). Reiser (1980) confirms that the biopsychosocial model forces realisation that states of health and illness can be fully understood in terms of their biological, psychological and social parameters only. Engel’s (1981) biopsychosocial model contains five elements that underpin the psychological aspects of health. These are:
The health needs of adolescents differ significantly from that of adults, with social and environmental factors playing a strong influence (Blackie et al, 1998). Adolescence is a time of transition from childhood to adulthood, a time when young people experience changes following puberty but do not immediately assume the roles, privileges and responsibilities of adulthood (WHO, 2002). Even as a purely biological phenomenon, puberty is far from being a simple, straightforward process (Gross, 2001).
Behaviour and beliefs
It is possible to argue that if young people were given more information and advice before they became sexually active then the incidence of teenage pregnancy and abortion would fall. This would suggest that young people are ignorant about contraception, proof of which comes from Quinn’s study (1999), which found that 70 per cent of women seeking termination of pregnancy said that they would have used emergency contraception had they known about it and where to obtain it.
Sexual health promotion in nursing practice has traditionally been equated with prevention at school level. However, practitioners face increasing demands to address the psychosocial aspects of sexual health, adapt theoretical paradigms from the behavioural sciences and increase the use of counselling skills (Irwin, 1997).
Although adolescents are enjoying greater freedom at a younger age, this brings more risks and greater costs when errors of judgements are made. Teenage pregnancy and abortion is one price some teenage girls pay for this extended freedom (Gross, 2001).
There are many biological, psychological and social reasons why women opt to terminate a pregnancy - this may include cultural, psychological, socioeconomic, education, career and genetic reasons. In some sociocultural settings, premarital sexual activity is taboo, using contraception is forbidden among unmarried youth, and abortion is viewed as the only solution to premarital pregnancy (WHO, 2002).
Adolescent pregnancy and abortion create a significant challenge for health care professionals, while social deprivation compounds the problems - the incidence has been shown to be inversely related to social class and educational attainment (Little, 1997).
In the 1960s teenage pregnancy began to be redefined as a social problem amenable to scientific scrutiny and intervention, rather than a moral problem of sexual transgression (Smith-Battle, 1998). The recommendations of the 1980 Black Report (Black, 1980), promoting sexual health in young people, was aimed at reducing unwanted teenage pregnancy and improving access to contraceptive services. Considering that this report was published almost a quarter of a century ago, the teenage conception rates in Wales remain high (Table 1).
The reasons why there is a high rate of unwanted teenage pregnancies in Wales could be attributed to a range of predisposing factors, which may include living in a challenging social environment, coming from a socially deprived area, low social class, lack of good-quality health care, high unemployment rates, and the effects of family background.
Smith-Battle (1998) believes that middle-class teenagers who become pregnant are more likely to choose abortion for educational and career reasons. However, Jolly (2002) believes that sexual health must depend on an understanding of why teenagers engage in unprotected sex, and stresses the need to recognise that social disadvantage and poverty are associated with increased risk-taking.
When the 1967 Abortion Act came into being, it defined therapeutic termination as one undertaken before the gestational age of 28 weeks. However, advances in technology have greatly improved the chances of survival for premature babies, and a reduction to 24 weeks was approved by parliament in 1990.
The Abortion Act made it possible for a woman to have an abortion legally, provided two doctors independently agreed that the termination was necessary to prevent:
- The likelihood of the woman’s death;
- Permanent illness - physical or psychological;
- Damage to a woman’s existing children;
- Prevent abnormality in the woman’s coming child.
Although this legislation extended the conditions under which a woman might be allowed to have an abortion, it stopped far short of endorsing the idea that a woman had an absolute right to control her body. Practically, therefore, the law relies on individual doctors exercising discretion as to who qualifies for an abortion (Timpson, 1996).
A pregnancy can be terminated by medical or surgical means and, although complications following termination are uncommon, there can be short and long-term complications (Liu and Lachelin, 1989). Women requesting termination should be made aware of these before the procedure is carried out.
There is evidence to suggest that a small percentage of women are affected by postnatal depression after abortion or miscarriage. Women’s reactions to abortion can vary from extreme relief to extreme distress (Gilchrist, 1995).
Having strategies to help patients cope with anxiety, stress, pain, anger, isolation, confusion and depression requires maturity, experience and a working knowledge of underlying theories of human behaviour (Kitson, 1999). Pre and postoperative visiting by a perioperative nurse can provide emotional support to teenagers choosing abortion, although nurses’ attitudes and behaviours also vary greatly.
McQueen (1997) demonstrates this in her qualitative study, which highlights situations when the use of ‘professional empathy’ may be incorporated in nurses’ behaviour. She reports that when caring for patients undergoing a termination, nurses show an appreciation of the mental turmoil that can precede the event and the possible emotional responses that can follow it. McQueen demonstrates that they tried to meet the needs of patients irrespective of their personal views on abortion.
There is, however, an opt-out clause. The Abortion Act states that ‘no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this act to which he has a conscientious objection’.
Overcoming the effects of stress
Stress can mean many different things. Psychologists define it as involving biochemical, physiological, behavioural and psychological changes (Ogden, 2000). Selye (1956) defined it as ‘a non-specific response of the body to any demand made on it’. His general adaptation syndrome hypothesised that the stress response was the body enhancing the function of the system best able to cope with it. He concluded that stress could be mild and controlled - and promote growth - or severe and prolonged - and the precursor of psychological and physical disturbances that disrupt health.
Usually the effects of stress are short-lived, and when the pressure recedes, the individual rapidly resumes normal life. However, where pressures are intense and sustained, stress can lead to long-term psychological and physical ill health (Harris, 2001).
Adolescents facing abortion are subject to many stresses. However, there is evidence to show that their psychological state improves postoperatively (Gilchrist, 1995). Studies on psychological response to abortion suggest that, although there may be sensations of regret, sadness and guilt, severe negative reactions are infrequent in the immediate and short-term aftermath of a first-trimester termination (Zolese and Blacker, 1992).
Anxiety can be the response to, or the cause of, stress, which is a biophysiological event. Adolescents undergoing surgical termination of pregnancy are often anxious and frightened, and for the majority it will be their first operating-theatre encounter.
The role of the perioperative nurse is to reduce anxiety and provide a sufficient explanation appropriate to the individual by means of biological and psychological care. Prolonged anxiety levels delay recovery and increase the risk of physiological complications.
The majority of patients require mild analgesia only following a termination. Physical recovery time from first-trimester abortion is short, although some patients may suffer mild abdominal cramps and post-procedural bleeding similar to a menstrual period.
There is mounting evidence to suggest that education is a large part of the solution to tackling and improving teenage sexual health. Young people need sex education at an appropriate age to teach them the facts about sexual development, pregnancy and contraception.
When caring for adolescents undergoing abortion, perioperative nurses can alleviate anxiety and pain by providing essential preoperative information, sensitive to the needs of the individual young person. They can provide holistic care that will take into account an adolescent’s biological and psychological requirements.