Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Inappropriate selection of cases and controls biased teenage pregnancy study
- Wai-Ching Leung (18 August 2000)
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Immorality of contraception
- John Hart (20 August 2000)
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Abortion also an evil
- John Hart (20 August 2000)
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Abstinence as a confounder
- Brian S Alper (21 August 2000)
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At last teenagers are using contraception
- Judy Murty (21 August 2000)
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Sex as an evil?
- Joseph Watine (23 August 2000)
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Not all teenagers are having sex
- Kate E Duffield (24 August 2000)
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What of STD rates?
- David Reardon (25 August 2000)
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Re: Abortion also an evil
- Peter Morrell (25 August 2000)
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Teenagers' use of emergency contraception
- Anne Murphy (25 August 2000)
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Re: Re: Abortion also an evil
- John Hart (26 August 2000)
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Re: Re: Re: Abortion also an evil
- James S Smeltzer (29 August 2000)
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Teenagers and contraception
- Ann McPherson (31 August 2000)
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A wider approach required
- Tim Dunnett (22 September 2000)
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Poor knowledge of the pill rules can be significantly improved
- Margaret Hook (22 November 2000)
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Was the Pill Scare a Factor?
- Christine Horrocks (30 November 2000)
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Wai-Ching Leung, Senior Registrar in Public Health Medicine Epidemiology & Public Health, Newcastle General Hospital, NE4 6BE
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In their case-control study, Churchill et al. (1) found that teenagers who become pregnant have higher consultation rates than their age matched peers. However, their conclusions may be biased by inappropriate selection of cases and controls. The authors defined cases as all registered patients in the practices who had a recorded termination, delivery or miscarriage resulting from conception. Since they ascertained cases from practice computer records, maternity books and knowledge of practice staff, the cases only included patients who received such services locally and not from other districts. However, controls were selected from the ordered list for the practice closest in chronological age as the cases. Hence, the control group included registered patients who were actually resident in other districts. Clearly, the inclusion of such patients would seriously underestimate the consultation rates in the control group. The median age of the subjects was 17 years. A significant proportion of the control subjects were in further education and well over a third of the over 18s were in higher education. (2) Hence, the selection bias is likely to be considerable and could account for the findings in the study. Reference 1. Churchill D, Allen J, Pringle M, Hippisley-Cox J et al. Consultation patterns and provision of contraception in general practice before teenage pregnancy: case-control study BMJ 2000; 321: 486-489 (19 August) 2. Higher education in the learning society. Report of the National Committee of Inquiry into Higher Education. London: Stationery Office, 1997. |
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John Hart
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This article appears to have failed to point out the immorality of contraception and the harm it can do to marriages. I believe contraception promotes selfishness, and a lack of unity between a husband and wife. Before the widespread use of contraception in the early 1900s, the divorce rate was a lot lower than it is today. In addition, if the authors are advocating contraception before marriage, then they are advocating yet another immoral act -fornication. The evils of pre-marital sex are rather obvious. John Hart, D.C. |
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John Hart
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In my other reply to this article I pointed out the author's apparent failure to affirm the immorality of contraception and fornication. I later noticed the author's gave us some information on abortion, and they apparently also fail to affirm the immorality of abortion. The immorality of contraception, fornication, and abortion should not be overlooked, or taken lightly. Thank you for allowing me to point this out. John Hart, D.C. |
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Brian S Alper, Academic Fellow and Clinical Instructor University of Missouri-Columbia
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This case-control study found a higher rate of consulting for contraception among cases (teenagers who became pregnant) than among controls (teenagers who did not become pregnant). Obviously, none of the teenagers who became pregnant were abstinent. How many of the controls had never had sexual activity? If a considerable proportion of controls were abstinent, then the conclusions are not surprising. Contraceptive use (with or without adherence) will never be more effective than abstinence. Likewise, if the control group was having sexual activity less often than the case group, this would confound against the effects of contraceptive consulting. Do the authors have data on the rates of abstinence and sexual activity frequency among the cases and controls? |
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Judy Murty, SCMO Family Planning Leeds Family Planning Services
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Dear Editor, The case-control study reviewing patterns and provision of contraception before teenage pregnancy1 discusses the limitations of the study. The comments included that the practice would not know of all the terminations of pregnancy in their populations or how many would be attending a family planning clinic. I have reviewed the use of contraception used by women requesting a termination of pregnancy from the provider aspect including those wanting confidentiality. The method used at time of the unintended pregnancy reflects the use of that method by a population2,3. Following these previous studies that show teenagers using nothing or condoms when they became pregnant, it is encouraging to see that 50% of the population in the study were using the combined pill when they became pregnant. This would imply that more teenagers are seeking contraceptive advice and beginning to take responsibility to prevent an unwanted pregnancy by using a method of contraception even though haphazardly. We now have to develop the skills and services to empower them to use the method correctly. There was an association between those teenagers becoming pregnant after emergency contraception and seeking a termination of pregnancy. It has been shown that there may be a link between the provision of emergency contraception and increase in unwanted pregnancy4. I too share the concerns of the authors that extending the provision emergency contraception per se will not reduce the unwanted pregnancy rate especially in the 'at risk' groups of the sexually active population. Dr Judy Murty
1. Churchill D, Allen J, Pringle M, Hippisley-Cox J, Ebdon D, Macpherson M, Bradley S. Consultation patterns and provision of contraception in general practice before teenage pregnancy: a case-control study. British Medical Journal 2000; 321: 486-489 2. Murty J, Firth S. Use of contraception by women seeking termination of pregnancy British Journal of Family Planning 1996: 22: 6-8 1996 3. Murty J. Women's Health: Is there more to pill warnings than meets the eye? British Journal of Sexual Medicine 1998 25; 6-7 4. Ziebland S, Scobie S. Could a publicity campaign for emergency contraception reduce the incidence of unwanted pregnancy and how would we know if it did? British journal of Family Planning 1995; 21: 68-71 |
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Joseph Watine, Eur Clin Chem Hôpital de Rodez, France
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According to John Hart, not only contraception and abortion, but also fornication, are immoral; in his opinion, "the evils of pre-marital sex are rather obvious" [1,2]. I can not see anything obvious in such a (religious?) opinion. Would the author of this statement be so kind as to explain us where is the evil of pre-marital sex between two healthy willing individuals? In the same way, when parents have children that they did not wish to have, can not it be an evil for both the parents and the children? He also believes that "before the widespread use of contraception in the early 1900s, the divorce rate was a lot lower than it is today". Many causes, others than contraception, can account for this situation. Among theses causes, one could cite: the fact that more women have a job which enables them to be financially independent from their husband, the progressive abandon of the hypocritical, superstitious, and stupid religious beliefs according to which sex would be an evil. [1] http://www.bmj.com/cgi/eletters?lookup=by_date&days=1#321/7259/486/EL3 [2] http://www.bmj.com/cgi/eletters?lookup=by_date&days=1#321/7259/486/EL2 |
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Kate E Duffield, Stage 3 medical student Dept of Epidemiology and Public Health, University of Newcastle upon Tyne Medical School
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Editor, Churchill et al (1) have conducted a valuable study which dispels the myth that teenagers do not consult their GPs about contraception. However they also conclude that teenagers who become pregnant have higher consultation rates than their age matched peers, most of the difference owing to consultation for contraception. We do not believe this claim is justified, as the potential confounder of sexual activity was not controlled for. While the case group (pregnant teenagers) must be sexually active, the same cannot be said of the age-matched controls. It is probable that rates of sexual activity were lower among controls, especially at the lower end of the age range used (13-19 years). In a recent survey only 20% of 13 year olds reported having had full or oral sexual intercourse (2). Abstinent controls would not be expected to consult about contraception. This would lower the average contraceptive consultation rate per individual within the control group, potentially masking higher consultation rates for sexually active controls. Therefore teenagers who become pregnant could be under-consulting for contraception compared to their sexually active peers. On the basis of this paper it cannot be assumed that teenagers who become pregnant make greater use of GP contraceptive services. Churchill et al acknowledge in discussion that sexual activity is a confounding variable, but proceed to draw an unjustified conclusion because of their use of inappropriate controls. K Duffield, PK Josen, E Low, K Teare, E Wray
1 Churchill D, Allen J, Pringle M, Hippisley-Cox J, Ebdon D, Macpherson M, Bradley S. Consultation patterns and provision of contraception: in general practice before teenagers pregnancy: case- control study. BMJ 2000;321:486-9 2 Burack R. Teenage sexual behaviour: attitudes towards and declared sexual activity. British Journal of Family Planning 1999;24:145-8 |
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David Reardon, Elliot Institute
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This study raises many interesting questions. One of which is whether prescription of contraception to unmarried minors also is predictive of contracting sexually transmitted diseases. I would urge the authors to explore this negative outcome in their data. |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
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Sir, John Hart says: "The immorality of contraception, fornication and abortion should not be overlooked, or taken lightly." Assuming he is being serious, it might be helpful if he were to explain what he means by 'immoral' and how his use of this term fits in with the injunction - allegedly by God - that his creatures should 'go forth and multiply'. It seems a contradiction for those who wish to lead moral lives - which command are they expected to follow? Fornicate and be damned as immoral? Or fornicate and be a good creature doing as one is told by the Creator. It would also be useful for him to say why immorality should not be taken lightly? Finally, maybe he could also elucidate whose opinion he is invoking - his own? Or one of the above two versions of a Creator? In this risky age in which we live, might not the Creator dispense a further amendment and advise that one should not in any case fornicate without a condom? Just a thought. |
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Anne Murphy, Paediatric SHO Northwick Park Hospital
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Easy access to emergency contraception is recommended to help reduce teenage pregnancies (1). Churchill et al (2) state that emergency contraceptive use is a marker for sexual risk-taking. They emphasise the importance of follow up. Gynaecology SHOs at Northwick Park Hospital provide a 24 hour emergency contraception service. A detailed protocol is used to ensure that follow-up and longer term contraception are discussed. Family Planning Services collect the protocol forms to help plan service provision. Requests for emergency contraception from January to June 2000 were audited. 39% of requests were from teenagers, suggesting that the service is accessible. Confidentiality is respected, but we strongly encourage clients to arrange follow up. Family Planning Services were notified of almost half (44%) of these requests and some GPs were informed. We are working to improve communication further, and aim to integrate our services with local initiatives to reduce teenage conceptions. (1) Mawer, C. Preventing teenage pregnancies, supporting teenage mothers (editorial) BMJ 2000;318 1713-4 (2) Churchill et al Consultation patterns and provision of contraception in general practice: case control study BMJ 2000;321 486-9 |
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John Hart
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In response to Peter Morrell's question about whether I was being serious when I stated that contraception, fornication, and abortion are immoral, the answer is yes, I was being serious about this. Is Mr. Morrell being serious when he asks for an explanation of what "immoral" means, and why it should not be taken lightly? Based on his reply, it appears Mr. Morrell may not know the meaning of fornication; it means sexual intercourse outside of marriage. I believe God wants the human race to continue within the confines of a monogamous marriage, between a husband and wife. John Hart, D.C. |
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James S Smeltzer, Consultant in Maternal and Fetal Medicine Wellstar Physicians Group
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In reply to Dr. Hart, Judge not lest ye be judged. |
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Ann McPherson
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Dear Editor - Dick Churchill et al’s paper on ‘Consultation patterns and provisions of contraceptive in general practice before teenage pregnancy: case-control study’ (BMJ 2000.321 486 – 9) and Basil Donovan’s leader ‘Never underestimate the force of reproduction’ (BMJ 2000.321 461- 2) have produced both media and professional debate about teenage pregnancy, sexual activity and contraception. This debate has however tended to focus on the types of contraception most suitable for use by teenagers and on how information about contraception is given. Whilst we would agree that the consultation process, including issues of confidentiality, are important, in fact contraception itself has never been more available nor have their ever been more contraceptive options. The truth is that if young people wish to use proper contraception – it is available. If the majority of young people can access to illegal drugs, then they are unlikely to have much difficulty with legal ones! We would therefore argue that, given the emphasis that our society puts on sex, and the force of reproductive biology, the most important issue at present is what motivates young people not to become pregnant. Because of the ‘force of reproduction’ girls, and young men, who lack ambition in other fields see ‘babies’ as an option. In fact Robert Blum reported (Society for Adolescent Medicine Newsletter Vol 11.1 Aug 2000.page 3) at this years White House Conference on Youth in the USA, where teenage pregnancies are also high, that ‘those young people who see pregnancy as having a high personal cost for their reputation or their future are much more likely to delay intercourse.’ General practitioners certainly need to make sure they are delivering a good and effective service to young people, teachers need to ensure that health education is properly taught, and parents need to do their bit (with USA research showing that adolescent perceptions of maternal disapproval of sex being associated with delay in first intercourse). Most importantly however, is how Government and society can make all young people feel that there other worthwhile alternatives to teenage pregnancy. Ambition for young people may well be the best contraceptive! Ann McPherson and Aidan Macfarlane |
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Tim Dunnett, 4th Year Medical Student Dept Epidemiology, Medical School, University of Newcastle-upon-Tyne
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EDITOR-Churchill et al's findings challenge the hypothesis that teenagers are reluctant to consult GP's about contraception. They found 93% of pregnant teenagers had consulted in the year preceding conception, 73% having talked about contraception at some point in the past. Those teenage pregnancies ending in terminations were more likely to have received emergency contraception than other teenage pregnancies. This rightly emphasises the lack of adequate follow-up. However, GP notes were the only source of data. These provide limited information, making it difficult to distinguish between an in-depth discussion and a casual mention of contraceptive use. As this study was performed with a view to improve GP services, this limits the conclusions that can be drawn. Cases and controls were matched for age only and no other demographic factors. Deprivation, however, was measured and levels were significantly different between the two groups. These factors have been shown to influence both consultation and teenage pregnancy rates. This was not incorporated in the analysis and future studies should adjust for this. A clear picture of the GP's role can only be seen in the wider context of all the family planning services available. The authors' conclusions regarding women who had a termination following emergency contraception are limited, as different consultation patterns would be expected among this group. We suspect that regarding these sensitive issues, more confidential and quicker services may be used and hence no record held in the GP's notes. These omissions could distort the results. The factors discussed limit the importance of the authors' findings. We suggest a multi-centre study incorporating all family planning services to establish and improve the role of general practice in tackling the nationally important issue of teenage pregnancy. Tim Dunnett, 4th year medical student
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Margaret Hook
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Sir - The use of contraception in women who conceive has been a concern of practitioners in Avon for some time. Local evidence published in 1996 1 found that 21% of over 500 women attending the Avon Pregnancy Advisory Service had used the combined oral contraceptive pill in the month of conception. The work of Churchill et al 2 has recently brought the issues about contraceptive efficacy into question. Their case controlled study found many teenagers who became pregnant had sought contraceptive advice. Basil Donovan in the accompanying editorial 3 considered that teenagers might not have asked enough questions to understand the method of contraception prescribed and called for better training methods to be evaluated. Avon Primary Care Audit Group has recently completed an audit project, which shows that it is possible to show a statistically significant increase in knowledge of the use of the combined oral contraceptive pill by women pill users. The audit protocol was developed following the publication of a randomised controlled trial in 1998 4 which showed that the use of summary cards and standardised questions led to a highly significant improvement in women's knowledge. We obtained permission to use the standard questions and to design a reminder card of similar credit card size with the 12 rules summarised in the same order as the question sheet. Due to the cost of replicating their postal questionnaire the same structured questions, asked during face to face consultations were used for both data collection periods. The outcome sought was not to measure the increase in knowledge of
individual women but to structure the way women were given information and
measure the change in knowledge of a population of women.
We set three criteria for our audit The audit report details 1224 client contacts for whom 902 women answered the same structured questions during their consultations with either nurses or community pharmacists. The percentage of women who knew all the pill rules increased from 6.7% to 14.4%. Which is statistically significant (p<0.05) and is consistent with the work by Little et al 1 The changes seen in the other criteria were not significant (p>0.05). The percentage of women asked about their knowledge increased from 69.1% to 81.1% and the number of summary cards given out showed a marginal decrease 92.6% to 88.1% but this could be accounted for by women who had previously been given cards. The work published by Little et al presented baseline data for which only
part of the 12 pill rules were known and collected the improvement in
knowledge from a postal questionnaire after 3 months. Our audit results
have
been presented in detail and show the areas of poor knowledge and was used
by participants to develop their action plans to implement changes. There
was an
overall improvement in women's knowledge of the 12 pill rules, however
three main areas can be identified where knowledge is limited:
The participating teams were from a variety of practices across the Avon Heath Authority area. The Townsend deprivation scores for the practice geographical areas covered in this audit ranged from -2.79 to 12.77 and included one practice with the highest teenage pregnancy rate in Avon. Audit and feedback is recognised as an intervention, which consistently promotes behavioural change among health professionals sometimes the process produces a change that cannot be differentiated from the outcome once the initial data collection has been analysed due to increase in awareness of practitioners. 5 The feedback from participants has shown this work to be such an example. This project has demonstrated that it is feasible for both practice nurses and community pharmacists to use the summary cards and standardised questions when consulting with patients. The, funding and resource implications need to be addressed if summary cards and questionnaires are to be used routinely. This will include increased consultation or dispensing time and the production costs of summary cards and questionnaires. Avon Primary Care audit Group has produced a detailed report for the Health Authority to look at how this work can continue and be expanded to include more practices and community pharmacies as part of health promotion or sexual health initiatives including the local teenage pregnancy strategy. The barriers to the wider dissemination of this work and adoption by more professionals needs to be considered more widely within the context the NHS plan. The 'Pharmacy in the future - Implementing the NHS plan A programme for pharmacy in the National Health Service' published in September identifies medicine management as a key area for development.6 Our audit project is an example of how the team approach can improve patient care for women prescribed the combined oral contraceptive. References 1. Bodard S and Baldwin B, 1996. A survey of women with unplanned pregnancies in Avon, January to March 1994.British Journal of Family Planning; 1996; 22: 42-5. 2. Churchill D, Allen J, et al. Consultation patterns and provision of contraception in general practice before teenage pregnancy: case- control study. BMJ 2000;321 486-489 3. Editorials Basil Donovan, Never underestimate the force of reproduction BMJ 2000;321 461-462 4. Little P, Griffin S, Kelly J, Dickson N, Sadler C. Effect of educational leaflets and questions on knowledge of contraception in women taking the combined contraceptive pill: randomised controlled trial. BMJ; 1998; 316: 1948-52. 5. Bero LA, Grilli R et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998;317 465-468 6. 'Pharmacy in the future - Implementing the NHS plan A programme for pharmacy in the National Health Service' Department of Health. Sept 00 www.doh.gov.uk/medicines.htm Margaret Hook MRPharm S
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Christine Horrocks, Head of Contraception and Sexual Health Service North Bristol NHS Trust
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Dear Editor, Avon Family Planning Doctors' Audit Group recently studied Churchill et al's paper on Consultation patterns and provision of contraception in general practice before teenage pregnancy: case control study.(1) This concluded that teenagers who became pregnant have higher consultation rates with their GPs than their aged matched peers,most of the difference owing to consultation for contraception. We noticed that no mention was made of the Pill Scare of October 1995 and the possible effects of this on the study which covered 1st January 1995 - 1st January 1998. The rates of termination of pregnancy among teenagers rose in 1996 compared with 1995 by 14.5% in under 16s and 12.5% in 16-19 year olds.(2) Teenagers becoming pregnant in 1996 because they had stopped the Pill in October 1995, or who had made errors in the changeover to a different contraceptive pill would have been part of the group who had consulted their GP for contraception in the year before conception. We also would have appreciated a breakdown of age of teenagers into at least two groups as some of the older teenagers in the 18-19 year group may have planned their pregnancies following contraceptive care from their GPs. (1) Churchill et al. Consultation patterns and provision of contraception in general practice:case contol study.BMJ 2000;321:486-489 (2) Nicholl et al. Sexual health of teenagers in England and Wales: analysis of national data. BMJ 1999;318:1321-1322 No competing interest. |
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