Preventing teenage pregnancies, supporting teenage mothers

“It sometimes seems as if sex is compulsory but contraception is illegal”1

At last an official report has recognised that the large numbers of young parents in the United Kingdom are not motivated to become parents by the promise of benefits or council flats. Last week's report from the government's Social Exclusion Unit says that instead these young people simply “see no reason not to get pregnant.”1 They have low expectations of employment; ignorance about what to expect in relationships and about contraception; and they receive mixed messages from an adult world that bombards them with sexual messages but turns away when they need advice, “at best embarrassed, at worst silent.” The result is not less sex, but less protected sex.

In response to the Social Exclusion Unit report, the government has allocated £60m to support its recommendations for local and national coordination, improvements in sex education and contraceptive services, and support for pregnant teenagers and teenage parents. Perhaps not surprisingly, some of this was lost in media reporting, which put a punitive “spin” on proposals to end lone council tenancies for teenage mothers. Support for teenage parents is actually about the sort of targeted midwifery offered for under 18 year olds in Southwark by the Bessemer practice; the Newpin parent support and personal development project in Peckham, which helps young parents develop their social skills and self esteem; and the supported accommodation, advice, and keyworkers in the Centrepoint young mothers project, Lewisham. Prevention includes improving life chances for training and employment as well as targeting high risk groups and offering education about what parenting really involves. But can we really halve conceptions in the under 18s within 10 years and reduce social exclusion in teenage parents, especially in deprived areas like south London? Lambeth, Southwark, and Lewisham have areas with conception rates in the under 16s over three times the national level and birth rates over five times the national level.

There is encouraging evidence that success is possible. In Stovner, Oslo, teenage abortion rates halved from 1988 levels after the introduction of an integrated package, including young people's clinics and age appropriate sex education (following the young people's own priorities of learning about relationships and negotiation skills, then moving on to sexually transmitted infections and contraception) (E Sandvik, Megapoles workshop, Amsterdam 1999). These results have been rolled out across Oslo, and the initial cohorts continue to have low abortion rates aged 20-24.

As the Social Exclusion Unit report notes, it is difficult to know what needs to happen to ensure that local strategies work. Sexual behaviour is extremely complex, and evidence from “high quality” controlled evaluation studies, with just a few measurable outcomes and input variables, is not always appropriate.2 The report recognises this by reporting case studies illustrating good practice, which should also come out from health action zones like Lambeth, Southwark, and Lewisham's “Children First.”

Evidence for recommendations about coordination is especially difficult to generalise from a specific project. The Social Exclusion Unit could have placed more emphasis on assessing the opportunities afforded by the development of primary care groups, some of which are already tackling this topic. Primary care trusts, when they develop, must involve even more players. National policy changes could also help: at present concerns about confidentiality mean that age specific abortion data are not available for areas below health authorities. Finding a way to provide such data, such as three year aggregations for the populations covered by primary care groups, would facilitate the audits recommended by the report and help activities to be better targeted.

Perhaps most immediately relevant for individual clinicians are the criteria for effective and responsible youth and contraception services. These should be influenced by known inconsistencies in contraceptive use.3 Visible marketing can significantly increase condom use (but not sexual activity) for high risk women.4 Improved method teaching for oral contraceptives has shown benefits.5 Knowledge of emergency contraception is poor,3 and access should be improved, especially with increasing evidence on the importance of timing. 6 7 Pharmacies should be an outlet, as in the United States and as supported by the Royal College of Obstetrics and Gynaecology and the Faculty of Family Planning.8 A large randomised trial has shown that self administration of emergency contraception is safe, does not lead to overuse, and reduces pregnancies.9

The report recommends that services for young people should be “joined up”—that is, to link with schools. The links could go wider, however. The Lewisham young people's health project is based in general practitioners' surgeries and does outreach based on popular youth culture, as in the “end of term jam,” which provides material on sexual health, working with popular local musicians and radio stations.10 As we understand more about the importance of working with young men, and about ethnicity,11 we can aim for services to be truly open to all.

More proactive school sex education is also planned, with links to broader frameworks of personal education and the involvement of parents. This is overdue since, although some community leaders and parents may disagree with health workers over issues like promoting abstinence, there is much more that they agree on, such as improving life chances and the quality of relationships, building self esteem and developing negotiation skills for their children. Some schools in the Healthy Schools Partnership Project pilots already offer this sort of approach. Providing even broader opportunities has also shown positive effects. Significant reductions occurred in sexual activity (especially unprotected sex) when pupils did community youth service, compared with those in a matched school.12 Results were significantly greater in classes randomised to greater community involvement. Unfortunately, although the government is to clarify guidance for health professionals on contraceptive advice for the under 16s, including confidentiality, the position for teachers—who are specifically trained to work with young people—is not clear. This is a missed opportunity, especially as visible confidentiality has been shown in qualitative studies to be key (Egg Research, qualitative research for Brook). Nevertheless, the report is certainly welcome. And clinicians who want to contribute to halving the conception rate among under 18s could start by thinking about how visible and visibly confidential their service is.