Has Britain solved its teenage pregnancy problem?BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2561 (Published 14 April 2014) Cite this as: BMJ 2014;348:g2561
In recent years, although many public health problems have been growing, Britain’s notoriously high teenage pregnancy rates have suddenly dropped. The number of 15-17 year olds getting pregnant in England and Wales started to fall significantly in 2008, and by 2010 it had fallen to the lowest level since records began in 1969. The rate continued to fall over the next two years with the result that by 2012 it was 40% down from 47.7/1000 girls in 1998 to 27.9/1000 (fig 1⇓).1
The implications in terms of maternal and child health are huge. At least 40% of teenage mothers leave school with no qualifications, and both teenage mothers and their children have poorer health outcomes and an increased chance of living in poverty.2 3
Yet not everyone agrees on what brought about this turnaround or how to bring the rate down further (it is still the highest in western Europe, fig 2⇓).4 Many would say it’s obvious. In 2000, the Labour government launched a 10 year teenage pregnancy strategy, which pumped over £250m (€300m; $415m) into a multipronged approach that aimed to halve the rate of conceptions among under 18 year olds by 2010.
The strategy included advertising campaigns, providing better information and access to contraceptives, encouraging good sex education, and more discussion of sexual health with general practitioners, youth services, and in specialised clinics. National and regional boards were set up to oversee the progress, and all 150 local authorities appointed local teenage pregnancy coordinators as the contact point for all those involved from local health services, education, social services, youth services, housing, and the voluntary sector.
“These [latest figures] are the dividends we are reaping from a big concerted effort,” said Alison Hadley, who was in charge of the strategy as head of the specially created teenage pregnancy unit within the Department of Health. “It’s an illustration of how long it takes to have an impact on such a big public health issue. You don’t get quick fixes overnight. But in time you can see services and culture changing.”
Advocates of improved access to contraception point out that that for every £1 spent on free contraception, the NHS saves between £11 and £12.50.5
But social conservatives argue studies show that encouraging children to talk to experts about sex and making contraceptives easily available to them may in fact encourage early sexual activity. They point out that promotion of the morning after pill, in particular, had led to an increase in the incidence of sexually transmitted infections.6
Loss of funding
When the coalition government came to power in 2010 it closed the teenage pregnancy unit, shelved a bill to make sex and relationships education compulsory in primary and secondary schools, and invited pro-life groups LIFE and CARE to participate in a new government forum on sexual health. The government says it remains committed to reducing teenage pregnancy and has made it one of four priority areas in its Sexual Health Improvement Framework, but it has not allocated funding to a specific, national strategy.
At the same time, reorganisation of the NHS, including making public health the responsibility of local government, and severe budget cuts across the NHS and all public services, mean that many of those who received training and had key roles at local level during the first decade of this century have now moved on or lost their jobs. An investigation by the Guardian newspaper found that 56 teenage pregnancy coordinator jobs had been axed by August 2011.7 In the past year, the budget for youth services—which are the main contact point for teenagers not attending school—has been cut by up to 50% by many local authorities.
So will Britain’s teenage pregnancy rate continue to fall? Or is it inevitably going to start rising again now that the national strategy has been dismantled? Those who led the strategy until 2010 are concerned but hopeful.
“We’re in a slightly fragile place at the moment,” says Hadley, who now runs the Teenage Pregnancy Knowledge Exchange, created at the University of Bedford in 2013. “The pegs are in the right place. But all the regional health structures have changed and the networks (we had created) have gone. The risk is that people who know things move on and that knowledge gets lost.”
Simon Blake, who heads the sexual health services charity Brook, says an emphasis on good sex education and access to contraceptives has shown that given support, teenagers make sensible choices, he says. “There’s been a shift in our culture, a change of mindset that has made people recognise that our [high teenage pregnancy] rate is not inevitable”, he says.
Reports from individual local authorities suggest that where the structures and philosophy of the teenage pregnancy strategy have been maintained, teen pregnancy rates are still falling.8 A teenage pregnancy coordinator in the West Country recently suggested this may have a lasting effect in the region because there is now a stigma attached to being a teenage mother among young women who previously might have assumed they would leave school and have a family early.9
But in some areas, access to contraceptives has become more difficult. In 2012, an advisory group on contraception, made up of leading sexual health clinicians and charities, found in 2012 that access to all forms of contraception had been significantly reduced for a third of all women of childbearing age because of clinics closing, reduced opening hours, and lack of availability of some forms of contraception.10 11
Scientific consensus is that improving access to contraception reduces teenage pregnancy rates.12 Research by John Santelli, public health expert at Columbia University, concluded that contraception was 75-85% responsible for the substantial fall in the rate in the US in recent years and abstinence accounted for the rest.13
The US has seen a dramatic drop in teenage pregnancy rates at almost exactly the same time as the UK,14 and Santelli remarks that while better condom use, promoted by the anti-HIV campaigns reduced teenage pregnancies in the 1980s and 1990s, recently teenagers have become more sophisticated in their knowledge and use of contraception.15
“What we think is going on is an increase of contraceptive use, with people shifting to methods that are more effective,” he said. “IUDs are much more effective and more teenagers are now using them. We are also seeing increases in dual use of contraceptives—more than one type of contraceptive at once, which clearly gives greater protection.”
Research shows that long acting reversible contraceptives (LARCs) are more effective than the pill or condoms, and in the UK the National Institute for Health and Care Excellence (NICE) recommended greater use of LARCs for all age groups.16
Santelli explains, however, that so far there is not sufficient evidence to establish just how much LARCs or dual use of contraceptives may be behind the recent change in the US.17
Many conservatives argue instead that it is a tightening of abortion laws in the US that has discouraged teenagers from taking risks. Although the US abortion rate has not fallen significantly in recent years, the teen pregnancy rate fell by at least 15% in all states apart from West Virginia and North Dakota between 2007 and 2011 at a time when many US states tightened their abortion laws. Rates in Arizona, Colorado, Idaho, Nevada, and Utah fell by 30% or more.18
NICE has just advised that the UK’s rates would fall further if the morning after pill is made available through schools for teenagers to stockpile should their chosen method of contraception fail.19
Many believe, however, that without making sex and relationship education compulsory Britain will not achieve the deep cultural shift it needs to bring its pregnancy rates in line with those of its neighbours. “If we’d had statutory sex and relationship education from the start of the 2000-2010 strategy, we’d have made more progress,” says Hadley. “We are a society still hidebound by a lack of openness. We have extreme sexualisation of things, but young people would still say they’d feel embarrassed about asking about contraception.” She points to the Netherlands and Sweden, which have the lowest teenage pregnancy rates in the developed world, as examples of societies where young people are more able to discuss sex and as a result less likely to engage in it or more likely to use contraceptives effectively. In the Netherlands, teenagers have sex younger and more often than Americans, and Rik van Lunsen of the University of Amsterdam has argued that this education had been crucial to the Dutch success.20 A study of US, UK, the Netherlands, and Sweden showed that family planning services work closely with schools in the Scandinavian countries, with support from parents and from government.21
Currently age appropriate sex education is recommended in schools in the UK, but it is not obligatory and different schools teach it in very different ways. While there is consensus across the political spectrum that education is important, there is disagreement on what it should cover. Sexual health charities recently published guidance for schools on issues such as online porn, “sexting,” and sexual violence after the government decided not to update official guidance that dates from 2000 and does not mention the internet.22
Cite this as: BMJ 2014;348:g2561
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.