Teenage pregnancy: mothers tide

It has become apparent over the past 10 years that reducing the rates of teenage pregnancy in England cannot be achieved by a single agency. Not just a health problem for the NHS to solve, the issue requires the involvement of social services, education, local communities, parents and teenagers themselves.

There is still a long way to go if England is to achieve the targets set by the 1999 teenage pregnancy strategy, namely, to reduce the rate of under-18 conceptions by half by 2010 and to get more teenage parents into education, training or employment, to reduce their risk of long term social exclusion. Devolved government means the strategy refers only to England, although the issues around teenage pregnancy are similar in the other UK nations.

At the strategy’s launch, the under-18 conception rate in England was 44.8 per 1,000. It has come down 12.6 per cent since then and by 2006 was at its lowest level for 20 years. Latest figures for 2007 show a slight increase for the first time since 2002, from 40.9 per 1,000 to 41.9 per 1,000.

The target for 2010 remains a long way off. Overall, 89 per cent of local areas have achieved reductions in teenage pregnancy rates compared with their 1998 baseline. Around 20 per cent have achieved reductions of over 25 per cent, including Hackney (down by 25.9 per cent) and Oldham (down by 29.4 per cent).

“Teenage pregnancy is a complex issue which requires a multifaceted approach. While some areas are on trajectory for their local 2010 target, progress towards the national 50 per cent reduction is challenging and it has taken other countries 30 years to bring the rates down,” says a spokesperson for the Department for Children, Schools and Families, where the government’s teenage pregnancy unit is housed.

Those that have succeeded include the Netherlands and Scandinavian countries, which have been held up as examples of how to grasp the socio-sexual revolution and equip young people to deal with it by promoting sex education and contraceptive advice, as well as regarding teenage sexuality with respect. The UK, meanwhile, has long been berated for having the “highest teenage pregnancy rate in Europe”, while the US has the highest rate among English speaking countries.

“When you talk to the countries which have got this more right than us, they say ‘we really respect and value young people’s sexuality. We want them to have sex lives that are positive, rewarding and exciting and we tell them that and we state our expectations of them.’ Here, at best, we are ambivalent about young people’s sexuality,” says Simon Blake, chief executive of young people’s sexual health charity Brook.

Teenage pregnancy risks

Teenage pregnancy is considered a poor choice on both health and social grounds. Teenage parents tend to have poor antenatal health, lower birth weight babies, higher infant mortality rates and an increased risk of congenital anomalies.

Likely to seek antenatal care much later in pregnancy than older women, teenage mothers miss out on important preconception and early pregnancy health measures, such as taking folic acid. Teenage mothers are less likely to breastfeed their babies than older mothers and are more likely, if from a deprived background, to remain poor and to experience higher levels of unemployment. They are also disproportionately likely to suffer relationship breakdown.

However, for some young women, having a baby is seen as a positive step, one that offers a sense of purpose in a life that might have few other options. It is towards this group of women that teenage pregnancy teams are directing their greatest efforts.

In 2006, the Department for Children, Schools and Families published a next steps document, after a “deep dive” review in 2005 of three high performing local authorities and three with static or increasing rates, looking at what was and what was not working in reducing teenage pregnancy rates.

Since then, the unit has focused closely on 21 areas with high and increasing teenage pregnancy rates, with the teenage pregnancy national support team being sent in to examine local issues and advise on best practice. Important in such work is joint working that starts at the top, with senior representation from agencies including the primary care trust, the local authority and voluntary sector organisations on a teenage pregnancy partnership board. In addition, work has to be incorporated into the local PCT and local authority children and young people plan.

Bristol and Wigan are just two of the “hotspot” areas where teenage pregnancy figures have failed to come down in the last 10 years. The most recent data available showed Bristol had a rate of 54.7 pregnancies per 1,000 girls aged 15-17. In Wigan the rate was 53.9 per 1,000.

Bristol teaching PCT associate director of public health Barbara Coleman acknowledges the city has been slower than other areas in adopting partnership working and believes this may have contributed to Bristol’s near static teenage pregnancy rate.

In Wigan, council teenage pregnancy co-ordinator Eleanor Mansell has high hopes that an extensive restructuring of teenage pregnancy management will co-ordinate efforts more effectively.

“A 50 per cent reduction target by 2010 is extremely challenging,” she says. The director of public health is a joint post across the local authority and PCT, while joint posts below that will line manage teenage pregnancy.

The area has also developed the You’re Welcome initiative, which sets down guidelines for healthcare organisations providing services to young people, increases access to contraception and sexual health services and provides health services in secondary schools.

Bristol has an outreach teenage health service in virtually every secondary school - a pattern repeated in most local authorities.

“The outreach service in schools and other settings is linked with Brook. We have got the service in almost every senior school, which means that young people who want access to sexual health services and contraception can do so as well as being signposted to mainstream health services,” says Ms Coleman.

Arsenal of prevention

Also common are condom distribution schemes such as the C card, a card that young people can produce at places such as clinics and youth centres, to be given free condoms.

Long acting reversible contraceptives are another key component in the arsenal of prevention but as they are historically surrounded by myths (that their use causes weight gain or can impair fertility), PCTs have their work cut out promoting their benefits to young people.

And the time lag for the reporting of conception statistics is lengthy due to the nine months of pregnancy plus the time it takes to register a birth and the time it takes for that statistic to appear in Office of National Statistics records, so it is difficult to evaluate the effectiveness of any service in reducing teenage pregnancy, especially in the short term.

“We started with one of the highest rates in the UK so our trajectory was a lot steeper than many other PCTs’. So far we have seen quite a dramatic reduction - a drop of 28 per cent from the 1998 figures of around 77 per 1,000 to around 56 per 1,000. Our target for 2010 is around 31.8 per 1,000 so we need to double what we have achieved so far,” says Hackney and City PCT deputy director of public health Jose Figueroa.

“We tried to commission two evaluations but it is probably quite ambitious to do something like that. For instance, sex and relationships education is provided through different routes - peer education, healthcare staff or theatre groups in schools. So far, we can see they are all complementing each other but what proportion of the impact should be allocated to each is very difficult to say.”

Known risk factors for teenage pregnancy are deprivation, poverty and poor educational attainment. In addition, the daughters of teenage mothers are twice as likely to become teenage mothers themselves. But while reducing health inequalities and providing accessible contraceptive and sexual health services are very much the remit of the NHS, what of dealing with the cultural issues embedded in communities that choose to have babies early?

“What we have struggled with for a number of years is this issue of why young people are choosing to take this route,” says Ms Coleman. “It’s not just about access to services and taking the prevention route. It’s about aspirations. In some areas there are cultural silos where getting pregnant and having a baby is the thing to do.”

The problem is similar in Wigan.

“Our own research shows a cultural acceptance of teenage pregnancy in Wigan,” says Ms Mansell. The PCT is now focusing on understanding the local picture behind the data and the reality of life in those areas where teenage pregnancy is the choice of local girls.

However, Dr Figueroa says: “I don’t think it is the role of the PCT to change culture unless the impact on health is really negative.”

After an audit of teenage pregnancy in Hackney showed a disproportionate number among black teenagers (black African and black Caribbean) and “white other” teenagers, more work was put into increasing access to sex and relationships education and contraception.

“We need the right kind of services for each community,” adds Dr Figueroa.

City and Hackney PCT has also launched a new sexual health website, www.sho-me.nhs.uk, which Dr Figueroa describes as “about sex rather than being sexual.” Within a month of its launch, the site had received more than 500 hits, including genuine questions pouring into “Dr Sarah”, the site’s medical advice service.

In Rotherham, where the teenage pregnancy rate is 50.7 per 1,000 15 to 17-year-old girls, local teenage pregnancy co-ordinator Melanie Simmonds says a scheme that began in 2006 in Maltby, an area of high teenage pregnancy, has enjoyed considerable success. The project helps young women make positive life choices and, of the 96 supported so far, only one became pregnant in the first year.

Now set to be rolled out to other areas of high teenage pregnancy in the town, the early intervention teams sit alongside children and young people’s teams, with access to support from the police, youth inclusion workers and Connexions and senior youth workers.

“This is an exciting area of work that we are very proud of. Not only does it help the girls to be aware of safe sex and contraception, it supports them to build their self confidence, make friends, develop respect for themselves and others and make positive choices about their lives,” says Ms Simmonds.

The spokesperson for the Department for Children, Schools and Families says : “Making progress requires changing young people’s knowledge, attitudes and behaviour.

“We know that good local delivery can impact on rates, even in areas with high levels of deprivation and ingrained culture that young parenthood is inevitable.”

Targeted messages

Social marketing has proved central to understanding how to reach young people.

Wigan is launching a social marketing campaign “to inform our delivery and look at all aspects of our young people and what they think”, says Ms Mansell.

Such techniques have also played a key role at City and Hackney PCT.

“Social marketing makes sure everything we do is adequately targeted and involves members of the specific community. We used social marketing to increase awareness of the availability of information and to empower young people to make informed decisions about when to start their sex lives and when to say no, if they want to say no,” says Dr Figueroa.

Ms Simmonds echoes this approach in Rotherham, where they are running a social marketing campaign around long acting reversible contraception.

“We hope to empower Rotherham women, in particular young women, to make informed choices about their method of contraception by gaining an understanding both of the barriers and of the motivating factors to using it.”

But raising the aspirations of young people is arguably the most vital step in reducing UK teenage pregnancy rates.

“Ambition is the best form of contraception” is the mantra on the lips of those who work in the field and teenage pregnancy team.

Raising aspirations is also important for teenage parents. In one such move, Wigan has managed to reduce the rate of second pregnancies among teenagers.

“Wigan does exceptionally well in supporting teenage parents. We have very low repeat rates or repeat abortion rates. We are trying to use some of these techniques to wrap around vulnerable teenagers to support them before they get pregnant,” says Ms Mansell.