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Teenage Pregnancy

Introduction

Teenage pregnancy (defined as under-18 conceptions including those leading to live births and terminations) and early parenthood are widely recognised to be associated with poor health and social exclusion. Having children at an early age can affect young women’s health and wellbeing and can limit their education, career and economic prospects. Although young people can be competent parents, longitudinal studies show that the children born to teenagers are more likely to experience a range of negative outcomes in later life, and are more likely to become a teenage parent themselves. In addition, serious case reviews have identified teenage parents as being vulnerable families who may need additional support to help them achieve positive futures for themselves and their children.

Evidence suggests that the mother’s age, disadvantaged socioeconomic background and limited uptake of antenatal care come together to contribute to poor outcomes overall (see footnote 1). The maternal and child outcomes associated with teenage parenthood include; late booking for maternity services, smoking in pregnancy, poor maternal health, postnatal depression, isolation and relationship breakdown, repeat unplanned pregnancies, no qualifications, not in education, training or employment, parenting difficulties, mothers at risk of poverty and poor housing in later life, premature birth and low birth weight, infant mortality, hospitalisation of the infant, low breastfeeding rates, poor diet, accidental injuries in childhood and finally children at risk of lower academic achievement, poverty and unemployment in later life. Therefore reducing the number of teenagers who become parents is central to the wider agenda of reducing health inequalities and child poverty.

See related JSNA chapters on sexual health, infant mortality, maternity, looked after children, safeguarding adults, safeguarding children, alcohol and substance misuse in children and young people, children and young people’s mental health, domestic violence, unemployment, housing and deprivation.

There is also a strong economic argument for reducing teenage pregnancy, which places a significant burden on public services, estimated at £63 million a year. It is estimated that every £1 spent on pregnancy prevention/contraception saves £11 in health plus welfare costs (see footnote 2).

Reducing teenage pregnancy continues as a priority for the coalition Government however the economic environment provides the government and local areas with an enormous challenge when it comes to planning teenage pregnancy prevention and support. The under-18 conception rate is an indicator within the Public Health Outcomes Framework, a measurement indicator in the Child Poverty Strategy and is a measure of success for the Positive for Youth Policy. Preventing under-18 conceptions and sexually transmitted infections will also be covered in the Department of Health’s forthcoming paper on Sexual Health (due Spring 2012), which will examine how improvements to sexual health can be achieved throughout life.

In Haringey, reducing the under-18 conception rate is a priority in the Health and Wellbeing Strategy, the Children and Young People’s Plan, the Child Poverty Strategy and the Strategy for Youth. The Health and Wellbeing Board have set a local target: to reduce Haringey’s rate to the rate for London by 2015.

ONS annual rates for under 18 conceptions rates released in February 2013 showed that Haringey’s rate was 36.2 per 1000 ( 152 actual number of conceptions with 56.6% leading to a termination). This shows a significant decrease from 2010’s high rate of 64.7 per 1000 and showed that Haringey achieved the greatest reduction (44%) in London. This reduction has finally brought Haringey’s rate closer to the rates for England and Wales (30.9 per 1000) and London (28.7 per 1000), however the local target remains challenging.

Under 16 conception rates for 2011 also showed that Haringey’s rate has continued to decrease to 9.3 per 1000 (41 actual number of conceptions with 53.7% leading to a termination) but still remains higher than the rates for England and Wales (6.1 per 1000) and London (5.7 per 1000).

In 2010 England and Wales saw an overall decrease to a rate of 35.5 conceptions (per 1000 women age 15-17) this is the lowest since 1969. Comparing 2010 with 2009, around a quarter of areas across England and Wales saw increases in their under-18 conception rates from 2009 to 2010. In Haringey the teenage pregnancy rate fell to its lowest ever rate in 2009 (51.1 per 1000 females aged 15-17) with an encouraging decrease of 18% since the 1998 base rate. However, Haringey’s rate increased in 2010 and at 64.7 per 1000 was the highest rate for England. Efficiency savings that led to service changes in both the council and local health partners during 2010 may have had an impact on the significant decreases achieved in 2008 and 2009. Positively, in 2010 Haringey’s under-16 conception rate decreased to its lowest rate, 10.0 per 1000 (see footnote 3).

In 2010, there were 203 conceptions with 62.1% leading to a termination, an increase on the percentage shown in the two previous years. In 2009, there were 171 conceptions compared to 184 in 2008. This number is significantly lower than the 248 conceptions in 2007 when the rate was 70.2 per 1000 and also significantly lower than its highpoint in 2002 when the rate was 80.4 per 1000 and there were 313 conceptions.

Haringey’s 2010 rate was clearly too high but it is important to bear in mind that, given the small numbers involved, there can be large year on year fluctuations in the rate and comparing the three year aggregate conception rate 2008-2010 against 1998-2000 gives a more robust picture of overall performance. The high 2010 rate needs to be seen within the overall trend, which shows a reduction of 16.3% since the 1998 baseline.

Figure 1: Under-18 conception trends shown in three year aggregate data

Source: ONS and DfE

As more teenage conceptions in Haringey lead to abortion, this suggests that the pregnancies were unplanned and indicate early onset of sexual activity, poor or no contraceptive use and increased risk of sexually transmitted infections therefore should be considered as an indicator of poor sexual health in the community. Interventions and services to reduce teenage pregnancy and support teenage parents need to be clearly integrated into local sexual health services.

Details on infant mortality, maternity, children in care, safeguarding – children, safeguarding – adults, alcohol, children and young people’s mental health, domestic violence, immunisations and vaccinations are dealt with in separate sections.

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Key Issues and gaps

Issues

Between 1998 and 2008 Haringey’s teenage pregnancy rate increased by 12%. In response Haringey introduced a comprehensive Teenage Pregnancy Strategy and Action Plan was in late 2007 (based on evidence from the Teenage Pregnancy Unit) and this contributed to the significant decreases in the teenage pregnancy rate between 2008 and 2009 (18% decrease). Two areas the strategy prioritised were:
Increasing access to local sexual health information and services including:

  • The extension of the targeted contraceptive and sexual health outreach nursing team as part of 4YP Haringey, (the young people’s outreach sexual health team)
  • The development of regular nurse sessions within high risk groups’ services, for example, The Leaving Care and Asylum Team and other targeted young people’s non healthcare settings such as the College of Haringey, Enfield and North East London and Haringey Sixth Form Centre
  • The free availability of Emergency Hormonal Contraception for under-18s in a number of Haringey’s community based pharmacies (this service has been consistently used by approximately 1000 Haringey clients annually since 2002). As Emergency Hormonal Contraception is the last service that can impact on a conception not taking place, it is essential that it continues to be available and in pharmacies across the borough that young women can access easily
  • A co-ordinated workforce training programme for Sex and Relationships Education

Improving the clinical and service pathway for termination of pregnancy including:

  • Introducing self-referral in abortion care has contributed to the increase in earlier stage abortions (termination data for 2010, show an increase in the percentage of conceptions leading to termination, compared to 2008 and 2009)
  • The introduction of follow up support for under-19s has shown to improve the uptake of Long Acting Reversible Contraception and condom use as well as contributed to a reduction in repeat abortions (in 2009, 18% of abortions to under-19s in Haringey were repeat abortions compared to 17% in London and 11% in England which suggests that targeting young women post termination for support to access contraception is essential to reducing further unplanned conceptions - see footnote 4).

Gaps

1. Following reductions in funding and service changes during 2010/11 and 2011/12 in the council and NHS partners directly involved in teenage pregnancy prevention and support and a number of services ended or capacity was reduced including:

  • Workforce training for Sex and Relationships Education for professionals and parents/carers
  • Outreach services
  • Support for teenage parents
  • Media and communications

2. Further abortion data analysis is needed to understand the barriers for young women experiencing poor or no contraceptive use following a termination.

3. Further analysis of repeat use of Emergency Hormonal Contraception is needed in order to reveal more opportunities to identify young women at risk of poor contraceptive use and sexual health

4. Further analysis is needed on the use of both Long Acting Reversible Contraception and condoms in young people under 25 including under 18s.

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Who is at risk and why

The Department of Health Teenage Pregnancy: Accelerating The Strategy to 2010 (see footnote 5) pointed out that :

‘young people experiencing risk factors for teenage pregnancy are highly concentrated within particular areas and among vulnerable groups and that the risk factors for teenage pregnancy are well recognised and provide a compelling case for targeted action on young people who are exposed to these risks. To target effectively those most at risk requires both a geographical focus on high rate neighbourhoods and the identification of vulnerable groups at high risk of teenage pregnancy’

1.Targeting high rate neighbourhoods

  • Variations in teenage pregnancy rates are highly correlated with levels of deprivation across England
  • Half of all under-18 conceptions in England occur in the 20% most deprived wards
  • Teenage pregnancy rates among the most deprived 10% of wards are four times higher than in the 10% least deprived wards
  • Teenage pregnancy ‘hotspots’, where more than 6% of girls aged 15-17 become pregnant, are found in virtually every local authority in England.

2.Identifying those most at risk of teenage pregnancy

Teenage pregnancy is a complex issue, affected by a wide range of personal, social, economic and environmental factors. However, research evidence has identified the key risk factors which are known to increase the likelihood of teenage pregnancy. These can be broadly grouped into: risky behaviours; education-related factors; and family and social circumstances.

a) Risky behaviours include early onset of sexual activity, poor contraceptive use, mental health/conduct disorder/involvement in crime, repeat abortions, teenage motherhood, Alcohol and substance misuse

  • Girls having sex under 16 years of age are three times more likely to become pregnant than those who first have sex over 16 years of age.
  • Around 60% of boys and 47% of girls leaving school at 16 with no qualifications had sex before 16, compared with around 20% for both males and leaving school at 17 or over with qualifications.
  • Early onset of sexual activity is also associated with some ethnic groups. Among 16-18 year olds surveyed in London, non-use of contraception at first intercourse was most frequently reported among Black African males (32%), Asian females (25%), Black African females (24%) and Black Caribbean males (23%)
  • Around a quarter of boys and a third of girls who left school at 16 with no qualifications did not use contraception at first sex, compared to only 6% of boys and 8% girls who left school at 17 or over, with qualifications
  • A number of studies have suggested a link between mental health problems and teenage pregnancy. A study of young women with conduct disorders showed that a third became pregnant before the age of 17
  • Teenage boys and girls who had been in trouble with the police were twice as likely to become a teenage parent, compared to those who had no contact with the police
  • Research among south London teenagers found regular smoking, drinking and experimenting with drugs increased the risk of starting sex under 16 for both young men and women
  • A study in Rochdale showed that 20% of white young women reported going further sexually than intended because they were drunk
  • Other studies have found teenagers who report having sex under the influence of alcohol are less likely to use contraception and more likely to regret the experience
  • A significant proportion of teenage mothers have more than one child when still a teenager. Around 20% of births conceived under 18 are second or subsequent births
  • Around 7.5% of abortions under 18 follow either a previous abortion or pregnancy. Within London this proportion increases to around 12% of under 18 abortions.

b) Education-related factors including leaving school at 16 with no qualifications, disengagement from school, low educational attainment

  • The likelihood of teenage pregnancy is far higher among those with poor educational attainment, even after adjusting for the effects of deprivation.
  • On average, deprived wards with poor levels of educational attainment had an under-18 conception rate double that found in similarly deprived wards with better levels of educational attainment (80 per 1000 girls aged 15-17 compared with 40 per 1000).
  • A survey of teenage mothers showed that disengagement from education often occurred prior to pregnancy, with less than half attending school regularly at the point of conception. Dislike of school was also shown to have a strong independent effect on the risk of teenage pregnancy.
  • Poor attendance at school is also associated with higher teenage pregnancy rates. Among the most deprived 20% of local authorities, areas with more than 8% of half days missed had, on average, an under-18 conception rate 30% higher than areas where less than 8% of half days were missed.
  • Overall, nearly 40% of teenage mothers leave school with no qualifications.
  • Among girls leaving school at 16 with no qualifications, 29% will have a birth under 18, and 12% an abortion under 18, compared with 1% and 4% respectively for girls leaving at 17 or over.
  • Leaving school at 16 is also associated with having sex under 16 and with poor contraceptive use at first sex.

c) Family/background factors including parental aspirations, ethnicity, daughter of a teenage mother, in care or a care leaver

  • Research has shown that by the age of 20 a quarter of children who had been in care were young parents, and 40% were mothers.
  • The prevalence of teenage motherhood among looked after girls under 18 are around three times higher than the prevalence among all girls under 18 in England.
  • Research findings from the 1970 British Birth Cohort dataset showed being the daughter of a teenage mother was the strongest predictor of teenage motherhood.
  • Data on mothers giving birth under age 19, identified from the 2001 Census, show rates of teenage motherhood are significantly higher among mothers of ‘Mixed White and Black Caribbean’, ‘Other Black’ and ‘Black Caribbean’ ethnicity. ‘White British’ mothers are also overrepresented among teenage mothers, while all Asian ethnic groups are under-represented.
  • A survey of adolescents in east London showed the proportion having first sex under 16 was far higher among Black Caribbean men (56%), compared with 30% for Black African, 28% for White and 11% for Indian and Pakistani men. For women, 30% of both White and Black Caribbean groups had sex under 16, compared with 12% for Black African, and less than 3% for Indian and Pakistani women.
  • Poor contraceptive use has also been reported for some ethnic groups.
  • Research shows that a mother with low educational aspirations for her daughter at age ten is an important predictor of teenage motherhood.

Those identified at risk in Haringey include those mentioned above. In addition:

  • Haringey is typical of many inner city areas, having a younger population than England and additionally, areas of high social disadvantage and income deprivation typically associated with higher rates of teenage pregnancy.
  • Haringey’s teenage pregnancy rates are higher in the eastern wards, similar to the wards with higher deprivation.
  • The two maps below show the downward trend in rates and decreases in levels achieved across the wards in the east of the borough but also highlight the on-going health inequality for girls and young women resident in these wards.

Figure 2: Teenage pregnancy rate across Haringey wards for conceptions in 2006-2008

Figure 3: Teenage conception rate by ward 2007-2009 (per 1,000 females ages 15-17)

With the unavoidable delay in reporting teenage conceptions, it is therefore necessary to collect more timely local data, including numbers of live births and terminations that suggest needs and can inform further analysis of the impact of interventions and services.

In 2010, local data suggests that there were approximately 173 under-18 conceptions with 62 leading to a live birth and 111 leading to termination. The data suggests that the number of births is highest amongst White British, Other White, Black Caribbean, Black African and Other Ethnic Groups. A low proportion is to women living in the west of the borough. The data suggests that the number of terminations is highest amongst White British, Black Groups and Other Ethnic Groups. A high proportion of local termination data does not have an ethnicity stated. Terminations are considerably higher in the east of the borough.

In 2009, local data collected on terminations suggested that a significant proportion (20%) of the young women attended the single sex school in the borough. A significant proportion (31%) was schooled outside of the borough.

Other at risk groups in Haringey include:

  • Children in care and care leavers. Nationally, children in care are more at risk of teenage pregnancy and poor sexual health and more likely not to choose a termination. In Haringey, teenage pregnancy amongst children in care has been low but increases with age, with care leavers being more at risk. Asylum seekers and young people with no recourse to public funds are also at risk. Since October 2010, 36.4% of Haringey’s Family Nurse Partnership clients (first time teenage mothers referred before 26 weeks of pregnancy) are currently, or have been historically children in care or care leavers
  • Referrals to Social Care. Since October 2010 49.9% of clients referred to the Family Nurse Partnership were known to social care at referral
  • Repeat terminations. Local data collected from the follow up support and tracking offered to vulnerable young women under 19 having a termination since April 2011 showed that 10 % of the young women seen had had a previous termination and of these, 0.04% had a subsequent termination since receiving the follow up support
  • Other BME groups. Haringey council’s Gypsy, Roma and Travellers Support Team based within the Children and Young People’s Service (the team ceased to exist from April 2011) identified teenage pregnancy and poor sexual health as a risk factor for their clients and families they came into contact with
  • Not in Employment, Education and Training (NEET). National and local data suggests that young women aged 16 to 19 who are NEET and teenage mothers who are NEET are at risk of teenage pregnancy and poor sexual health.
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The level of need in the population

In 2010, there were 203 conceptions with 62.1% leading to a termination, an increase on the percentage shown in the two previous years. In 2009, there were 171 under 18 conceptions, compared to 184 in 2008. This number is significantly lower than the 248 conceptions in 2007 when the rate was 70.2 per 1000 and significantly lower than its highpoint in 2002 when the rate was 80.4 per 1000 and there were 313 conceptions.

Only five of Haringey’s nineteen wards have teenage pregnancy rates lower than the national average. The five wards are in the west of the borough.

Haringey’s under-16 conception rates for 2007- 09 was 14.6 per 1000 with 61.1% leading to an abortion. This was significantly higher than the rates for London (8.5 per 1000) and England (7.9 per 1000). Haringey’s under 16 conceptions rate for 2010 reduced to its lowest rate of 10.0 per 1000 and the 2008 – 2010 rate reduced to 12.00 per 1000.

As Haringey’s under-18 conception rates decreased in 2008 and 2009, the Department of Health’s estimate of teenage mothers in Haringey aged under 20 also decreased as shown in the table below (see footnote 6).

Figure 4: Estimates of numbers of teenage mothers in Haringey and the circumstances in 2011 of those known to the Youth, Community and Participation Service

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Current services in relation to need

The following section does not include the range of services implemented in 2008 and 2009 that were significantly affected by efficiency savings in 2010/2011 and the loss of Area Based Grant funding in 2011/2012.

1.Teenage pregnancy prevention

  • Whittington Health’s Contraception and Sexual Health Service provides the following; a sexual health telephone helpline available Monday to Friday, 9.30am to 4.30pm. Advice and information available in various clinics and health centres across the borough. Clinic details and appointments can be found on the website Shhout - Lets talk about sex (external link)
  • Shh..! Is an A5 booklet (hard copy and electronic) developed with young people providing a range of sexual health information
  • The C-Card Scheme is a free condom distribution scheme for young people under 25
  • Emergency Hormonal Contraception (EHC) is free to all women under 25 in Haringey and can be accessed from a number of pharmacies across the borough
  • Haringey commissions the British Pregnancy Advisory Service to provide local termination of pregnancy services. The service can be accessed through self-referral or via GPs and other health services. In addition, Haringey commissions an assessment service and a service to track vulnerable under-19s and provide support post termination from Whittington Health.
  • Speakeasy/RU READY is an accredited training course which enables parents and professionals to speak comfortably about sex and relationship issues.
  • The Teens and Toddlers is a targeted youth development programme for pupils at risk in a number of targeted secondary schools (funding has not yet been secured from April 2012)
  • Sex and Relationships Education is provided in schools.

2. Support available for teenage mothers and fathers

  • The Family Nurse Partnership is a programme providing intensive support for first time teenage mothers in Haringey. Clients must be referred before 28 weeks of pregnancy and support is provided until the child is 2 years of age.
  • The Young Parents Team is a group of specialist midwives at Whittington Hospital.
  • Family support for teenage mothers and fathers is provided via the CAF.
  • The Youth, Community and Participation Service in Haringey council provide targeted support for teenage mothers and fathers.
  • Children’s Centres offer support for teenage parents including a weekly drop in support group at The Triangle Children, Young People and Community Centre.
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Service users and carers opinion

The Haringey Sexual Health Needs Assessment 2009 (revised in 2010) (see footnote 7) included interviews and focus groups from at risk groups. The following is a synopses of the findings and the participants views and feedback of services:

1.Young mothers

They were very well informed about sexual health and were comfortable and familiar with accessing services in Haringey. They were the most satisfied with the services received from St. Ann’s Clinic although the geographical location caused some difficulties.

Relationships with their own parents affect the choices that young women make about their own sexual and reproductive health. Some of the young mothers described how their inability to talk about sexual health with their parents negatively affected the choices they made. Young mothers suggested that Sex and Relationships Education (SRE) and especially education, information and advice on contraception should begin at an earlier age for school children.

Several young mothers saw prevention, especially through contraceptive provision testing for sexually transmitted infections (STIs), as the most important goal for sexual health services.

Some young mothers preferred to access pregnancy and antenatal services in GP settings rather than hospitals or clinics.

Young mothers stressed the importance of targeted advice and counselling for both women and men.

2.Young people in care and unaccompanied minors

Young people in care have a diverse range of sexual health needs and concerns. They listed STIs as their primary sexual health concern. Half of the young people in care had accessed services at St. Ann’s Sexual Health Clinic, and many had also received sexual health services through GPs and the 4YP service. Most listed parents and siblings as important sources of advice and information for sexual health, despite the fact that they were living in care. Only one in five said that they would not talk to any family members about sexual health.

Incorrect information about some aspects of sexual health presented a barrier to accessing the appropriate services. This was especially the case around contraception, with several young people concerned that long term use of oral contraceptives or repeated use of EHC would likely cause infertility. There was also misinformation about HIV, with many young people believing that HIV was a “death sentence” and not knowing that advances in HIV treatment have dramatically extended the lives of people living with HIV.

Though half of the young people in care had accessed St. Ann’s Sexual Health Centre, most felt the location was not convenient and this created a barrier to access for many young people. In addition to more clinics throughout the borough, young people in care were interested in seeing more sexual health services offered through GP practices in order to improve accessibility and convenience. Young people in care often lack the confidence to access sexual health services on their own. This barrier can be mediated by caseworkers who accompany young people to a clinic or GP appointments. However, when young people leave care the confidence issues may persist.

Confidentiality and anonymity were important to most young people in care. For some of them concerns about being recognised while accessing sexual health services presented barriers and made them uncomfortable going to sexual health clinics.

3.Young people

When asked what their main sexual health concerns were, young people ranked HIV testing as most important, with access to contraception and STI testing the other main concerns. Sex and relationship education is a major source of information and learning about sexual health. Friends were also listed as a major source of sexual health information, followed by family and public health information such as posters, leaflets and television advertisements.

Young people are familiar with Haringey’s sexual health services and most in the interview sample had accessed clinics in the borough. Several of the young people described feeling intimidated or unwelcome at times when confronted with staff that they perceived as too busy or un-empathetic.

Though most of the young people interviewed displayed relatively high levels of awareness about sexual health issues and the services available in Haringey, several described low levels of awareness amongst their peers and young people in general.

Provision of contraception in educational settings was seen as an effective method of outreach and a convenient alternative to accessing clinics.

In 2009 Haringey commissioned the Schools Health Education Unit to undertake a Health Related Behaviour Survey (see footnote 8). This included responses from over 1200 secondary age pupils in Year 8 and Year 10 from eight Haringey schools, including the Pupil Referral Unit.

  • 72% of boys and 61% of girls had heard of the 4YP service. 25% of Year 10 boys had used it and found it useful.
  • 62% of pupils said that their lessons on sex and relationships had been useful.
  • 62% of pupils said they thought that condoms were reliable to stop pregnancy. 34% (53% Year 10 girls) said that the ‘morning after pill’ was reliable to stop pregnancy.
  • 34% thought condoms would be reliable to stop infections like HIV.
  • 16% of pupils said that they thought chlamydia can be treated and cured. 43% said either they have never heard of it or know nothing about it.

A Sex and Relationships Education Pupils Survey (see footnote 9) was completed by 100 young people in 2008. All the pupils were elected members of their School Council and were spread across the 11 to 18 age range. Eight secondary schools participated in the survey.

We asked participants about the subjects they had learnt about. The most common five topics were human reproduction, puberty, sexually transmitted infections, peer pressure and contraception. When asked what they would like to learn about, the most important five topics were being a parent, self-awareness and emotional resilience, strategies for making choices, managing risk and assertiveness skills and same sex relationships. The emphasis on aspects of relationships issues and emotions reinforces the findings of the UK Youth Parliament Report ‘Are You Getting It? (based on a survey of over 21,000 young people nationally)

We also asked students how they would like to learn. Interactive and participatory approaches came out top underlining the importance of making lessons active and varied in the style of delivery. The top preferred learning approaches were DVD/film, visiting speakers/experts, debate, discussion, theatre groups and TV programmes. Least popular were textbooks and worksheets.

67% of participants had heard about the 4YP Service and 55% had someone in school to ask for SRE help.

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Expert opinion and evidence base

1. The Department of Health requested the National Institute for Health and Clinical Excellence (NICE) to produce public health guidance on the NHS provision of contraceptive services for socially disadvantaged young people up to the age of 25 (see footnote 10). Draft guidance was issued in October 2010 for public consultation but a decision was subsequently made to end the consultation process. Although the guidance was never published a summary of the findings for effectiveness and cost effectiveness was released and is provided below.

Figure 5: Effectiveness and cost effectiveness of contraceptive services amongst socially disadvantaged young people.

Strong

Moderate

Weak

Unclear
Advanced supply of EHCOutreach to mainstream servicesSocial marketingHome visiting (repeat conceptions)
Promotion of condomsVirtual world interventionsGeneric programmes for young mothers (repeat conceptions)
School-based provisionComputer-based mediaGeneric youth interventions
Community Outreach

Source: NICE

Strong evidence was found for:

i) Advanced supply of emergency hormonal contraception
Four randomised controlled trials support the advanced provision of EHC to adolescents to increase EHC use. In most cases increased use was not at the expense of other contraceptive use, and did not promote risky sexual behaviour; the exception was one study with adolescent mothers.

ii) Interventions to promote adolescent condom use
Five studies support interventions that combine discussion and demonstration of condom use to increase adolescent condom use and engagement with clinical services.

iii) School based health centres
Four papers support the direct provision of contraceptives dispensed on site from school based health centres as a way to increase contraceptive provision.

iv) Community outreach
Three studies suggest curriculum interventions that include community outreach components can be effective in preventing teenage pregnancy and risky sexual behaviour.

Moderate evidence was found for:

i) Outreach to existing mainstream services
Five studies suggest that outreach programmes may be effective in increasing service use, but the effect on reducing teenage pregnancy rates is unclear.

ii) Virtual world intervention
One study suggests that a virtual world intervention was effective when associated with a curriculum based intervention about sexual risk behaviour.

iii) Media based interventions:
Evidence for computer based interventions from one randomised control trail (RCT).

Weak evidence was found for:
i) Social marketing campaigns from two before and after studies.

Unclear evidence was found for:
i and ii) Interventions to prevent repeat pregnancy

There is inconsistent evidence from three RCTs for home visitor interventions. There is moderate evidence from one RCT for generic programmes for teenage mothers.

iii) Generic youth interventions
There is conflicting evidence from two studies suggesting that a generic youth programme run after school could be effective in preventing pregnancy, reducing sexual activity and improving contraceptive use.

Cost-effectiveness

The economic analysis indicates that, from a public sector perspective, the provision of contraceptives within schools is effective. Compared with no dispensing of contraceptives within schools it results in net cost savings. The analysis also suggests that dispensing hormonal contraceptives within schools is likely to be more effective for preventing pregnancies and may lead to greater cost savings than dispensing condoms within schools, although this comparison is subject to considerable uncertainty.

The economic analysis also suggests that, from a public sector perspective, intensive case management results in a cost per repeat teenage pregnancy averted of £4000 compared with no follow up after a teenage birth. Excluding government-funded benefits from the analysis leads to an estimated cost per repeat teenage pregnancy averted of £15,000.

Advanced provision of EHC is estimated to be more effective and less costly than no advanced provision of emergency EHC from a public sector perspective. The analysis suggests that the advanced provision of EHC is likely to remain cost saving from a public sector perspective when provided alongside the dispensing of contraceptives within schools.

2. The ten areas for action identified by the Teenage Pregnancy Unit’s Self-Assessment Toolkit (see footnote 11) supported local areas in monitoring and performance management of the their teenage pregnancy strategies to ensure actions were in line with the key guidance issued by central government to local authorities and primary care trusts (PCTs). The ten areas were:

a) Strategic leadership of the teenage pregnancy strategy

b) Detailed, accurate and up-to-date data and information

c) An effective media and communications strategy

d) Strong delivery of Sex and Relationship Education /Personal Social Health Education

e) Provision of young people focused contraception and sexual health services

f) Workforce training on teenage pregnancy and sex and relationship issues

g) Targeted work with at risk groups of young people

h) Work on raising aspirations

i) Work with parents/carers on preventing teenage pregnancy

j) Supporting teenage mothers and young fathers

Haringey adopted the ten areas in the redevelopment of its Teenage Pregnancy Prevention and Support Strategy and Action Plan in 2008

3. Teenage Pregnancy Strategy: Beyond 2010 (see footnote 12)

Sets out the progress that has been made in reducing England's teenage pregnancy rate between 1998 and 2008 and presents a review of the evidence-base on what works in reducing teenage pregnancy rates, including examples of effective practice in local areas.

4.Teenage Pregnancy Independent Advisory Group final report (see footnote 13)

Teenage Pregnancy: Past successes – future challenges is the final report from the Teenage Pregnancy Independent Advisory Group which for 10 years advised ministers on reducing teenage pregnancy and improving support for teenage parents. The report says that over the past decade there has been significant progress in reducing teenage pregnancy, but there have also been missed opportunities while England’s under-18 pregnancy rate is currently at its lowest level for 20 years, it is still unacceptably high.

5. Getting maternity services right for pregnant teenagers and young fathers (see footnote 14)

This guide was first produced in 2008 by the Department of Health. It was revised in 2009 with the help of the Fatherhood Institute, following feedback from midwives and other maternity workers who wanted more guidance on engaging young fathers.

6. Teenage parents: Who cares? A guide to commissioning and delivering maternity services for young parents (see footnote 15)

The revised edition of this guide, published jointly by the Department of Health and the Royal College of Midwives contains practical pointers as to how commissioning and delivery of maternity services for young parents can be achieved, with case studies of successful services. It places renewed emphasis on multi-agency working in the commissioning and delivery of services.

7. Targeted youth support and teenage pregnancy - working together to reduce teenage pregnancy rates and support young parents (see footnote 16)

The publication reports that local authorities that have reduced teenage conception rates have successfully developed strong, effective partnerships with health, education, social care and youth services.

8. Lead members for children’s services briefing on teenage pregnancy (see footnote 17)

This is a summary of key points in relation to progress in reducing teenage pregnancy rates; what works; and what action lead members in local authorities can take to challenge and support local teenage pregnancy strategies.

9. You’re welcome quality criteria - making health services young people friendly (see footnote 18)

This is Department of Health guidance to make health services young people-friendly.

10. Improving access to sexual health services for young people in further education settings (see footnote 19)

Sets out the rationale for, and examples of good practice, in relation to the provision of contraceptive and sexual health in further education colleges.

11. Multi-agency working to support pregnant teenagers Department of Health (see footnote 20)

This midwifery guide, jointly published by the Department of Health and the Royal College of Midwives, highlights effective practice on issues of confidentiality and sharing information about individual teenage mothers.

12. Teenage Parents Next Steps: Guidance for Local Authorities and Primary Care Trust on Improving Outcomes for Teenage Parents and their Children (see footnote 21)

It describes the poor outcomes to which teenage parents are at risk and sets out measures that can be taken locally and what is being done nationally to improve these poor outcomes.

13. Teenage pregnancy next steps: Guidance for local authorities and primary care trusts on effective delivery of local strategies (see footnote 22)

This guidance for councils and PCTs gives advice on what works in areas with declining rates and confirms the evidence base for reducing teenage pregnancies. It highlights seven key factors to help reduce rates including active engagement of mainstream delivery partners, a strong senior champion, accessible young people-centered contraceptive and sexual health advice services, and priority being given to developing comprehensive sex and relationship education programmes.

14. Teenage pregnancy: Accelerating the strategy to 2010 (see footnote 23)
Accompanying guidance to Teenage pregnancy next steps, showing how local areas need to develop strategies taking account of what has worked in areas with rapidly declining rates.

15. Enabling young people to access contraceptive and sexual health information and advice (see footnote 24)

This is guidance for Youth Support workers. Youth support workers can play a key role in helping young people develop the confidence and self-esteem to resist peer pressure to be sexually active until they feel ready to make safe and responsible choices.

16. Enabling young people to access contraceptive and sexual health information and advice (see footnote 25)

This report provides the legal and policy framework for social workers, residential social workers, foster carers and other social care practitioners.

17. NICE One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under-18 conceptions, especially among vulnerable and at risk groups (see footnote 26)

Public health intervention guidance

18. Teenage Pregnancy and Parenthood: a review of reviews. Evidence Briefing, Health Development Agency (see footnote 27)

A review of reviews about the prevention of teenage pregnancy and the effectiveness of interventions to improve outcomes.

18. Sure Start Plus national evaluation - final report (see footnote 28)

An independent evaluation of the Sure Start Plus pilot programme aimed at supporting teenage parents.

19. Reaching out to pregnant teenagers and teenage parents (see footnote 29)

This report provides briefings on innovative practice from the Sure Start Plus pilot programme including:

  • Briefing 1 - Long-term consequences of teenage births for parents and their children
  • Briefing 2 - Living on the Edge: Sexual behaviour and young parenthood in rural and seaside areas
  • Briefing 3 - The education of pregnant young women and young mothers in England
  • Briefing 4 - Protective and risk factors for early sexual activity and contraception use among black and minority ethnic adolescents in East London
  • Briefing 5 - Exploring the attitudes and behaviours of Bangladeshi, Indian and Jamaican young people in relation to reproductive and sexual health
  • Briefing 6 - An exploration of the teenage parenting experiences of black and minority ethnic young people in England
  • Briefing 7 - Teenage parenthood and social exclusion: A multi-method study
  • Briefing 8 - Consequences of teenage parenthood: Pathways which minimise the long-term negative impacts of teenage childbearing

20. Family Nurse Partnership: Developing an instrument for identification, assessment and recruitment of clients (see footnote 30)

This publication reports on work that was commissioned in support of a proposal to pilot the Nurse-Family Partnership a model of intensive home visiting targeted at selected women and their partners having their first baby. The programme looked to reduce adverse outcomes and social exclusion for the children of these families. The research aimed to design an ‘Instrument’ that could be used to identify women eligible for the health-led parenting programme.

21. Early Intervention Findings from the C4EO research evidence (see footnote 31)

The Teens and Toddlers projects in Birmingham and Manchester and the Westminster families Teens and Toddlers were identified as an effective early intervention programme including working families with multiple problems and looked after children and young people.

22. Positive for Youth (see footnote 32)

The Government’s Positive for Youth strategy includes the following objectives so that all young people:

  • receive the information, advice and support they need – from parents, teachers and other professionals – to deal with pressure to have sex; enjoy positive and caring relationships; and experience good sexual health; and
  • can access and know how to use contraception effectively when they do reach the stage that they become sexually active, so they can avoid unplanned pregnancies and sexually transmitted infections.

Projected service use in 3-5 years and 5-10 years

Haringey’s population estimates and fertility rates identified in the JSNA Demographic section suggests that contraception and sexual health service use in 3-5 years and 5-10 years will increase.

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Unmet needs and service gaps

The following were identified in the NICE draft guidance on NHS provision of contraceptive services for socially disadvantaged young people up to the age of 25 and are gaps in local service provision:

  • Advanced supply of Emergency Hormonal Contraception- identify opportunities for administration of advanced supply to high risk groups
  • Promotion of condoms – significantly increase take up of the free condom distribution scheme across young people aged 25 and under
  • School-based provision – reintroduce provision of school based contraception services (all these services ended by March 2011) and extend to other targeted secondary schools, including single sex secondary school
  • Community outreach – increase opportunities for contraception and sexual health services in community settings
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Recommendations for Commissioning

  • Speakeasy Training. Sex and Relationships Education is the earliest possible intervention provided to children and young people that can impact on a conception not taking place, it is essential that training is available to parents/carers and professionals.
  • Free Emergency Hormonal Contraception for young women under 25. Emergency Hormonal Contraception is the last service that can impact on a conception not taking place, it is essential that it continues to be available and in pharmacies that young women can access easily, including increasing availability on Sundays as analysis of local use to date suggests that Mondays are the busiest days.
  • A comprehensive borough-wide free condom scheme for young people under 25.
  • Continue the 4YP service, a targeted community outreach service to include provision of Long Acting Reversible Contraception and other contraception and sexual health services, including post termination support, advanced supply of Emergency Hormonal Contraception to be available in a range of school based and non-healthcare settings for young people under 25.
  • Re-commission the Teens and Toddlers targeted youth development programme for secondary pupils at risk of teenage pregnancy and becoming Not in Employment, Education and Training.
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Recommendations for further needs assessments

  1. Further cost effectiveness analysis is needed to integrate teenage pregnancy and sexual health services for young people under 25.
  2. Further abortion data analysis is needed to identify if young women are experiencing poor or no contraceptive use following a termination.
  3. Further analysis of repeat use of Emergency Hormonal Contraception needs to take place in order to reveal more opportunities to support young women at risk of poor contraceptive use and sexual health and identify opportunities for advanced supply of Emergency Hormonal Contraception.
  4. Further analysis is needed on increasing use of both Long Acting Reversible Contraception and condoms in young women under 25, including under-18s.

Needs assessment needs to include access to contraception and sexual health services with GPs by under-18s in Haringey.

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Key Contact

Vivien Hanney, Teenage Pregnancy Coordinator - email: vivien.hanney@haringey.gov.uk

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Footnotes

  1. Berrington, A., Diamond, I., Ingham, R., et al. (2005) Consequences of teenage parenthood: Pathways which minimise the long term negative impacts of teenage childbearing. Final report – Nov 2005
  2. McGuire A and Hughes D. (1995). The Economics of Family Planning Services (London: FPA)
  3. Office for National Statistics (2012) Statistical Bulletin. Conceptions in England and Wales 2010 Under-18 conception
  4. Department of Health, Abortions by PCT of residence
  5. Department of Health, (2006) Teenage pregnancy: Accelerating the strategy to 2010
  6. North London Client Caseload Information System (NCCIS) , (2012)
  7. NHS Haringey Public Health Directorate. (2009) Sexual Health Needs Assessment 2009 (revised November 2010) (PDF: 2,591kb)
  8. London Borough of Haringey. (2009) Schools Health Education Unit , Every Child Matters, Health Related Behaviour Survey Summary Report (PDF: 193kb)
  9. London Borough of Haringey. (2008) Sex and Relationships Education, Pupils Survey (PDF: 362kb)
  10. National Institute of Health and Clinical Excellence (NICE). (2010) Draft guidance, NHS provision of contraceptive services for socially disadvantaged young people up to the age of 25, NICE website (external link)
  11. Teenage Pregnancy Unit (2009). Teenage pregnancy prevention and support: A self-assessment toolkit for local performance management (PDF 258KB)
  12. Department for children, schools and families and the Department of Health. (2010) Teenage Pregnancy Strategy: Beyond 2010 (external link)
  13. Teenage Pregnancy Independent Advisory Group. (2010). Teenage pregnancy: past successes – future challenges
  14. Department for children, schools and families and the Department of Health. (2009). Getting Maternity Services right for pregnant teenagers and young fathers. 2nd edition
  15. Department of Health and the Royal College of Midwives. (2009) Teenage parents: Who cares? A guide to commissioning and delivering maternity services for young parents (2nd edition)
  16. Department of Education. (2008) Targeted youth support and teenage pregnancy - working together to reduce teenage pregnancy rates and support young parents www.education.gov.uk (external link)
  17. Department of Education. (2008) Lead members for children’s services briefing on teenage pregnancy
  18. Department of Health. (2007) You’re welcome quality criteria - making health services young people friendly
  19. Department of Health. (2007) Improving access to sexual health services for young people in further education settings
  20. Department of Health. (Revised 2009) Getting maternity services right for pregnant teenagers and young fathers
  21. Department for children, schools and families and the Department of Health. (2007). Teenage Parents Next Steps: Guidance for Local Authorities and Primary Care Trust on Improving Outcomes for Teenage Parents and their Children
  22. Department for children, schools and families and the Department of Health. (2006) Teenage pregnancy next steps: Guidance for local authorities and primary care trusts on effective delivery of local strategies
  23. Department of Education. (2006). Teenage pregnancy: Accelerating the strategy to 2010
  24. Department of Education. (2005). Enabling young people to access contraceptive and sexual health information and advice
  25. Department for Education and Skills and the Teenage Pregnancy Unit. (2004). Enabling young people to access contraceptive and sexual health information and advice
  26. National Institute for Health and Clinical Excellence. (2007) One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under-18 conceptions, especially among vulnerable and at risk groups
  27. Health Development Agency. (2007) Evidence Briefing. Teenage Pregnancy and Parenthood: a review of reviews.
  28. Social Science Research Unit, Institute of Education, University of London. (2005). Sure Start Plus national evaluation - final report
  29. Department of Education. (2005) Reaching out to pregnant teenagers and teenage parents
  30. Hall, David and Hall, Susan, Department for Children, Schools and Families (DCSF). (2007) Family Nurse Partnership: Developing an instrument for identification, assessment and recruitment of clients
  31. Centre for Excellence in Outcomes. (2010).Early Intervention Findings from the C4EO research evidence www.c4eo.org.uk (external link)
  32. Department of Education. (2011) Positive for Youth
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Page Last Updated: 24 April 2013

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