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Teenage pregnancy: strategies for prevention
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Teenage mothers are more likely to experience post-natal depression and other mental health issues, are more likely to smoke and are less likely to breast feed Children of teenage pregnancies have a 60% higher infant mortality rate than babies born to older mothers, and are 63% more likely to be born into poverty. Since 1998, the termination of pregnancy rate for under-18s has increased in the UK from 42% to 50%. It is important to remember that statistics count only live births, still births and terminations of pregnancy. Miscarriages in women are not recorded in the UK and there is some evidence to suggest that up to 25% of teenage pregnancies will spontaneously miscarry. Although not the hoped-for success story of the 1999 Teenage Pregnancy Strategy, there are many efforts ongoing in the UK to address all aspects of this issue. We discuss these, and also the issue of a rather negative view of teenage pregnancy, later. Firstly, how does the UK, compare with the rest of the World?
Teenage pregnancy: strategies for prevention Aisling S Baird Charlotte C Porter
Abstract Teenage pregnancy (TP) rates in the UK are high, and are associated with high levels of socio-medical morbidity. Correspondingly, in the UK, teenage pregnancies are considered undesirable, but this is not the case in many non-European cultures. Recent education and enhanced contraception services are initiatives which have met with variable success. In this summary, we discuss these, and the welcome recognition of other contributing factors, such as poverty; unless such contributing factors are addressed, any prevention initiatives are threatened. The gynaecologist should be constantly prepared to consider the issue in any young woman.
The international picture The terms adolescent, a young person in the period between childhood and adulthood, and teenager are often used interchangeably. We sometimes overestimate the capacity of the adolescent to actively choose to have sex and make informed decisions, since the maturation of the conscious brain is still continuing into the second decade of life e a time of profound biological, social and psychological change, and an increasing interest in sex. The risk of unintended pregnancy is correspondingly high and in the developed world this risk is considered unacceptable, particularly since teenage pregnancy bears the negative associations of poor economic, social and health outcomes. Worldwide, not all teenage pregnancy is considered undesirable. Internationally, 13 million children are born to women under aged under 20 every year, more than 90% in developing countries, and teenage birth and marriage rates are much higher than in the UK. However, complications of pregnancy and childbirth are the leading cause of mortality among women between the ages of 15 and 19 in the developing and resourcepoor world. The highest rates of teenage pregnancy are recorded in sub-Saharan Africa, where early marriage is a cultural norm. In Niger for example, 87% women are married before the age of 18, and more than 50% will have a baby before their 18th birthday. Contraceptive usage is around 11% and maternal mortality 650/100,000. In the Indian subcontinent, early marriage is also the norm, although urban areas have lower rates of early marriage and teenage pregnancy than rural areas, representing enhanced educational and financial opportunities for young women in towns and cities. The rate of early marriage and pregnancy has decreased sharply in Indonesia and Malaysia, although it remains relatively high. In industrialized Asian nations such as South Korea and Singapore, teenage birth rates are among the lowest in the world. The overall trend for conception rates in Northern Europe since 1970 has shown a decreasing total fertility rate, an increase in the age at which women experience their first birth, and a decrease in the number of births among teenagers. Most continental Western European countries have very low teenage
Keywords prevention; strategies; teenage pregnancy; United Kingdom
Introduction 4% births in the UK are to women aged 18 or less. However, in England and Wales 50% of the pregnancies occurring in under-18s are terminated. Our societal view of teenage mothers is negative e associated with the benefit culture, lack of social mobility, poor educational attainment and suboptimal life chances for the children. Prevention of teenage pregnancy has become a political imperative. The teenage pregnancy strategy was introduced in 1999 to support teenage parents, and to reduce the conception rate in this age group. The Government’s target was to reduce the teenage pregnancy rate by 50% before 2010. Thus far, however, Office of National Statistics (ONS)figures do not show significant change. In England and Wales there has been a 13.7% reduction in under-18 conceptions between 1998 and 2008. As summarized in the 2010 teenage pregnancy strategy report: At age 30, teenage mothers are 22% more likely to be living in poverty than mothers bearing children aged 24 and over, are much less likely to be employed, and are less likely to be living with a partner Teenage mothers are 20% more likely to have no qualification at age 30 and are more likely to partner poorly qualified and unemployed men
Aisling S Baird MRCOG MFRSH MAcadMEd is a Locum Consultant in Sexual and Reproductive Healthcare at the Centre for Contraception and Sexual Health, Wolverhampton, UK. Conflicts of interest: none declared. Charlotte C Porter MRCOG MFRSH MRCGP is a Consultant in Community Gynaecology and Sexual and Reproductive Healthcare at the Centre for Contraception and Sexual Health, Nottingham, UK. Conflicts of interest: none declared.
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birth rates, particularly the Netherlands (Table 1). This is varyingly attributed to good sex education and high levels of contraceptive use (in the case of the Netherlands and Scandinavia), traditional values and social stigmatization (in the case of Spain and Italy) or both (in the case of Switzerland). The teenage birth rate in the United States is the highest in the developed world, and the teenage abortion rate is correspondingly high. The U.S. teenage pregnancy rate was at a high in the 1950s and has decreased since then, particularly in the 1990s; this decline was manifest across all racial groups, although teenagers of African-American and Hispanic descent retain a higher rate of teen conception, in comparison to that of European-Americans and Asian-Americans. The WHO collaborating centre (the US Guttmacher Institute for sexual & reproductive health), at one time attributed about 25% of the decline to abstinence (quite a force in the US) and 75% to the effective use of contraceptives. Yet, in 2006, the teenage birth rate rose for the first time in 14 years. This could imply that teen pregnancy rates are also on the rise, but the rise could also be due to other factors: a possible decrease in the number of abortions or a decrease in the number of miscarriages, to name but two. The ‘abstinence movement’ in the US has received much publicity, although some social commentators have said that even defining the term is problematic, yet the UK Independent Advisory Group on Teenage Pregnancy has suggested that recent research confirms the greater efficacy of contraception over abstinence. Researchers from Columbia University have said that 86% of the decline in teenage pregnancy was due to improved use of contraception. Only 14% of the drop amongst 15e19 year olds was linked to reduced sexual activity, according to the Columbia study, published in the American Journal of Public Health.
intercourse, lead to variable rates of contraceptive use for teenagers commencing sexual activity. Other reasons are summarized in Box 1. Some work has demonstrated the attitudinal differences between adolescents in the UK and the Netherlands with less emphasis on peer pressure in the Netherlands and a greater importance given to feelings of love and commitment. British teenagers seem to have greater opportunity for sexual activity.
National initiatives in the UK and elsewhere The first teenage pregnancy strategy was launched in 1999; subsequently there have been yearly reports. The 2010 document reports ‘significant reductions’ in teenage conception rates, and yet the modest reductions of 15.2% in under 16s and 11.1% in the under-18s come nowhere near to the 1999 challenge of 50% reduction. The strength of the 2010 report is the recognition of the significance of underlying factors such as poverty, poor educational attainment and ‘low aspirations’ (we would consider these co-factors rather than causative ones). To address the issue, the 2010 report asks professionals to 1) identify and target high rate neighbourhoods and vulnerable groups, associated with risky behaviour, poor education, family and other background factors, 2) drive up local preventative performance and, 3) deepen strategy to tackle broader risk factors as well as risky behaviour. In order to achieve these aims, the report proposes strategies summarized in Box 2. Evidence shows that children whose parents talk to them openly and honestly about sex and relationships have later coitarche and are more likely to use contraception when they do become sexually active. The Department for Children, Schools and Family has provided funding to the Family Planning Association to extend to more local areas its ‘Speakeasy’ initiative: a structured programme of advice and support for parents on talking to their children about sex and relationships. The 2010 strategy report emphasizes and commends as good practice those sex education (SE) or Personal, Social and Health Education (PSHE) programmes which engage elements of peer education, address emotions (rather than bare facts), dismiss myths (such as easy access to state benefits and good housing) and promote self-esteem, empowerment and informed decision-
The UK picture The majority of teenage pregnancies in the UK are unplanned: between 8 and 22% teenagers at their first coitus do not use contraception, with lower usage rates occurring in the younger ages. Of those who do use contraception, many use less effective methods such as the condom or the coitus interruptus. Why is the UK pregnancy rate so high and lack of preparedness for first coitus so low? One factor is an earlier coitarche: 26% of 16-year-old females in the UK have been sexually active. Declining age at first sexual intercourse, linked to peer pressure and lack of planning for
What leads young people into early sexual experience? Percentage of total births nationally in European countries in women aged 12e18 years Netherlands Italy France Spain Germany Ireland UK
0.7 0.9 1.5 1.7 1.9 2 4
Young people overestimate how many of their peers are sexually active
C
Young people have sex in the hope that it will deliver other things such as a loving relationship
C
Low self-esteem
C
Cultural pressure and assumption of the normality of sexual experience (for example ‘celebrity’ and teenage magazines)
C
Variable availability of sex and relationship education (SRE)
C
Inability to communicate with parents or carers.
Box 1
Table 1
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C
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C
Engagement of delivery partners: active engagement of all of the key mainstream delivery partners who have a role in reducing teenage pregnancies: health, education, social services, youth support services, and the voluntary sector.
C
Selection of a senior champion: a strong senior champion who is responsible for the local strategy and can take the lead in implementing it.
C
Effective sexual health advice service: the availability of a wellpublicized contraceptive and sexual health advice service which is centred on young people. The service needs to have a strong remit to undertake health promotion work, as well as delivering reactive services.
C
Prioritization of sex and relationships education: high priority given to PSHE in schools, with support from the local authority to develop comprehensive programmes of sex and relationships education (SRE) in all schools.
C
Focus on targeted interventions: a strong focus on targeted interventions with young people at greatest risk of teenage pregnancy, in particular with looked-after children.
C
Training on SRE for partner organizations: the availability and consistent take-up of SRE training for professionals in partner organizations who work with the most vulnerable young people, such as Connexions personal advisers, targeted youth support (TYS) lead professionals, youth workers and social workers.
C
Well-resourced youth service: providing things to do and places to go for young people, with a clear focus on addressing key social issues affecting young people, such as sexual health and substance misuse.
was no effect of ‘primary prevention strategies’ (including 10 PSHE programmes) on age of coitarche, more effective use of contraception, or incidence of teenage pregnancy. However, there were some methodological criticisms of the identified trials. In 2006, Henderson and her group found no effect upon unintended pregnancy, across 13 secondary schools in Scotland, of a specially-designed twenty-session PSHE initiative (‘SHARE’, 2071 participants analysed). The initiative involved active learning and skills development, and was compared with a randomized control group of 12 schools (2125 participants analysed), matched for socio-demographic characteristics. The conclusions were that the SHARE programme improved knowledge and reduced regret, but there was no effect upon unintended pregnancy. Henderson et al recommended that highquality PSHE (as defined by previous authors) should continue but that it should be complementary to other longer-term initiatives that address socio-demographic inequalities. In addition, they recommended that the influence of parents should be rigorously evaluated. A more recent cluster-randomized trial from England of peer-led PSHE reported similar results. Nine thousand pupils in 37 schools took part, and were randomized to either standard teacher-led PSHE or peer-led PSHE. Adjusted for randomization strata, the odds ratio for girls experiencing abortion before age 20 years was 1.07 (95% CI 0.80e1.42 p ¼ 0.64). However, fewer girls in the peer-led arm reported a pregnancy by age 18 (adjusted OR 0.62, 95% CI 0.42e0.91). There were no significant differences in self-reported unprotected first sex, regretted or pressurized sex, quality of current sexual relationship, STI or ability to identify local SRH services. It should be noticed that these latter two trials compared different types of PSHE programme, rather than PSHE versus no PSHE. Professionals working with the young often feel that PSHE produces variable results since it should take place within an encouraging and acceptable atmosphere. Peer education often achieves that goal. In Sheffield, the Peer Activities in Sexual Health young people’s peer education project (PASH) has trained over 50 knowledgeable and committed peer educators to work with teenagers in the city areas with the highest teenage pregnancy rates, and with at risk young people. It covers sex education and awareness, and promotes self-esteem. It also covers contraception and access to sexual health services. Comments from peer educators have included:
From: http://www.ic.nhs.uk/webfiles/publications/003_Health_ Lifestyles/nhscontra0910/NHS_Contraceptive_Services_England_ 2009_10.pdf with kind permission.
‘I am most certainly glad I had the opportunity to experience [the programme]’
Key factors for reducing teenage pregnancy Evidence from areas with the largest reductions has identified a range of factors that need to be in place to successfully reduce teenage pregnancy rates. All areas are now being asked to implement these factors, which are
‘Being a PASH volunteer.is one of the most challenging yet rewarding experiences you can have’
Box 2
Teachers have been very positive:
making. In a new Department of Health white paper (Healthy lives, Healthy People), PSHE is heavily promoted in schools; schools are encouraged be active promoters of age-appropriate teaching on relations and sexual health. The Department for Education will conduct a review to consider how schools may be supported to improve the quality of PHSE. Nevertheless, there is some evidence that sex education is not as effective with respect to reducing teenage pregnancy as could be intuitively be expected. In a 2002 systematic review of controlled trials, DiCenso and colleagues found that in the 26 studies that they identified, there
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‘The volunteers were able to pitch the session correctly and create an atmosphere that was safe and secure’ ‘Students were very focussed when led by someone nearer their own age’ In the US, nurse-family partnership programmes aim to support young mothers and reduce repeat pregnancy rates. Working in particularly areas of high deprivation, they try to tackle the wider issues identified in the UK in the 2010 UK strategy report. A similar
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programme is running in pilot form in the UK. Nottingham City was selected as one of the second wave sites to test the national pilot of the Family Nurse Partnership, an intensive home visiting programme offered to first time pregnant teenagers and their partners from early pregnancy until the child is 2 years old. It aims to tackle complex issues associated with deprivation and accompanying social phenomena, and is designed to help improve parenting skills and outcomes for both parents and their child by: Improving pregnancy outcomes by helping young women engage in good preventative health practices, including antenatal care, healthy diet and reduction in smoking and substance misuse, Improving a child’s health and development by supporting parents to provide responsible and competent care, and Improving the economic self sufficiency of the family by supporting parents to develop a vision for their own future, planning of future pregnancies, continuing education and finding work. A work in progress, the Nottingham programme has been successfully delivered to 170 young women who have borne 135 babies. Short-term positive outcomes include improved health of mothers (mental health and smoking cessation), increased return to education, increased father engagement and improved parenting skills. Participants have developed positive changes in behaviour resulting in greater confidence and raised aspirations for the future. Results from a recent user survey show that 90% rated the usefulness and value of the programme and relationship with their Family Nurse as ’excellent’. All survey respondents reported that the programme had encouraged them to make positive changes in their lives, whilst 60% reported changes in either their partners or in wider family members.
developed increasingly thoughtful and locally-effective ways of addressing the issue. For example, accessible youth clinics (and staffed by sympathetic, well-trained and approachable staff) have become the norm in most towns and cities. Most of these services provide outreach services in places used by young people, and visit young offenders’ institutions, for example. CASH staffs are also proactive in training school nurses to provide sexual health services (such as ‘Clinic in a Box’). In the sexual health strategy, promotion of such accessible and outreach contraceptive services for teenagers is key. Young people seem to prefer to access services other than their general medical practitioner because of accessibility, perceived concerns about judgemental treatment and lack of confidentiality, and sensitivity to the clinical atmosphere in the GP’s surgery. Emergency contraception has become available from pharmacies and walk-in centres. These have more accessibility than doctors’ surgeries, with flexible opening hours, such as afterschool and at weekends. Such walk-in centres have been promoted, yet there is no evidence that increasing the uptake of emergency contraception decreases the pregnancy rate for any group of women. Additionally, provision of follow-on contraception in such sites is not the norm (although some services are beginning to address the issue). Unfortunately, teenagers may be unaware of the services available to them. They sometimes maintain that services are inaccessible due to location, opening hours or other difficulties with appointments. A 1997 report from the UK Social Exclusion Unit recommended more accessible services, such as appropriately-staffed lunchtime sessions in schools, and after-school and Saturday appointments. Surveys from general practice have showed an association between lower teen pregnancy rates and appropriate staffing. In particular, the inclusion of female or younger doctors and more nurse time have been shown to be beneficial. In 2007, the Department of Health published a set of benchmarking criteria for making health services ‘young people friendly’ (the ‘You’re Welcome’ quality criteria). Services are encouraged to make themselves more accessible and public, to encourage confidentiality and to provide a young people-sensitive environment. Those meeting the criteria are certified. In the 2009/10 returns from NHS community contraceptive clinics (which exclude data of services provided by general practitioners and out-patient clinics) 11% of the female population aged 13e44 attended NHS community contraceptive clinics. Approximately 14% females aged 15 and approximately 5% females aged under 15 attended. However, the highest percentage of the female population attending these clinics was in the 16e19 year olds (22%). In this era of large NHS cost savings, it is important that funding is not withheld from services which may be seen as a soft target. Long-acting contraceptive methods are being promoted as the gold standard for contraception by the National Institute for Clinical Excellence, particularly for younger women, and the intrauterine device e whether copper or hormone containing e is no longer regarded as the unique realm of older, parous women. Unfortunately, most UK teenagers in 2009/10 were still using user-dependent methods of contraception, which have the greater failure rates (Table 2). Unfortunately, most areas in the England have experienced a reduction in budget for teenage pregnancy services, but there is clear indication that it remains a priority through the child poverty strategy. Teenage pregnancy is also an impact indicator in the English Department for
Participant’s comments have included: “The team and programme do not judge you but support you and help you make the right decisions.” “I have calmed down and my behaviour and my diet is a lot healthier.” “[We are] more confident with our baby.” “. I have been lucky and I think the programme should be available to all young parents.” “My partner has changed e he helps me a lot more with my baby and understands me more.” “. I look forward to my visits, I love it.” “She [Family Nurse] has helped me realise my baby comes first.”
Developments in contraception services By addressing both medical and sociological issues and espousing a ‘broad-brush’ approach to the contraception, the aims of the 1999 UK teenage pregnancy strategy were admirable. In the UK targetdriven NHS mind set, the simplistic determination to drive down figures, always courted the danger that service delivery might become focused around termination of unwanted teenage pregnancy. Termination rates have certainly increased in this age group. However, contraception and sexual health (CASH) services have
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Failure rates of contraceptive methods
The ‘Fraser Guidelines’ for health professionals
Method
In 1985, Lord Fraser said in a judgement of the Gillick case that a doctor can give contraceptive advice or treatment to a person under 16 without parental consent providing the doctor is satisfied that
No methoda Withdrawal Diaphragmb Condomsc Female Male Combined pill and progestogen-only pill EvraÒpatch NuvraRingÒ Depo-ProveraÒ Copper-bearing intrauterine device Levonorgestrel-releasing intrauterine system ImplanonÒ Female sterilization Male sterilization
Percentage of women experiencing an unintended pregnancy within the first year of use (%) Typical use Perfect use 85 85 29 18 16 6 21 15 8
5 2 0.3
8 8 3 0.8
0.3 0.3 0.3 0.6
0.2
0.2
0.05 0.5 0.15
0.05 0.5 0.10
The young person will understand the advice
C
The young person cannot be persuaded to tell his or her parents or to allow the doctor to tell them that they are seeking contraceptive advice
C
The young person is likely to begin or continue having unprotected sex with or without contraceptive treatment
C
The young person’s physical or mental health are likely to suffer unless he or she received contraceptive advice or treatment
C
It is in the young person’s best interests to give contraceptive advice or treatment
These guidelines are known as Fraser guidelines. Although they are only legally binding for doctors, they represent good practice for other health professionals too. Box 3
opportunity (particularly at cessation of pregnancy for whatever reason), the gynaecologist should consider providing a long-acting, reversible contraceptive. The gynaecologist will be aware of the failure rates of the properly- and the inadequately-used condom e it is a helpful strategy to advise on the ‘Double-Dutch’ method (simultaneous use of both contraception and an STI-preventing condom). Clearly unwanted pregnancy is a sexually-associated phenomenon and there should be a low threshold for screening for STI. There is guidance on contraceptive use and initiation postpartum, post-termination of pregnancy and during breast feeding (United Kingdom Medical Eligibility Criteria (UKMEC), Table 3). The strategy of referring young women in the post-natal period to their GP for contraception is questionable e many such patients fail to consult their GP at the recommended 6 weeks and the opportunity is therefore lost of providing early, adequate and appropriate contraception. Hospitals should develop policies to provide contraception by the twenty first post-natal day, since conception is feasible by day 28 (time must be given for the contraceptive to become effective). Targeting teenage mothers by a qualified midwife/nurse during the immediate post-natal period and early provision of a LARC is effectively used in some centres. Some hospitals have a dedicated antenatal service for young mothers at which all of the issues we have discussed are effectively managed.
Reproduced from: http://www.fsrh.org/admin/uploads/ceuGuidanceYoung People2010.pdf with kind permission of the Faculty of Sexual and Reproductive Healthcare. a The percentages becoming pregnant in typical and perfect use are based on data from populations where contraception is not used and from women who cease using contraception in order to become pregnant. Among such populations, about 89% become pregnant within 1 year. This estimate was lowered slightly (to 85%) to represent the percentage who would become pregnant within 1 year among women now relying on reversible methods of contraception if they abandoned contraception altogether. b With spermicide. c No spermicide.
Table 2
Education business plan and Healthy Lives, Healthy People also makes frequent reference to young people and sexual health.
How can the obstetrician & gynaecologist contribute? The obstetrician & gynaecologist can contribute in several ways and at several levels. Firstly, every gynaecologist should be aware of the rates of sexual activity in younger teens at a time when educational attainment and access to contraception may be poor, and peer and personal pressure with regard to sex is high. Each should consider it their responsibility to address the issue in the adolescent patient. Under-age young people should be subject to a risk assessment of vulnerability and potential abuse, and an assessment of Fraser competence (Box 3). Information regarding sexual activity should ideally be gathered in private, without the presence of an accompanying parent, and the young person given the opportunity to raise issues or ask questions in private. Should there be a medical indication to cease a previously effective contraceptive in a sexually active younger woman, this should not be done without substituting another suitable method. At every
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C
Conclusion In conclusion, teenage pregnancy can be normal and positive, and it is important to support a young person’s choice. It becomes problematic when associated with adverse medical and social outcomes, particularly social exclusion. Compared with the rest of the developed world, poor outcomes have become an issue for the UK government and the healthcare professions. As a reflection of its importance, and with the recent change of UK government, the new white paper, Healthy Lives, Healthy People, 155
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Recommendations for contraceptive methods in postpartum, non breastfeeding and breastfeeding women and following miscarriage or abortion Contraceptive Method
Circumstance
Recommendations for timing of initiation
Additional contraception advised
Combined hormonal contraception (ie COC, transdermal patch, vaginal ring)
Postpartum (not breast feeding)
Start on Day 21 postpartum if normal vaginal delivery and no additional risk factors for VTE If beyond day 21 postpartum and menstrual cycle has returned can start CHC as for other women having menstrual cycles If >21 days postpartum and menstrual cycles have not retuned can start if CHC as long as the women is not at risk of pregnancy If over 6 months postpartum can start CHC as for other women having menstrual cycles 6 weeks to <6 months (partial breast feeding) UKMEC 2 Initiated within 7 days in gestations <24 weeks
No
Postpartum (breast feeding)
Progestogen-only pill
Progestogen-only implant
Following miscarriage or abortion Postpartum (breast feeding and artificial feeding) Following miscarriage or abortion
Postpartum (breast feeding and artificial feeding) Following miscarriage or abortion
Progestogen-only injectable
Cu-IUD & LNG-IUS
Postpartum (breast feeding and artificial feeding) Following miscarriage or abortion Postpartum (breast feeding and artificial feeding)
Following miscarriage or abortion
Initiated up to Day 21 Initiated after Day 21 Initiated on the day of surgical abortion or second part of medical abortion or immediately following miscarriage Initiated >5 days after surgical abortion or second part of medical abortion or miscarriage Initiated up to Day 21. Insertion can be prior to Day 21 but bleeding maybe a problem (unlicensed use) Initiated after Day 21 Initiated on the day of surgical abortion or second part of medical abortion or immediately following miscarriage Initiated >5 days after surgical abortion or second part of medical abortion or miscarriage Initiated up to Day 21 Initiated after Day 21 (If initiated <6 weeks and breast feeding ¼UKMEC2) Initiated on the day of surgical abortion or second part of medical abortion or immediately following miscarriage Initiated up to 48 h 4 weeks
(Use between 48 h to 4 weeks UKMEC 3) Ideally inserted at the time of a first or second trimester surgical abortion for immediate contraceptive effect Following medical or surgical abortion ideally inserted within the first 48 h or delay until 4 weeks postpartum. As waiting for 4 weeks may put women at risk of pregnancy, intrauterine contraception can be inserted by an experienced physician at any time provided that there is no risk of pregnancy
None or for 7 days
7 days
None or for 7 days None or for 7 days No No Yes, for 48 h No
Yes, for 48 h No Yes, for 7 days No Yes, for 7 days No Yes, for 7 days No No Yes, for 7 days after inserting the LNG-IUS unless inserted in the first 7 days of the cycle No Yes, for 7 days after inserting the LNG-IUS unless inserted in the first 7 days of the cycle
COC, Combined oral contraception; CHC, Combined hormonal contraception; Cu-IUD, Copper-bearing intrauterine device; LNG-IUS, Levonorgestrel-releasing intrauterine system; UKMEC 1, No restriction on the use of the contraceptive method; UKMEC 2, Advantage of using a contraceptive method generally outweigh the theoretical or proven risks; UKMEC 3, Theoretical or proven risks usually outweigh the advantages of using the method; UKMEC 4, A condition that represents an unacceptable health risk if the contraceptive method is used. Adapted from FSRH guidelines for postnatal sexual and reproductive health, September 2009.
Table 3
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statistics/Publications/PublicationsPolicyAndGuidance/DH_121941 (last accessed 10/12/10). You’re welcome quality criteria, Department of Health, London 2/4/07 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_073586 (last accessed 10/12/10). Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Contraceptive choices for young women, March 2010. http://www.fsrh. org/admin/uploads/ceuGuidanceYoungPeople2010.pdf; (accessed 10/12/10). Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Postnatal sexual and reproductive health, September 2009. http:// www.fsrh.org/admin/uploads/CEUGuidancePostnatal09.pdf; (last accessed 10/12/10). About the teenage pregnancy strategy, Department for Children, Schools and Family. http://www.dcsf.gov.uk/everychildmatters/ healthandwellbeing/teenagepregnancy/about/strategy/ (last accessed 10/12/10).
has emphasized addressing the issues discussed here. It is hoped that the work done so far will be consolidated, integrated and unified in respect of sexual health, particularly in the young. Preventing first and repeat pregnancies for teens would meet teenage pregnancy strategy numbers e a less negative approach than promoting termination of pregnancy as a solution. All gynaecologists should be prepared to engage with the problem and address the issues discussed in this summary. A
FURTHER READING Wellings K, Hutchinson C, Guthrie K, Baker PN, eds. ‘Teenage pregnancy’. London: RCOG Press, 2007. Wellings K, Nanchahal K, Macdowall W, et al. Sexual behaviour in Britain: early heterosexual experience. Lancet 2001; 358: 1843e50. Healthy lives, healthy people. white paper, Department of Health, London. 30/11/2010. http://www.dh.gov.uk/en/Publicationsand
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Teenage mothers are more likely to experience post-natal depression and other mental health issues, are more likely to smoke and are less likely to breast feed Children of teenage pregnancies have a 60% higher infant mortality rate than babies born to older mothers, and are 63% more likely to be born into poverty. Since 1998, the termination of pregnancy rate for under-18s has increased in the UK from 42% to 50%. It is important to remember that statistics count only live births, still births and terminations of pregnancy. Miscarriages in women are not recorded in the UK and there is some evidence to suggest that up to 25% of teenage pregnancies will spontaneously miscarry. Although not the hoped-for success story of the 1999 Teenage Pregnancy Strategy, there are many efforts ongoing in the UK to address all aspects of this issue. We discuss these, and also the issue of a rather negative view of teenage pregnancy, later. Firstly, how does the UK, compare with the rest of the World?
Teenage pregnancy: strategies for prevention Aisling S Baird Charlotte C Porter
Abstract Teenage pregnancy (TP) rates in the UK are high, and are associated with high levels of socio-medical morbidity. Correspondingly, in the UK, teenage pregnancies are considered undesirable, but this is not the case in many non-European cultures. Recent education and enhanced contraception services are initiatives which have met with variable success. In this summary, we discuss these, and the welcome recognition of other contributing factors, such as poverty; unless such contributing factors are addressed, any prevention initiatives are threatened. The gynaecologist should be constantly prepared to consider the issue in any young woman.
The international picture The terms adolescent, a young person in the period between childhood and adulthood, and teenager are often used interchangeably. We sometimes overestimate the capacity of the adolescent to actively choose to have sex and make informed decisions, since the maturation of the conscious brain is still continuing into the second decade of life e a time of profound biological, social and psychological change, and an increasing interest in sex. The risk of unintended pregnancy is correspondingly high and in the developed world this risk is considered unacceptable, particularly since teenage pregnancy bears the negative associations of poor economic, social and health outcomes. Worldwide, not all teenage pregnancy is considered undesirable. Internationally, 13 million children are born to women under aged under 20 every year, more than 90% in developing countries, and teenage birth and marriage rates are much higher than in the UK. However, complications of pregnancy and childbirth are the leading cause of mortality among women between the ages of 15 and 19 in the developing and resourcepoor world. The highest rates of teenage pregnancy are recorded in sub-Saharan Africa, where early marriage is a cultural norm. In Niger for example, 87% women are married before the age of 18, and more than 50% will have a baby before their 18th birthday. Contraceptive usage is around 11% and maternal mortality 650/100,000. In the Indian subcontinent, early marriage is also the norm, although urban areas have lower rates of early marriage and teenage pregnancy than rural areas, representing enhanced educational and financial opportunities for young women in towns and cities. The rate of early marriage and pregnancy has decreased sharply in Indonesia and Malaysia, although it remains relatively high. In industrialized Asian nations such as South Korea and Singapore, teenage birth rates are among the lowest in the world. The overall trend for conception rates in Northern Europe since 1970 has shown a decreasing total fertility rate, an increase in the age at which women experience their first birth, and a decrease in the number of births among teenagers. Most continental Western European countries have very low teenage
Keywords prevention; strategies; teenage pregnancy; United Kingdom
Introduction 4% births in the UK are to women aged 18 or less. However, in England and Wales 50% of the pregnancies occurring in under-18s are terminated. Our societal view of teenage mothers is negative e associated with the benefit culture, lack of social mobility, poor educational attainment and suboptimal life chances for the children. Prevention of teenage pregnancy has become a political imperative. The teenage pregnancy strategy was introduced in 1999 to support teenage parents, and to reduce the conception rate in this age group. The Government’s target was to reduce the teenage pregnancy rate by 50% before 2010. Thus far, however, Office of National Statistics (ONS)figures do not show significant change. In England and Wales there has been a 13.7% reduction in under-18 conceptions between 1998 and 2008. As summarized in the 2010 teenage pregnancy strategy report: At age 30, teenage mothers are 22% more likely to be living in poverty than mothers bearing children aged 24 and over, are much less likely to be employed, and are less likely to be living with a partner Teenage mothers are 20% more likely to have no qualification at age 30 and are more likely to partner poorly qualified and unemployed men
Aisling S Baird MRCOG MFRSH MAcadMEd is a Locum Consultant in Sexual and Reproductive Healthcare at the Centre for Contraception and Sexual Health, Wolverhampton, UK. Conflicts of interest: none declared. Charlotte C Porter MRCOG MFRSH MRCGP is a Consultant in Community Gynaecology and Sexual and Reproductive Healthcare at the Centre for Contraception and Sexual Health, Nottingham, UK. Conflicts of interest: none declared.
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birth rates, particularly the Netherlands (Table 1). This is varyingly attributed to good sex education and high levels of contraceptive use (in the case of the Netherlands and Scandinavia), traditional values and social stigmatization (in the case of Spain and Italy) or both (in the case of Switzerland). The teenage birth rate in the United States is the highest in the developed world, and the teenage abortion rate is correspondingly high. The U.S. teenage pregnancy rate was at a high in the 1950s and has decreased since then, particularly in the 1990s; this decline was manifest across all racial groups, although teenagers of African-American and Hispanic descent retain a higher rate of teen conception, in comparison to that of European-Americans and Asian-Americans. The WHO collaborating centre (the US Guttmacher Institute for sexual & reproductive health), at one time attributed about 25% of the decline to abstinence (quite a force in the US) and 75% to the effective use of contraceptives. Yet, in 2006, the teenage birth rate rose for the first time in 14 years. This could imply that teen pregnancy rates are also on the rise, but the rise could also be due to other factors: a possible decrease in the number of abortions or a decrease in the number of miscarriages, to name but two. The ‘abstinence movement’ in the US has received much publicity, although some social commentators have said that even defining the term is problematic, yet the UK Independent Advisory Group on Teenage Pregnancy has suggested that recent research confirms the greater efficacy of contraception over abstinence. Researchers from Columbia University have said that 86% of the decline in teenage pregnancy was due to improved use of contraception. Only 14% of the drop amongst 15e19 year olds was linked to reduced sexual activity, according to the Columbia study, published in the American Journal of Public Health.
intercourse, lead to variable rates of contraceptive use for teenagers commencing sexual activity. Other reasons are summarized in Box 1. Some work has demonstrated the attitudinal differences between adolescents in the UK and the Netherlands with less emphasis on peer pressure in the Netherlands and a greater importance given to feelings of love and commitment. British teenagers seem to have greater opportunity for sexual activity.
National initiatives in the UK and elsewhere The first teenage pregnancy strategy was launched in 1999; subsequently there have been yearly reports. The 2010 document reports ‘significant reductions’ in teenage conception rates, and yet the modest reductions of 15.2% in under 16s and 11.1% in the under-18s come nowhere near to the 1999 challenge of 50% reduction. The strength of the 2010 report is the recognition of the significance of underlying factors such as poverty, poor educational attainment and ‘low aspirations’ (we would consider these co-factors rather than causative ones). To address the issue, the 2010 report asks professionals to 1) identify and target high rate neighbourhoods and vulnerable groups, associated with risky behaviour, poor education, family and other background factors, 2) drive up local preventative performance and, 3) deepen strategy to tackle broader risk factors as well as risky behaviour. In order to achieve these aims, the report proposes strategies summarized in Box 2. Evidence shows that children whose parents talk to them openly and honestly about sex and relationships have later coitarche and are more likely to use contraception when they do become sexually active. The Department for Children, Schools and Family has provided funding to the Family Planning Association to extend to more local areas its ‘Speakeasy’ initiative: a structured programme of advice and support for parents on talking to their children about sex and relationships. The 2010 strategy report emphasizes and commends as good practice those sex education (SE) or Personal, Social and Health Education (PSHE) programmes which engage elements of peer education, address emotions (rather than bare facts), dismiss myths (such as easy access to state benefits and good housing) and promote self-esteem, empowerment and informed decision-
The UK picture The majority of teenage pregnancies in the UK are unplanned: between 8 and 22% teenagers at their first coitus do not use contraception, with lower usage rates occurring in the younger ages. Of those who do use contraception, many use less effective methods such as the condom or the coitus interruptus. Why is the UK pregnancy rate so high and lack of preparedness for first coitus so low? One factor is an earlier coitarche: 26% of 16-year-old females in the UK have been sexually active. Declining age at first sexual intercourse, linked to peer pressure and lack of planning for
What leads young people into early sexual experience? Percentage of total births nationally in European countries in women aged 12e18 years Netherlands Italy France Spain Germany Ireland UK
0.7 0.9 1.5 1.7 1.9 2 4
Young people overestimate how many of their peers are sexually active
C
Young people have sex in the hope that it will deliver other things such as a loving relationship
C
Low self-esteem
C
Cultural pressure and assumption of the normality of sexual experience (for example ‘celebrity’ and teenage magazines)
C
Variable availability of sex and relationship education (SRE)
C
Inability to communicate with parents or carers.
Box 1
Table 1
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C
Engagement of delivery partners: active engagement of all of the key mainstream delivery partners who have a role in reducing teenage pregnancies: health, education, social services, youth support services, and the voluntary sector.
C
Selection of a senior champion: a strong senior champion who is responsible for the local strategy and can take the lead in implementing it.
C
Effective sexual health advice service: the availability of a wellpublicized contraceptive and sexual health advice service which is centred on young people. The service needs to have a strong remit to undertake health promotion work, as well as delivering reactive services.
C
Prioritization of sex and relationships education: high priority given to PSHE in schools, with support from the local authority to develop comprehensive programmes of sex and relationships education (SRE) in all schools.
C
Focus on targeted interventions: a strong focus on targeted interventions with young people at greatest risk of teenage pregnancy, in particular with looked-after children.
C
Training on SRE for partner organizations: the availability and consistent take-up of SRE training for professionals in partner organizations who work with the most vulnerable young people, such as Connexions personal advisers, targeted youth support (TYS) lead professionals, youth workers and social workers.
C
Well-resourced youth service: providing things to do and places to go for young people, with a clear focus on addressing key social issues affecting young people, such as sexual health and substance misuse.
was no effect of ‘primary prevention strategies’ (including 10 PSHE programmes) on age of coitarche, more effective use of contraception, or incidence of teenage pregnancy. However, there were some methodological criticisms of the identified trials. In 2006, Henderson and her group found no effect upon unintended pregnancy, across 13 secondary schools in Scotland, of a specially-designed twenty-session PSHE initiative (‘SHARE’, 2071 participants analysed). The initiative involved active learning and skills development, and was compared with a randomized control group of 12 schools (2125 participants analysed), matched for socio-demographic characteristics. The conclusions were that the SHARE programme improved knowledge and reduced regret, but there was no effect upon unintended pregnancy. Henderson et al recommended that highquality PSHE (as defined by previous authors) should continue but that it should be complementary to other longer-term initiatives that address socio-demographic inequalities. In addition, they recommended that the influence of parents should be rigorously evaluated. A more recent cluster-randomized trial from England of peer-led PSHE reported similar results. Nine thousand pupils in 37 schools took part, and were randomized to either standard teacher-led PSHE or peer-led PSHE. Adjusted for randomization strata, the odds ratio for girls experiencing abortion before age 20 years was 1.07 (95% CI 0.80e1.42 p ¼ 0.64). However, fewer girls in the peer-led arm reported a pregnancy by age 18 (adjusted OR 0.62, 95% CI 0.42e0.91). There were no significant differences in self-reported unprotected first sex, regretted or pressurized sex, quality of current sexual relationship, STI or ability to identify local SRH services. It should be noticed that these latter two trials compared different types of PSHE programme, rather than PSHE versus no PSHE. Professionals working with the young often feel that PSHE produces variable results since it should take place within an encouraging and acceptable atmosphere. Peer education often achieves that goal. In Sheffield, the Peer Activities in Sexual Health young people’s peer education project (PASH) has trained over 50 knowledgeable and committed peer educators to work with teenagers in the city areas with the highest teenage pregnancy rates, and with at risk young people. It covers sex education and awareness, and promotes self-esteem. It also covers contraception and access to sexual health services. Comments from peer educators have included:
From: http://www.ic.nhs.uk/webfiles/publications/003_Health_ Lifestyles/nhscontra0910/NHS_Contraceptive_Services_England_ 2009_10.pdf with kind permission.
‘I am most certainly glad I had the opportunity to experience [the programme]’
Key factors for reducing teenage pregnancy Evidence from areas with the largest reductions has identified a range of factors that need to be in place to successfully reduce teenage pregnancy rates. All areas are now being asked to implement these factors, which are
‘Being a PASH volunteer.is one of the most challenging yet rewarding experiences you can have’
Box 2
Teachers have been very positive:
making. In a new Department of Health white paper (Healthy lives, Healthy People), PSHE is heavily promoted in schools; schools are encouraged be active promoters of age-appropriate teaching on relations and sexual health. The Department for Education will conduct a review to consider how schools may be supported to improve the quality of PHSE. Nevertheless, there is some evidence that sex education is not as effective with respect to reducing teenage pregnancy as could be intuitively be expected. In a 2002 systematic review of controlled trials, DiCenso and colleagues found that in the 26 studies that they identified, there
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‘The volunteers were able to pitch the session correctly and create an atmosphere that was safe and secure’ ‘Students were very focussed when led by someone nearer their own age’ In the US, nurse-family partnership programmes aim to support young mothers and reduce repeat pregnancy rates. Working in particularly areas of high deprivation, they try to tackle the wider issues identified in the UK in the 2010 UK strategy report. A similar
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programme is running in pilot form in the UK. Nottingham City was selected as one of the second wave sites to test the national pilot of the Family Nurse Partnership, an intensive home visiting programme offered to first time pregnant teenagers and their partners from early pregnancy until the child is 2 years old. It aims to tackle complex issues associated with deprivation and accompanying social phenomena, and is designed to help improve parenting skills and outcomes for both parents and their child by: Improving pregnancy outcomes by helping young women engage in good preventative health practices, including antenatal care, healthy diet and reduction in smoking and substance misuse, Improving a child’s health and development by supporting parents to provide responsible and competent care, and Improving the economic self sufficiency of the family by supporting parents to develop a vision for their own future, planning of future pregnancies, continuing education and finding work. A work in progress, the Nottingham programme has been successfully delivered to 170 young women who have borne 135 babies. Short-term positive outcomes include improved health of mothers (mental health and smoking cessation), increased return to education, increased father engagement and improved parenting skills. Participants have developed positive changes in behaviour resulting in greater confidence and raised aspirations for the future. Results from a recent user survey show that 90% rated the usefulness and value of the programme and relationship with their Family Nurse as ’excellent’. All survey respondents reported that the programme had encouraged them to make positive changes in their lives, whilst 60% reported changes in either their partners or in wider family members.
developed increasingly thoughtful and locally-effective ways of addressing the issue. For example, accessible youth clinics (and staffed by sympathetic, well-trained and approachable staff) have become the norm in most towns and cities. Most of these services provide outreach services in places used by young people, and visit young offenders’ institutions, for example. CASH staffs are also proactive in training school nurses to provide sexual health services (such as ‘Clinic in a Box’). In the sexual health strategy, promotion of such accessible and outreach contraceptive services for teenagers is key. Young people seem to prefer to access services other than their general medical practitioner because of accessibility, perceived concerns about judgemental treatment and lack of confidentiality, and sensitivity to the clinical atmosphere in the GP’s surgery. Emergency contraception has become available from pharmacies and walk-in centres. These have more accessibility than doctors’ surgeries, with flexible opening hours, such as afterschool and at weekends. Such walk-in centres have been promoted, yet there is no evidence that increasing the uptake of emergency contraception decreases the pregnancy rate for any group of women. Additionally, provision of follow-on contraception in such sites is not the norm (although some services are beginning to address the issue). Unfortunately, teenagers may be unaware of the services available to them. They sometimes maintain that services are inaccessible due to location, opening hours or other difficulties with appointments. A 1997 report from the UK Social Exclusion Unit recommended more accessible services, such as appropriately-staffed lunchtime sessions in schools, and after-school and Saturday appointments. Surveys from general practice have showed an association between lower teen pregnancy rates and appropriate staffing. In particular, the inclusion of female or younger doctors and more nurse time have been shown to be beneficial. In 2007, the Department of Health published a set of benchmarking criteria for making health services ‘young people friendly’ (the ‘You’re Welcome’ quality criteria). Services are encouraged to make themselves more accessible and public, to encourage confidentiality and to provide a young people-sensitive environment. Those meeting the criteria are certified. In the 2009/10 returns from NHS community contraceptive clinics (which exclude data of services provided by general practitioners and out-patient clinics) 11% of the female population aged 13e44 attended NHS community contraceptive clinics. Approximately 14% females aged 15 and approximately 5% females aged under 15 attended. However, the highest percentage of the female population attending these clinics was in the 16e19 year olds (22%). In this era of large NHS cost savings, it is important that funding is not withheld from services which may be seen as a soft target. Long-acting contraceptive methods are being promoted as the gold standard for contraception by the National Institute for Clinical Excellence, particularly for younger women, and the intrauterine device e whether copper or hormone containing e is no longer regarded as the unique realm of older, parous women. Unfortunately, most UK teenagers in 2009/10 were still using user-dependent methods of contraception, which have the greater failure rates (Table 2). Unfortunately, most areas in the England have experienced a reduction in budget for teenage pregnancy services, but there is clear indication that it remains a priority through the child poverty strategy. Teenage pregnancy is also an impact indicator in the English Department for
Participant’s comments have included: “The team and programme do not judge you but support you and help you make the right decisions.” “I have calmed down and my behaviour and my diet is a lot healthier.” “[We are] more confident with our baby.” “. I have been lucky and I think the programme should be available to all young parents.” “My partner has changed e he helps me a lot more with my baby and understands me more.” “. I look forward to my visits, I love it.” “She [Family Nurse] has helped me realise my baby comes first.”
Developments in contraception services By addressing both medical and sociological issues and espousing a ‘broad-brush’ approach to the contraception, the aims of the 1999 UK teenage pregnancy strategy were admirable. In the UK targetdriven NHS mind set, the simplistic determination to drive down figures, always courted the danger that service delivery might become focused around termination of unwanted teenage pregnancy. Termination rates have certainly increased in this age group. However, contraception and sexual health (CASH) services have
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Failure rates of contraceptive methods
The ‘Fraser Guidelines’ for health professionals
Method
In 1985, Lord Fraser said in a judgement of the Gillick case that a doctor can give contraceptive advice or treatment to a person under 16 without parental consent providing the doctor is satisfied that
No methoda Withdrawal Diaphragmb Condomsc Female Male Combined pill and progestogen-only pill EvraÒpatch NuvraRingÒ Depo-ProveraÒ Copper-bearing intrauterine device Levonorgestrel-releasing intrauterine system ImplanonÒ Female sterilization Male sterilization
Percentage of women experiencing an unintended pregnancy within the first year of use (%) Typical use Perfect use 85 85 29 18 16 6 21 15 8
5 2 0.3
8 8 3 0.8
0.3 0.3 0.3 0.6
0.2
0.2
0.05 0.5 0.15
0.05 0.5 0.10
The young person will understand the advice
C
The young person cannot be persuaded to tell his or her parents or to allow the doctor to tell them that they are seeking contraceptive advice
C
The young person is likely to begin or continue having unprotected sex with or without contraceptive treatment
C
The young person’s physical or mental health are likely to suffer unless he or she received contraceptive advice or treatment
C
It is in the young person’s best interests to give contraceptive advice or treatment
These guidelines are known as Fraser guidelines. Although they are only legally binding for doctors, they represent good practice for other health professionals too. Box 3
opportunity (particularly at cessation of pregnancy for whatever reason), the gynaecologist should consider providing a long-acting, reversible contraceptive. The gynaecologist will be aware of the failure rates of the properly- and the inadequately-used condom e it is a helpful strategy to advise on the ‘Double-Dutch’ method (simultaneous use of both contraception and an STI-preventing condom). Clearly unwanted pregnancy is a sexually-associated phenomenon and there should be a low threshold for screening for STI. There is guidance on contraceptive use and initiation postpartum, post-termination of pregnancy and during breast feeding (United Kingdom Medical Eligibility Criteria (UKMEC), Table 3). The strategy of referring young women in the post-natal period to their GP for contraception is questionable e many such patients fail to consult their GP at the recommended 6 weeks and the opportunity is therefore lost of providing early, adequate and appropriate contraception. Hospitals should develop policies to provide contraception by the twenty first post-natal day, since conception is feasible by day 28 (time must be given for the contraceptive to become effective). Targeting teenage mothers by a qualified midwife/nurse during the immediate post-natal period and early provision of a LARC is effectively used in some centres. Some hospitals have a dedicated antenatal service for young mothers at which all of the issues we have discussed are effectively managed.
Reproduced from: http://www.fsrh.org/admin/uploads/ceuGuidanceYoung People2010.pdf with kind permission of the Faculty of Sexual and Reproductive Healthcare. a The percentages becoming pregnant in typical and perfect use are based on data from populations where contraception is not used and from women who cease using contraception in order to become pregnant. Among such populations, about 89% become pregnant within 1 year. This estimate was lowered slightly (to 85%) to represent the percentage who would become pregnant within 1 year among women now relying on reversible methods of contraception if they abandoned contraception altogether. b With spermicide. c No spermicide.
Table 2
Education business plan and Healthy Lives, Healthy People also makes frequent reference to young people and sexual health.
How can the obstetrician & gynaecologist contribute? The obstetrician & gynaecologist can contribute in several ways and at several levels. Firstly, every gynaecologist should be aware of the rates of sexual activity in younger teens at a time when educational attainment and access to contraception may be poor, and peer and personal pressure with regard to sex is high. Each should consider it their responsibility to address the issue in the adolescent patient. Under-age young people should be subject to a risk assessment of vulnerability and potential abuse, and an assessment of Fraser competence (Box 3). Information regarding sexual activity should ideally be gathered in private, without the presence of an accompanying parent, and the young person given the opportunity to raise issues or ask questions in private. Should there be a medical indication to cease a previously effective contraceptive in a sexually active younger woman, this should not be done without substituting another suitable method. At every
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Conclusion In conclusion, teenage pregnancy can be normal and positive, and it is important to support a young person’s choice. It becomes problematic when associated with adverse medical and social outcomes, particularly social exclusion. Compared with the rest of the developed world, poor outcomes have become an issue for the UK government and the healthcare professions. As a reflection of its importance, and with the recent change of UK government, the new white paper, Healthy Lives, Healthy People, 155
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Recommendations for contraceptive methods in postpartum, non breastfeeding and breastfeeding women and following miscarriage or abortion Contraceptive Method
Circumstance
Recommendations for timing of initiation
Additional contraception advised
Combined hormonal contraception (ie COC, transdermal patch, vaginal ring)
Postpartum (not breast feeding)
Start on Day 21 postpartum if normal vaginal delivery and no additional risk factors for VTE If beyond day 21 postpartum and menstrual cycle has returned can start CHC as for other women having menstrual cycles If >21 days postpartum and menstrual cycles have not retuned can start if CHC as long as the women is not at risk of pregnancy If over 6 months postpartum can start CHC as for other women having menstrual cycles 6 weeks to <6 months (partial breast feeding) UKMEC 2 Initiated within 7 days in gestations <24 weeks
No
Postpartum (breast feeding)
Progestogen-only pill
Progestogen-only implant
Following miscarriage or abortion Postpartum (breast feeding and artificial feeding) Following miscarriage or abortion
Postpartum (breast feeding and artificial feeding) Following miscarriage or abortion
Progestogen-only injectable
Cu-IUD & LNG-IUS
Postpartum (breast feeding and artificial feeding) Following miscarriage or abortion Postpartum (breast feeding and artificial feeding)
Following miscarriage or abortion
Initiated up to Day 21 Initiated after Day 21 Initiated on the day of surgical abortion or second part of medical abortion or immediately following miscarriage Initiated >5 days after surgical abortion or second part of medical abortion or miscarriage Initiated up to Day 21. Insertion can be prior to Day 21 but bleeding maybe a problem (unlicensed use) Initiated after Day 21 Initiated on the day of surgical abortion or second part of medical abortion or immediately following miscarriage Initiated >5 days after surgical abortion or second part of medical abortion or miscarriage Initiated up to Day 21 Initiated after Day 21 (If initiated <6 weeks and breast feeding ¼UKMEC2) Initiated on the day of surgical abortion or second part of medical abortion or immediately following miscarriage Initiated up to 48 h 4 weeks
(Use between 48 h to 4 weeks UKMEC 3) Ideally inserted at the time of a first or second trimester surgical abortion for immediate contraceptive effect Following medical or surgical abortion ideally inserted within the first 48 h or delay until 4 weeks postpartum. As waiting for 4 weeks may put women at risk of pregnancy, intrauterine contraception can be inserted by an experienced physician at any time provided that there is no risk of pregnancy
None or for 7 days
7 days
None or for 7 days None or for 7 days No No Yes, for 48 h No
Yes, for 48 h No Yes, for 7 days No Yes, for 7 days No Yes, for 7 days No No Yes, for 7 days after inserting the LNG-IUS unless inserted in the first 7 days of the cycle No Yes, for 7 days after inserting the LNG-IUS unless inserted in the first 7 days of the cycle
COC, Combined oral contraception; CHC, Combined hormonal contraception; Cu-IUD, Copper-bearing intrauterine device; LNG-IUS, Levonorgestrel-releasing intrauterine system; UKMEC 1, No restriction on the use of the contraceptive method; UKMEC 2, Advantage of using a contraceptive method generally outweigh the theoretical or proven risks; UKMEC 3, Theoretical or proven risks usually outweigh the advantages of using the method; UKMEC 4, A condition that represents an unacceptable health risk if the contraceptive method is used. Adapted from FSRH guidelines for postnatal sexual and reproductive health, September 2009.
Table 3
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statistics/Publications/PublicationsPolicyAndGuidance/DH_121941 (last accessed 10/12/10). You’re welcome quality criteria, Department of Health, London 2/4/07 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_073586 (last accessed 10/12/10). Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Contraceptive choices for young women, March 2010. http://www.fsrh. org/admin/uploads/ceuGuidanceYoungPeople2010.pdf; (accessed 10/12/10). Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Postnatal sexual and reproductive health, September 2009. http:// www.fsrh.org/admin/uploads/CEUGuidancePostnatal09.pdf; (last accessed 10/12/10). About the teenage pregnancy strategy, Department for Children, Schools and Family. http://www.dcsf.gov.uk/everychildmatters/ healthandwellbeing/teenagepregnancy/about/strategy/ (last accessed 10/12/10).
has emphasized addressing the issues discussed here. It is hoped that the work done so far will be consolidated, integrated and unified in respect of sexual health, particularly in the young. Preventing first and repeat pregnancies for teens would meet teenage pregnancy strategy numbers e a less negative approach than promoting termination of pregnancy as a solution. All gynaecologists should be prepared to engage with the problem and address the issues discussed in this summary. A
FURTHER READING Wellings K, Hutchinson C, Guthrie K, Baker PN, eds. ‘Teenage pregnancy’. London: RCOG Press, 2007. Wellings K, Nanchahal K, Macdowall W, et al. Sexual behaviour in Britain: early heterosexual experience. Lancet 2001; 358: 1843e50. Healthy lives, healthy people. white paper, Department of Health, London. 30/11/2010. http://www.dh.gov.uk/en/Publicationsand
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