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Literature searches completed on 27.6.99

Chapter 4: Unintended teenage pregnancy

This bulletin is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation.
The rates of teenage pregnancy in Wales are the highest in Western Europe and are a cause for concern, particularly in view of recent increases in conceptions to girls under 16. There are links between teenage pregnancy and social exclusion, and early pregnancy is associated with a number of risks for mother and child. Many of the interventions aimed at reducing unintended teenage pregnancy also contribute to reducing the incidence of sexually transmitted infections.
The Statements The Evidence
4.1. Background
4.1a. The UK has the highest rate of teenage conceptions in Europe: three times that in Germany, four times that in France and seven times the Dutch ratei. i. Council of Europe. Recent Demographic Developments in Europe. Strasbourg: Council of Europe Publishing, 1997
(Type IV evidence – statistics)
4.1b. Within the UK, Wales has the highest rate of teenage conceptioni. i. Social Exclusion Unit. Teenage Pregnancy. CM 4342. London: The Stationery Office, 1999
(Type IV evidence – statistics)
4.1c. The overall conception rate for women in Wales has generally been lower in recent years than in England. In 1997, the rate per 1000 women aged 15-44 in Wales was 71.8, compared to 74.6 in England. However, the rate for teenage conceptions has remained consistently higher in Wales. In 1997, the rate per 1000 women aged 15-19 in Wales was 68.5, compared to 62.2 per 1000 for women of this age group in Englandi,ii. i. Welsh Office Statistical Directorate. Statistical Brief SDB 64/98: Teenage Conceptions. Cardiff: Welsh Office, 1998
(Type IV evidence – statistics)
ii. Office of National Statistics. Birth Statistics 1998. Series FMI, No. 27. London: Stationery Office, 1999
(Type IV evidence – statistics)

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4.1d. The annual number of conceptions to girls under 16 in Wales is relatively small and variable. The number or rate for a single year should therefore be treated with caution. However, the rate in Wales has been rising quite sharply over the last three years. Although the annual rate has previously been in line with that for England, since 1992 the rate in Wales has been consistently higher and rising more rapidly. In 1997, the rate per 1000 women aged 13-15 was 10.3, compared with 8.8 in Englandi,ii. i. Welsh Office Statistical Directorate. Statistical Brief SDB 64/98: Teenage Conceptions. Cardiff: Welsh Office, 1998
(Type IV evidence – statistics)
ii. Office of National Statistics. Birth Statistics 1998. Series FMI, No. 27. London: Stationery Office, 1999
(Type IV evidence – statistics)
4.1e. Overall, rates of teenage pregnancy are highest in the areas of greatest deprivation and among the most vulnerable young people, including those in care and those who have been excluded from schooli,ii.
The Acheson Report concluded that the risk of pregnancy is increased in association with a number of social, socioeconomic and individual factors, many of which are more common in people experiencing disadvantage – for example, low educational attainment, poor housingiii.
i. Social Exclusion Unit. Teenage Pregnancy. CM 4342. London: The Stationery Office, 1999
(Type IV evidence – statistics)
ii. Office of National Statistics. Conceptions to women under 18 in England and Wales, 1995-1997: Local authority areas. Population Trends 1999; 97: 83-86
(Type IV evidence – statistics)
iii. Scientific Advisory Group. Acheson D (Chairman). Independent Inquiry into Inequalities in Health. London: The Stationery Office, 1998.
(Type V evidence – expert opinion based on commissioned papers, submissions and other presentations to the enquiry)
4.1f. Of those young women who do get pregnant, nearly half of under 16s and more than a third of 16 and 17 year olds opt for terminationi. In general, areas in Wales with high teenage conception rates also have the lowest abortion ratesii. i. Office of National Statistics. Birth Statistics 1998. Series FMI, No. 27. London: ONS, 1999
(Type IV evidence – statistics)
ii. Office of National Statistics. Conceptions to women under 18 in England and Wales, 1995-1997: Local authority areas. Population Trends 1999; 97: 83-86
(Type IV evidence – statistics)
4.1g. For women living in Wales, the rate of terminations among young women under 15 increased from 3.1 per 1,000 in 1995 to 3.92 in 1997, and the rate for 15 year-olds increased from 7.9 to 9.0. Rates in England were higher than those in Wales for all age groups except for those aged 15 and underi. i. Office for National Statistics. Abortion Statistics 1998. Series AB, No. 25. London: ONS, 1999.
(Type IV evidence – statistics)

 

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4.2. Adverse health and social effects
4.2a. Teenage pregnancy is associated with increased risk of poor social, economic and health outcomes for both mother and childi. i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997; 3(1): 1-12
(Type IV evidence – systematic review of 8 observational studies)
4.2b. Teenage parents are more likely than their peers to live in poverty and unemploymenti. i. Social Exclusion Unit. Teenage Pregnancy. CM 4342. London: The Stationery Office, 1999
(Type V evidence – expert opinion)
4.2c. Teenage mothers smoke more during pregnancy than mothers of any other age. They are at increased risk of suffering anaemia and pre-eclampsia. On average, children born to teenage girls have lower birth-weights, increased risk of infant mortality and an increased risk of some congenital abnormalities. They are less likely to be breastfed and more likely to live in deprived circumstances. The daughters of teenage mothers have a higher chance of becoming teenage mothers themselvesi. i. Botting B, Rosato M, Wood R. Teenage mothers and the health of their children. Population Trends 1998; 93: 19-28
(Type IV evidence - well-designed longitudinal study using Office for National Statistics data)

 

 

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4.3. Educational Interventions
4.3a. School-based sex education plays an important role in the prevention of teenage pregnancy. Characteristics of successful sex education programmes include use of social learning theories; provision of factual, accurate information; inclusion of activities that address social or media influences on sexual behaviours; and practice of communication and negotiation skillsi.ii,iii. The ways that young men and young women think and talk about sex vary and can also differ between social groups of young people. The needs and interests of young men should be addressed as well as those of young womeniv.
There is consistent evidence that providing sex and contraceptive education within school settings does not lead to an increase in sexual activity or incidence of pregnancy; rather, the provision of clear information about contraceptive methods and how and when to access contraceptive services appears to be important to the success of educational programmesi.ii,iii.
(Health gain notation - 1 "beneficial")
i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997: 3(1): 1-12 http://www.york.ac.uk/inst/crd/ehc31.htm [accessed 10.3.00]
(Type I evidence – systematic review of 42 evaluations of educational programmes)

ii. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports 1994: 109(3): 339-360
(Type I evidence - systematic review of 23 studies including 16 intervention studies)
iii. Grunseit A, Kippax S, Aggleton P, Baldo M, Slutkin G. Sexuality education and young people’s sexual behaviour: a review of studies. Journal of Adolescent Research 1997; 12(4): 421-453
(Type I evidence - systematic review of 47 intervention studies including 11 randomised controlled trials)
iv. Aggleton P, Oliver C, Rivers K. Reducing the Rate of Teenage Conceptions – The Implications of Research into Young People, Sex, Sexuality and Relationships London: Health Education Authority, 1998
(Type IV evidence – systematic review of observational studies)
4.3b. Educational programmes promoting abstinence have not been found to have any additional effect compared with the usual sex education programme either in delaying sexual activity or in reducing conceptionsi,ii.
(Health gain notation – 5 "unlikely to be beneficial")

 

i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997: 3(1): 1-12 http://www.york.ac.uk/inst/crd/ehc31.htm [accessed 10.3.00]
(Type I evidence – systematic review of 42 evaluations of educational programmes)

ii. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports 1994: 109(3): 339-360
(Type I evidence - systematic review of 23 studies including 16 intervention studies)
4.3c. Programmes which combine sex education with access to contraceptive services have been shown to be effective in increasing contraceptive usei.
(Health gain notation - 1 "beneficial")
Young people’s perceived barriers to services might be overcome through clinic staff or GP visits to schools, or through school visits to the contraceptive servicei.
(Health gain notation - 2 "likely to be beneficial")
i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997: 3(1): 1-12 http://www.york.ac.uk/inst/crd/ehc31.htm [accessed 10.3.00]
(Type I evidence – systematic review of 42 evaluations of educational programmes)

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4.3d. Within health care settings, education programmes targeted at young women presenting for emergency contraception or with negative pregnancy tests may improve effective contraceptive usei.
(Health gain notation - 2 "likely to be beneficial")
i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997: 3(1): 1-12 http://www.york.ac.uk/inst/crd/ehc31.htm [accessed 10.3.00]
(Type I evidence – systematic review of 42 evaluations of educational programmes)
4.4. Contraceptive services
4.4a. The costs of providing contraceptive and counselling services to teenagers are far less than the health and social costs of unplanned pregnancyi.
(Health gain notation - 1 "beneficial")
i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997: 3(1)
http://www.york.ac.uk/inst/crd/ehc31.htm [accessed 10.3.00]
(Type IV evidence – systematic review citing 2 cost-effectiveness studies)
4.4b. There is an association between conception rates and the level and type of contraceptive services available locallyi, including the distance to the nearest youth-orientated family planning clinicii. The effect of these services in terms of use and pregnancy rates appears to be stronger when they are provided by clinics orientated to the needs of young people. In order to attract young people, services need to be well-advertised, easily accessed outside school-hours (in terms of opening times and location), informal and confidential. They should be developed in collaboration with key statutory agencies, relevant voluntary organisations and community groups, and should be staffed by people trained to work with young peoplei.
(Health gain notation - 1 "beneficial")
i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997: 3(1)
http://www.york.ac.uk/inst/crd/ehc31.htm [accessed 10.3.00]
(Type III evidence – systematic review citing more than 20 intervention and observational studies)

ii. Clements S, Stone N, Diamond I, Ingham R. Modelling the spatial distribution of teenage conception rates within Wessex. The British Journal of Family Planning 1998; 24: 61-71
(Type IV evidence – relation of postcoded data for all teenage conceptions that occurred between 1991 and 1994, in the Wessex Regional Health Authority, to ward based population characteristics and indicators of accessibility to family planning services)
4.4c. Hormonal emergency contraception (the "post-coital pill") has an important role in the prevention of pregnancy with this age group because of the unplanned and sporadic nature of many teenagers’ sexual activity. It is an inexpensive method of pregnancy prevention, and should be made more easily available. In order to maximise uptake of this method, there is a need for more publicity about emergency contraception. Programmes are needed to educate teenagers about the timing and availability of the post-coital pill; in addition, both young people and health professionals, including GPs, need more information about emergency contraception in order to reduce anxiety about its use and repeat usei.
(Health gain notation - 1 "beneficial")
i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997: 3(1): 1-12 http://www.york.ac.uk/inst/crd/ehc31.htm [accessed 10.3.00]
(Type IV evidence – systematic review citing 6 observational studies)

 

 

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4.5. Antenatal care and social support
4.5a. Specialised antenatal care programmes for pregnant teenagers involving, for example, GPs, district nurses, health visitors and social workers are likely to improve health outcomes. These may also save resources for health, education and social servicesi.
(Health gain notation - 2 "likely to be beneficial")
i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997: 3(1): 1-12 http://www.york.ac.uk/inst/crd/ehc31.htm [accessed 10.3.00]
(Type I evidence – systematic review citing 6 studies including a meta-analysis [Scholl TO, Hediger ML, Belsky DH. Prenatal care and maternal health during adolescent pregnancy: a review and meta-analysis. Journal of Adolescent Health 1994; 15: 444-456])
4.5b. Health visitors and social workers can usefully provide targeted support for teenagers and their families during and after pregnancy. Programmes involving home visits and support from other young mothers, and home-based parenting schemes for teenagers who may be reluctant to attend clinics, may also be beneficiali.
(Health gain notation - 2 "likely to be beneficial")
i. NHS Centre for Reviews and Dissemination. Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care 1997: 3(1): 1-12 http://www.york.ac.uk/inst/crd/ehc31.htm [accessed 10.3.00]
(Type I evidence – systematic review citing 2 reviews of randomised controlled trials)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk