(Type a title for your page here) Royal Society of Medicine Forum: A child for a child. Teenage pregnancy – whose problem?

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Thursday 19th June 2003. The meeting was chaired by Mrs. Faith Haddad, consultant gynaecologist, St. John & Elizabeth Hospital, London, and she opened the meeting:

The report was first published in The Midwives Journal of the Royal College of Midwives. It is reproduced here with their consent and our thanks.

In the UK we have the second highest teenage birth rate in developed countries in girls between 15 and 19; our rate is outstripped only by the USA. Two thirds of those who conceive give birth to babies, of whom only a tenth are born to married couples. In 1999 a government strategy with the aims of halving conception rates in under 18s and reducing their social exclusion was started. Adolescence, a phase of physical and emotional transition, is not the time to embark on a pregnancy.

Social and contextual aspects of teenage pregnancy; research evidence and policy implications.
From Dr. Roger Ingham (RI), Director, Centre for sexual health research, and reader in health and community psychology, University of Southampton.

“Crisis” and “catastrophy” are words used in the House of Commons Select Committee report on sexual health.

Sexual health comprises largely the avoidance of unplanned (as distinct from unintended) conceptions and sexually transmitted infections (STIs); the last is increasing massively at present. It also addresses the issues of mutuality and respect, coercion and pressure to engage in sex, much of which is regretted and may lead to negative psychological reactions.

The advent of HIV infections triggered funding and research into sexual health for the first time about 20 years ago. The belief that talking to young people about sex will encourage them to engage in it has lead to the American abstinence policy, with its emphasis on the ineffectiveness of contraception. Conversely it may lead to safer sexual practices. We need very seriously to take a positive view of young people, helping them to cope with the demands they face, rather than regarding them as riven with problems requiring control.

The United Nations convention on the rights of the child (up to 18 years) clearly states that policies should invariably be in the best interests of children, giving their views due weight, should guarantee full access to education including that concerning health and to health services, and should create supportive and safe environments that respect and respond to their concerns and needs. This for example means that insistence by health professionals on the presence of parents when their children consult constitutes denial of a right. Policies impinge on the many and various contexts in which young people move and live: the impact of the general economic situation on their aspirations, policies in legal contexts, gender issues and those of discrimination and stigma, any of these may affect them. What is the policy of a school when a young man teases a young woman?

Research findings are happily compatible with the human rights issues, and confirm that multi-faceted approaches help to create safer environments in both physical and psychological terms. The World Health Organization's report on the effect of sex education is that it is if anything positive, supporting the idea that a well designed programme of education can be protective. Internationally the evidence is supportive (Alan Guttmacher Institute 1999; UNICEF Innocenti Research Centre 2001; Health Education Board for Scotland review of sexual health policies and trends in the USA, Australia and New Zealand). The Alan Guttmacher Institute studies reported that where young people receive social support, full information and positive messages about sexuality and sexual relationships, and have easy access to sexual and reproductive health services, they achieve healthier outcomes and lower rates of pregnancy, birth, abortion and sexually transmitted disease (STD). A 1999 league table of unplanned pregnancies in 28 developed countries showed huge variation, from Korea's 2.9% to USA's 52.1%, indicating that cultural and contextual factors play a great part. The UNICEF report stated that success in lowering teenage birth rates is a matter of both motivation (a stake in the future, a sense of hope, and an expectation of inclusion in an economically advanced society) and means (availability of contraception and education to enable informed and mutually respectful choices).

In the Netherlands, where teenage conception rates are relatively low, the attitude to sex is very open, both in schools and in the home, and sex education is rooted in relationships; despite this sexual activity starts at a later age there than in the UK, where at last we can refer to sex and relationships education, with the understanding that sex is one way of expressing relationships rather than an unstoppable biological drive. Asked what motivated them to start having sex, 65% of men in the Netherlands named love or commitment (and were much more likely to have discussed contraception beforehand and to use it), compared with only 15% in the UK, where peer pressure and personal rationalisations were usual.

In our study of large numbers of teenage conceptions in the Wessex and South-West regions (Ingham et al. 1998 & 1999) we found that the incidence was related to the proximity of young persons sexual health services as well as to measures of deprivation, which are important. Deprivation circumscribes future plans and prospects; termination of accidental pregnancies is common although many hold strong anti-abortion views. Discussion of sexual matters within families is limited; gender-based sexual stereotypes are the rule. It is unfortunate but true that these young people often become aware of prejudiced feelings toward them among the staff who deal with them.

Regrettably 75 – 80% of young people seek advice after first intercourse, explaining delay as being due to their ignorance of sex and of the services available, or that the sex was unexpected, but frequently that they feared lack of confidentiality or the inappropriate attitude of staff. Emergency contraception, the need for a pregnancy test and the new status – becoming sexually active – are common triggers for seeking the services. All this reflects the degree to which there is general unease around the whole subject.

All parents want schools to provide more sex education earlier, but there is an apprehension among teachers that they might disapprove. Young people are falling through this communication gap, which looms largest over contraception and abortion but is substantial over the whole range of matters which bear on sexual health.

The Health of the Nation government initiative set targets in the 1990s for reduction in under 16 year-old conceptions. Performance analysis showed variation between a 55% increase in the Croydon area and a 28% decrease in Manchester; successful areas were more likely to have set up inter-agency groups combining health education and social services, appointing new staff specifically to focus on sex and relationship education. They engaged in consultation and health promotion with young people, set up additional training for teachers, and established new young people's services. The Croydon case was apparently influenced by the attitudes of a powerful director of public health, clearly derived from the American abstinence policy. The efforts of workers to set up a package of services likely to be beneficial were blocked. The lesson to be learned is that personal views on this emotive subject must not be allowed to interfere with effective policy making.

A cultural change is required, while respecting personal opinions; funding of initiatives has to be reasonably long term, as their take up is often slow. There is a huge need for more training, and young people have to be involved in the details of planning, with research always guiding policy.

References.

Clements, S., Stone, N, Diamond, I. and Ingham, R. (1998) Modelling the spatial distribution of teenage conception rates within Wessex, British Journal of Family Planning, 24, 61-71

Diamond, I., Clements, S., Stone, N. and Ingham, R. (1999) Spatial variation in teenage conceptions in south and west England, Journal of the Royal Statistical Society, series A, 162 (3), 273-29

Alan Guttmacher Institute (1999) Teenage Pregnancy; overall trends and
state-by-state information, http://www.agi-usa.org/pubs/teen_preg_stats.html

UNICEF (2001) A League Table of Teenage Births in Rich Nations, Innocenti Report Card No. 3, Florence, Unicef Innocenti Research Centre


Health Education Board for Scotland. A review of sexual health policies and trends in the USA, Australia and New Zealand http://www.hebs.scot.nhs.uk/research/cr/crscripts

Midwives working with teenagers.
From Jemma Bryant (JB), Midwifery lecturer, Thames Valley University, London.

I used to be the teenage pregnancy coordinator at Queen Charlotte's Maternity Hospital.

There is no agreement about whether the range of problems to which babies born to teenage mothers are liable are caused by maternal age alone or by socio-economic factors including inadequate antenatal care. Likewise research has contested the association of pregnancy complications with the age of the young mothers. However it is the case that teenagers frequently experience family conflict and stress in their relationships; their housing may be unsatisfactory and money short, and a shortfall in education is not unusual. They often conceal their pregnancies, book late for care and attend poorly, are more likely to smoke, consume alcohol, take inappropriate medications, and to be ignorant of healthy diet. They are less likely to breastfeed, and have a threefold increase in postnatal depression compared with older women. These young mothers are more likely to have mothers who were themselves pregnant at an early age, and one in eight of them will have a second baby before the age of 20.

Good midwifery support can help a teenager to regard her pregnancy as a positive event and help her to become a good mother. Inflexible antenatal care programmes which are inappropriate for the needs of teenagers must be avoided; accordingly we developed the Young Mums One to One Scheme in 2001. Funding has come from the hospital's budget, with a small annual amount from the local authority. Each mother has a named midwife pair who see them through the whole maternity episode. The six midwives in the scheme have caseloads of 36 per annum, working alternate 24 hours and weekends with their partners, a working pattern which suits some midwives well, but not all. The service is user friendly in every way, including the use of mobile phone text messaging and home visiting at any preferred location; uniforms are not worn. Informed choice is the rule, and attendances are excellent.

The scheme has forged links with the local Tackling Teenage Pregnancy co-ordinator, social services, child protection, housing department, school re-integration project, and GPs and health visitors. In contrast to the practice in many obstetric units the mothers are treated as in the low risk category in all ways, including the possibility of home births. Teenagers are unenthusiastic about parentcraft classes where there are couples and older women, and our classes for them are at a convenient time and are reasonably well attended – 60%. Peer support and the return of mothers with their babies are encouraged, easily achieved since the postnatal support sessions (with the popular baby massage) precede the parentcraft classes.

80% of the births take place from 37 to 41 weeks, with an 11% induction rate. While there was little difference between the birth outcomes (spontaneous, caesarian section, instrumental) before and during the operation of our scheme, there was a 60% reduction in the use of epidural analgesia to 28%. Most of the teenagers are in water for some of their time in labour, 30% delivering in water. The breastfeeding rate improved to 66% from an already fairly high level, perhaps due to the example given by those attending the postnatal group. We hope to extend our postnatal care to six weeks, examine them and give contraceptive advice.

Plans for the future include audit and classes for expectant grandparents – helping them to come to terms with their babies having babies, and in the hope that it will further improve the breastfeeding rate; other projected classes are for young fathers - we hope to be able to supply free condoms to them and to the women - and water birth.

If a scheme such as this is eligible we shall apply for Baby Friendly status. We are proud to have been shortlisted for the Royal College of Midwives Centenary Awards, and to have been recognised as an example of good practice in the government response to the first annual report of the Independent Advisory Group on Teenage Pregnancy in June 2002.

Contact details: Jemma Bryant phone 020 8280 5193; email jemma.bryant@tvu.ac.uk

Maria Patterson (current Young Mums coordinator, Queen Charlotte's Hospital)
mobile 07957 331540; email mpatterson@hhnt.org


Sex and relationship education in schools : a dynamic approach to preventing teenage pregnancy.
From Kathy Dargave (KD), The schools teenage pregnancy project, London.

The project operates now in two Local Education Authorities (LEAs) in forms appropriate to the age, gender, culture and faith of the schoolchildren and college students, in an age range up to 19 years.

The assumptions made about the reasons why teenagers engage in unprotected sex are well known and numerous:

· Low aspirations
· Peer influence
· Media influence
· High fertility
· Myths and misunderstandings about the realities of parenthood
· Pressure to have sex
· Poor education
· Low confidence in accessing services
· Faith and cultural factors
· Ignorance

The factors determining unintentional pregnancy apply to adults as well as to teenagers, sexual behaviour being a function of a person in their situation; not every teenage parent is a problem parent, and having a baby can bring them self actualisation and fulfillment, but adults without exception carry personal emotional baggage around the subject, whether because of their own fertility problems or their religious beliefs or otherwise. Teachers and trainers have to come to terms with this in themselves and in their work with young people, who will opt out given one loose comment or any suspect body language. We must be aware of their needs, no different from ours, as propounded by Maslow in his hierarchy of needs in 1968, ascending from the basic such as food and shelter through security, belongingness, self esteem and self actualisation.

The first principles of our preventative programmes are giving high quality information, making explicit the reality of teenage pregnancy, and providing every opportunity for young people to express their emotions; we want them to feel that they are in an environment where it is safe for them to say what they feel. “Don't do it” doesn't work; if they are helped to be in control they will make good decisions. We prefer to work with boys and girls separately. The boys get input on attitudes, influences, behaviour and consequences, on the roles, feelings, experiences and responsibilities of fatherhood; the girls hear about feelings, realities, contraception, sexually transmitted infections, risky situations and negotiating sex.

The programme is one lesson weekly for four weeks, usually delivered to the whole of years 9, 10, and 11 (numbering up to 240) in the secondary schools, pupil referral units and special schools where we work. In the tough noisy schools which we visit the need for good delivery of the information is paramount, and we employ a team of ten trained sessional workers, all representative of the community – black, mixed race, white, middle aged - and with track records of being able to engage immediately with young people in groups numbering up to 45, and able to hold their attention throughout.

When asked, girls will say that they had known not a few who were pregnant while still at school, and will recognize that the stereotype of the teenage mother is untrue – anybody can get pregnant. “Everybody in this room is pregnant. How does that feel?” “Scared, worried by the secret I carry”. “How hard will it be to tell your parents? What will they feel?” “ They'll be livid, beat me, throw me out…..”. We use role play, which may be hilarious or very moving, but played to a resolution; most parents are supportive. On returning to school: exclusion is illegal, and a girl must not lose sight of her future. We work through money management and accommodation. Will the partner stay or walk away? Peer educators, mostly no longer with their partners, tell their stories. Empathy bellies are popular and, at the end of the course, Real Care Dolls are used – they can't be switched off; both are happily used by the boys also, as long as there are no girls present and a male worker is.

The boys' programme challenges their views of maleness and faces them with the influences to which they are subject – clothes, TV, films and music, especially black music, which is violently homophobic, about having sex rather than making love, and which glorifies the gun culture, status and wealth. The black boys need good, strong black role models challenging these attitudes. How do you react on learning that she's pregnant? Will you stay, or walk away? What would having your baby for the weekend be like? We make sure to sabotage the weekend in role play, usually with a sick baby in need of attention; the boys always give up before Sunday night. Other aspects are necessarily similar to the girls' programme.

Almost 4,000 young people are playing their parts and hearing these messages annually. OFSTED, pupils and staff all agree that they work, and we get repeat bookings from the schools. Being outsiders we are seen as safe to approach with real life problems, and we often are. The pace of the teaching and learning style, with its role play and practical exercises such as condom practice, is popular, partly because there is no written work. The young people can speak freely and know that they are taken seriously. The impact of the workers is crucial, and the peer educators are very effective. We link to and sometimes bring in representatives from other services, and this is appreciated. This can make it easier for them to access clinics from which they might otherwise quail.

The developing fatherhood programme has been purposely risky. Asking boys to reflect on the fathering they had received unleashed much emotion and anger; up to 75% of boys in some groups were not living with their biological fathers, who might be unknown or might fly in and out with a gift while the mothers bore the burden of parenting and were the naggers. A common immediate response to discovering that your girl was pregnant was denial, but the boys have usually wanted to discuss their feelings, filling the father-shaped hole in the universe with their imaginings. Exercises we use: Here's a scenario; what would mum and dad say? Getting involved, being involved, staying involved with your baby. How do you stay in touch with your girl now she's pregnant? What are the obstacles? What if you split up and another man ends up fathering your baby? We have young fathers in this situation, who may never have seen the baby, come to tell their stories, expressing the fear of the knock on the door which, in 15 years, might be heard when an unknown child comes to berate the absentee father. A surprising number of the school age boys claimed to have fathered a child. We have used Ed Clarke's photos of young fathers holding their babies with remarkable effect and continue to use them.

Have we affected the incidence of unintended pregnancy? We believe so. We hope so.

Discussion.

JB: We contact health visitors for each mother as available. The Trust has not favoured the notion of health visitors being assigned to our caseloads, although some have asked to become attached.

RI: Some of the very low rates of teenage births are due to the easy availability of termination of pregnancy, as in some Eastern European countries, where it is virtually the chosen method of birth control. In some cultures the control imposed by adults on young people limits their sexual activity. In countries with low rates but where such control is absent, such as Switzerland, Germany, the Netherlands and Scandinavian countries, the educational systems and services are open and approachable on sexual matters for teenagers. The low numbers of unintended births in any area militate against the validity of research into rate changes, and the lack of such validation discourages funding; evaluation of the process rather than the outcome should be acceptable to funding bodies.

Wendy Savage: We are up against the national hypocrisy around sex matters. Straight speaking government material has been criticized, as was I when invited to speak on the subject to first year medical students, an attitude little if at all changed in the 21
st century. KD: Government initiatives are doubtless money driven – fewer teenage parents means less benefit to be paid out. RI: The Prime Minister's introduction to an otherwise excellent social exclusion report, starting with the admonition “Young people should not be having sex, but if they do…….”, placed the wrong gloss on the sensible message which followed. Fortunately there are now first class staff in the teenage pregnancy and sexual health units at the Department of Health (DoH), supporting local initiatives and promising a breakdown of the barriers to progress. A few but powerful voices in the Houses of Parliament regularly speak out against progressive proposals. KD: We have been impressed by the proactive attitudes of the Catholic schools which we visit. The support of the Diocesan Board has been crucial, and is worth invoking in areas where the schools are still frightened and reluctant.

JB: A lot of our time is spent in linking to services such as rape counselling and care homes.

KD: The effort and cash put into training schoolteachers has usually been wasted when staff have changed and expensive equipment has not been used; the government's Healthy Schools initiative should be useful in supporting the continuity of sex and relationship education.

Anecdote (from the author, at the meeting): My patient Elsa had a baby daughter. 15 years later this girl came to me to ask why she was not pregnant. I said that perhaps this was not exactly the right time. “But my friend has had a baby, and I'm going to”. I demurred. A year later she had her baby – at Queen Charlotte's Hospital, under my care.

Wendy Savage: I was encouraged to hear the new Minister for Public Health mention sex in a speech, having been disappointed by New Labour's reluctance to tackle women's problems, despite the number of young women Labour MPs. However I was appalled to learn of a teacher who disapproved of the use of the word masturbation by a boy during a discussion on sexuality; mutual manual stimulation is after all a resource alternative to penetrative sex which is unlikely to lead to pregnancy. RI: Our interviews have revealed a huge amount of discomfort, even disgust and guilt, felt by women about their bodies in this regard; the impact of this on sexual health needs to be explored. The issue of “semen loss” outside the body in India has led young men to resort to sex workers and homosexual intercourse with the risk of STIs; a woman speaking about the public health issues consequent upon a widespread taboo has aroused interest. The Royal College of Nursing is to introduce a distance learning course on sexual health.

RI: There is a higher than average incidence of depression in teenage mothers possibly related to deprivation, and consequent effects on the children. (See Dr. Tom O'Connor's presentation at the Forum meeting Caring for the emotions in pregnancy, birth and beyond.)