Underage pregnancy

Teenage pregnancy hit the headlines recently with the welcome news that the rate of underage conceptions in England decreased in 2012 for the fifth successive year and is now at the lowest rate since the 1960s.  Many commentators have been quick to attribute the decrease to more sex education and provision of family planning to teenagers and especially emergency birth control (the morning after pill).  However, when we look at the actual evidence, the reality is much more complex.   So what has worked in reducing teenage pregnancy and what has not?

Let’s start with the Teenage Pregnancy Strategy which was announced in 1999 and led to the investment of hundreds of millions of pounds in earlier sex education, teen contraceptive services and emergency birth control (the ‘morning after pill’).

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For the first eight years, there was very little obvious effect: pregnancy rates were already decreasing when the Strategy started and, if anything, this decrease levelled off in the first few years of the Strategy.   Indeed abortion rates in 2007 were higher than at the start of the Strategy.  From 2008, the rates take a sharp turn downwards.  But that is a period when expenditure on the Strategy was actually decreasing.  Indeed, after the Strategy finished its operations in 2010, the decrease in teenage pregnancy has, if anything, accelerated.

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To see this from another angle, let’s take a look at what happened to access by under-16s to family planning clinics (including those at schools).  From 1999, the Teenage Pregnancy Strategy caused a massive investment in contraceptive services for young people and take-up increased dramatically.  As expenditure on the Strategy started to drop from 2005, so did take-up of contraception.  After the Strategy finished in 2010, take-up dropped even more.  Yet this is precisely the period in which abortion (and conception) rates dropped most quickly.

Could it be that the Teenage Pregnancy Strategy just took several years to start working?  Well, certainly, the effects of measures such as the welcome efforts to e-integrate young mothers into the education system aimed at breaking the long run cycle of deprivation and early motherhood may not be fully realised for many years.  On the other hand, providing emergency birth control to underage girls in pharmacies should have an effect straight away and certainly within a year or two.  It seems unlikely that measures like this should have no effect for 8 years and then suddenly start to work from 2008.

Further, research to date has failed to establish a causal effect on teenage pregnancy of specific measures promoted by the strategy such as increased provision of family planning services to young people.  To take just one example, a wide range of research published in peer-reviewed journals has established beyond reasonable doubt that easier access to emergency birth control has no effect in reducing unwanted pregnancy rates.  More worryingly, recent research from the US and the UK suggests that the promotion of emergency birth control is associated with increases in rates of sexually transmitted infections.

What about earlier and more intensive sex education at schools?  Unfortunately, the evidence that SRE has much of an effect on unwanted pregnancy is at best ambivalent.  That does not mean that schools should not have a role in helping parents and carers in the task of education young people in the area of sexuality.  Rather, we should not require schools to adopt a particular approach to sex education on the grounds that it is likely to reduce unwanted pregnancy rates – there is just not enough evidence to support such a conclusion.

Given all this, it is implausible to attribute the recent and sudden downturn in teenage pregnancy to the general approach of the Strategy. Recent research by Tim Blackman published in Social Policy and Society strongly backs this up.  Remarkably, he finds that dedicated planning and commissioning of services aimed at tackling high teenage conception services actually “appears to make things worse”.

So what factors can explain the decrease?  There are several plausible candidates.  The first is high quality school education which is a known to be an important factor in preventing early motherhood.  In the past few years, significantly more young people have been staying in post-16 education or training and fewer leave school with no qualifications.  Almost certainly this has contributed to the reduction in early motherhood.  Second, demographic change and ethnicity are also likely to have played a significant role.  Third, there has been a significant shift towards long acting reversible contraception (LARC).  We know that most abortions occur as a result of contraceptive failure.  Condoms and the pill have particularly high failure rates amongst young people so the switch towards LARCs may well help to explain why abortions have decreased (although we don’t yet have research evidence to confirm this).

Although these factors may all have played a role in cutting teenage pregnancies, they probably don’t explain everything and particularly why the trend line changed so suddenly from 2008.  There is another and quite intriguing possible explanation but to see what that is, you will have to wait for my next post!

Notes

(i) Abortion and conception rates are per 100 females aged 13-15.   Source is the ONS Conception Statistics series.

(ii) Family planning rates are first contacts by females at NHS-funded contraceptive clinics. Source is the Health and Social Care Information Centre series NHS Contraceptive Series, England.

(iii) TPS expenditure is taken from figures reported in Hansard.

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