2 Public health need and practice

2 Public health need and practice

Background

Young people's adolescent years, and the period up to their mid-twenties, are a time when they are exploring and establishing sexual relationships. According to the 2000/01 'National survey of sexual attitudes and lifestyles' (Johnson et al. 2005), the median age of first intercourse was 16 years for both men and women.

It is estimated that between one-quarter and one-third of all young people have sex before they reach age 16. Among those leaving school at 16 with no qualifications, 60% of boys and 47% of girls had sex before they were 16 (Wellings et al. 2001). Among those aged 16–19, 7% of men and 10% of women reported using no form of contraception at first intercourse.

Unprotected first sex was more likely for the youngest age groups (Johnson et al. 2001). A survey of young people aged 16–18 in London reported that 32% of black African men, 25% of Asian women, 25% of black African women and 23% of black Caribbean men did not use contraception at first intercourse (Testa and Coleman 2006).

Access to contraceptive services is most problematic for people in disadvantaged communities. There is a 6-fold difference in teenage conception and birth rates between the poorest areas in England and the most affluent. There is a clear link between sexual ill-health, deprivation and social exclusion; unintended pregnancies can have a long-term impact on people's lives.

Under‑18 conceptions can lead to socioeconomic deprivation, mental health difficulties and lower levels of educational attainment. In addition, resulting children are at greater risk of low educational attainment, emotional and behavioural problems, maltreatment or harm, and illness, accidents and injuries (Department for Children, Schools and Families 2008).

England has one of the highest rates of teenage pregnancy in western Europe. Figures for England and Wales show that the 2010 under‑18 conception rate (35.5 conceptions per 1000) is the lowest estimated rate since 1969. The 7.3% decline in under‑18 conceptions from 2009 to 2010 represents the greatest single year decrease since 1975/76.

Data for England and Wales show that conception numbers and rates fell among all age groups under‑18. Younger age groups (especially those under 15) continue to account for a very small proportion of teenage conceptions. In 2010, under‑15s accounted for 5% of under‑18 conceptions (Department for Education 2012).

National progress masks significant variation in local area performance. In England, the north east region had the highest pregnancy rate of 44.3 per 1000 young women aged 15–17 years while the east of England had the lowest rate at 29.8 per 1000. In virtually every local authority there are hotspots in which annual conception rates are greater than 60 per 1000 young women aged 15–17. However, some of the most deprived boroughs in the country have achieved reductions of more than 25% since 1998 (Department for Children, Schools and Families 2010).

Although 88% of women in a heterosexual relationship report using at least 1 method of contraception, abortion rates have increased since the Teenage Pregnancy Strategy was published (Office for National Statistics 2009).

In 2009, the highest abortion rate was in women aged 19–21, at 33 per 1000 pregnancies (DH 2010). The abortion rate for those under 16 was 4 per 1000, and for those under 18 the rate was 17.6 per 1000 (DH 2010). Repeat abortions accounted for 25% of all abortions in women under 25 in 2009.

The percentage of conceptions among women under 25 that end in abortion demonstrates that many of these pregnancies are unwanted. It suggests that contraceptive services are failing to meet the needs of young people, who are not getting access to effective methods of contraception and advice about using contraception effectively. Since the Teenage Pregnancy Strategy was published in 1999, the focus has been on reducing under‑18 conceptions.

The contraceptive and sexual health needs of those aged between 19 and 24, a group that has high rates of unintended or unwanted pregnancy, may have been neglected. Campaigns and services aimed at teenagers may not be as relevant to this group (Independent Advisory Group on Sexual Health and HIV and Medical Foundation for AIDS and Sexual Health 2008).

Teenage pregnancies have a high cost implication for public funds. It has been estimated that the cost to the NHS is £63 million a year (Department for Children, Schools and Families 2006).Teenage pregnancies place significant pressures on local authority social care, housing and education services.

In 2006/07, local authorities spent £23 million on support services for teenage parents (Department for Children, Schools and Families 2008). National Statistics data on abortions during 2009, combined with reference cost data for the same year, indicate that abortions for women aged under 25 cost the NHS approximately £53.3 million in 2009.

Government action

The Framework for Sexual Health Improvement in England aims to reduce unwanted pregnancies by ensuring people:

  • have access to the full range of contraception

  • can obtain their chosen method quickly and easily

  • can plan the number of children they have and when.

A review of the previous National Strategy for Sexual Health and HIV identified that contraceptive services needed further attention (Independent Advisory Group on Sexual Health and HIV and Medical Foundation for AIDS and Sexual Health 2008). Some local areas have suffered from disinvestment in community contraceptive services, although young people and those from vulnerable communities generally prefer these services to primary care services (Independent Advisory Group on Sexual Health and HIV 2009).

The recommended standards for sexual health services suggest that people should have access to accurate information about, and free provision of, all contraceptive methods (Medical Foundation for AIDS and Sexual Health 2005).

To reinforce these standards and the continuation of the Teenage Pregnancy Strategy, the Department of Health announced additional resources for primary care trusts and strategic health authorities between 2008 and 2011 to improve access to and uptake of effective contraception. The additional funding was focused on developing services in more schools and colleges and extending the range of services they provide, although the Teenage Pregnancy Independent Advisory Group was concerned that take up of the new money had been patchy and there was no national monitoring (Teenage Pregnancy Independent Advisory Group 2009).

From April 2009, GPs have been provided with incentives, through the quality outcomes framework, to provide advice on contraception and particularly long-acting methods, and abortion services are required to provide advice on contraception to all their clients (Department for Children, Schools and Families 2010).

From 1 April 2013, local authorities have a mandatory responsibility for commissioning and delivering all community and pharmacy contraceptive services (apart from services provided by general practitioners). Clinical Commissioning Groups are responsible for commissioning termination of pregnancy services (abortions) and a fully integrated range of contraception, STI testing and treatment services. They are also responsible for commissioning vasectomy and female sterilisation services.

  • National Institute for Health and Care Excellence (NICE)