Seven years of teenage pregnancy in an inner London genitourinary medicine service

Abstract

Summary

Young people attending genitourinary medicine services are at high risk of unplanned pregnancy. We performed a retrospective cohort study to identify characteristics of pregnant teenagers accessing an inner London genitourinary medicine service. There were 481 pregnancies in 458 teenagers with 54 previous pregnancies and 46 previous terminations of pregnancy. The under-18 and under-16 teenage pregnancy rates were 92.1 and 85.8 per 1000 age-matched clinic attendees, respectively. Median age was 17.1 years. ‘Black Other’ teenagers (‘Black British’, ‘Mixed White-Black Caribbean’ and ‘Mixed White-Black African’) were over-represented, compared to our clinic population, while those of White ethnicity were under-represented. Few pregnancies (1.5%) were planned with the majority (64%) intending terminations of pregnancy. Most teenagers did not use consistent contraception. Two-thirds of patients had attended genitourinary medicine services in the past and sexually transmitted infection prevalence at presentation was high. Effectively targeting the sexual and reproductive health needs of teenage genitourinary medicine clinic attendees may have a significant impact on reducing sexually transmitted infections, unplanned pregnancy and terminations of pregnancy in this group.

Keywords

Europe location women sexual behaviour sexually transmitted infection unplanned pregnancy contraception young people genitourinary medicine services

Introduction

Reducing the under-18 teenage pregnancy rate (TPR) has been a national public health priority since the publication of the Social Exclusion Unit’s Teenage Pregnancy report in 1999.¹ Since the launch of England’s Teenage Pregnancy Strategy over 10 years ago, the under-18 conception rate has dropped by 34% from 47.1 to 30.9 conceptions per 1000 women in 2011, the lowest figure since records began in 1969.² Despite this success, the UK still has a TPR higher than that seen in most developed countries and has the highest TPR in Western Europe.³

Lower socio-economic status and social exclusion are the most consistent factors strongly associated with an increased risk of teenage pregnancy.^4–7 In the UK, those identifying their ethnicity as Black Caribbean’, ‘Mixed White-Black Caribbean’ or ‘Black Other’ (‘Black British’ who do not identify as either Black African or Black Caribbean) are significantly over-represented among teenage mothers.⁷ Other factors include: having a mother who herself had a teenage pregnancy, living in a lone parent family, early menarche (<12 yrs) age < 16 at first sex, drug, alcohol and tobacco use, low aspiration and poor educational attainment.^5,7–9 More recently, analysis from the National Child Development Cohort Study have suggested that early life conditions such as low birth weight and childhood emotional and behavioural adjustment are also independently associated with teenage childbearing.⁸

A large number of visits by young persons (aged ≤ 24) to genitourinary medicine (GUM) clinics involve pregnancy testing and studies have found teenage girls attending GUM clinics who have negative pregnancy tests to be at high risk of subsequent unplanned pregnancy.^10,11 Those requesting emergency contraception are also a high-risk group, with the majority failing to return for contraceptive follow-up and continuing to use unreliable methods of contraception.¹² Many young people attending GUM clinics are using inadequate contraception^11,13 and the need for increased contraceptive provision in this setting has previously been highlighted.^14,15

Wandsworth is an ethnically diverse South West London borough with a largely young population (median age = 32 years).¹⁶ In 2008, Wandsworth launched a review of its local Teenage Pregnancy strategy which resulted in several targeted interventions and a drive to increase the uptake and provision of Long Acting Reversible Contraception (LARC) to YP by promoting awareness, introducing dedicated services at TOP settings and increased staff training. In 2012, a ‘reducing repeat termination project’ saw 54 YP under-19 and a 43% uptake of the offer of LARC. The borough has seen a 58% reduction in its under-18 teenage conception rate which has dropped from 69.6 in 1999 to 29.4 in 2011.¹⁷

The study was carried out at a GUM service based at large Wandsworth hospital. The GUM clinic is easily accessible via transport links and operates largely walk-in GUM clinics on weekdays and evenings. In addition to open access adult GUM clinics, the service provides three dedicated young person’s clinics (YPCs) each week, two of which are outreach clinics which take place in a socially deprived area of the borough. These see mainly those aged 18 and under and provide a full range of contraceptive services including LARC. The clinic has strong links with and receives referrals from community initiatives including a Vulnerable Young People’s Development Worker, specialist contraceptive services and The ‘Brook and Men’ (BAM) project; working with young men to improve their sexual health and condom/contraception use.

This study aimed to describe demographic, social and key behavioural characteristics of pregnant teenagers accessing a GUM service in Wandsworth to enable the effective targeting of interventions to reduce sexually transmitted infections (STIs) and unplanned pregnancies in this group.

Methods

A retrospective cohort study of all pregnant teenagers aged 18 or under attending an Inner London GUM service between 01 January 2005 and 10 June 2012. The study was divided into two time periods (before and after the local 2008 initiatives to increase LARC uptake). Cases were identified retrospectively by searching an electronic database of clinic attendees for all eligible patients coded as either ‘Pregnant’, ‘Referred for TOP’, ‘Pregnancy Testing Positive’, ‘Miscarriage’ or ‘Ectopic Pregnancy’. Five cases that had been miscoded as being pregnant were excluded from the study. ‘Age-matched attendees’ was defined as the number of unique female clinic attendees in the relevant age range during the study period.

Patient records were reviewed and data were extracted on a standardised proforma to include; demographics, contraceptive use, drug and alcohol use, diagnosis of STIs, gestation at presentation, pregnancy intentions and onward referral, partner history, risk assessment framework parameters. In all, 286 paper records and all electronic patient records (458 patients) were reviewed. Data were entered and analysed in MS Excel 2007. Chi square tests and confidence intervals were calculated using Graphpad Quick Calcs (www.graphpad.com/quickcalcs; GraphPad Software Inc, La Jolla, CA, USA).

Results

Four hundred and eighty-one pregnancies occurred in 458 patients with 23 patients pregnant twice during the study period. Median age at attendance was 17.4 (range 13.9–18.9; Table 1). Three hundred and twenty-one pregnancies were seen in the 15–17 age group giving an overall under-18 TPR for the clinic of 92.1 per 1000 age-matched attendees. There were 79 pregnancies in under-16s, giving an under-16 TRP of 85.8 per 1000 age-matched attendees. A decline in TPR was seen in the second period of the study, but this was not statistically significant (Table 2).

Table 1.

Pregnancies by age at attendance.

Age	Number of pregnancies
13	1
14	14
15	64
16	100
17	157
18	145
Total	481

Table 2.

Teenage pregnancy rates (TPR) per 1000 age-matched non-pregnant clinic attendees.

	Period 1 01/01/2005– 10/10/2008 (3.8 years)	Period 2 10/10/2008– 10/06/2012 (3.7 years)	p Value (Chi square test)	Both periods 01/01/2005– 10/06/2012 (7.4 years)
Under 18 (ages 15–17)
Pregnant attendees (n)	150	171		321
Non-pregnant attendees(n)	1624	1861		3485
Under 18 TPR	92.4	91.9	NS	92.1
Under 16 (ages 13–15)
Pregnant attendees (n)	35	44		79
Non-pregnant attendees (n)	319	602		921
Under 16 TPR	109.7	73.1	0.1	85.8

Sixty-eight percent of pregnancies presented to the adult walk-in clinic, with the remainder presenting to the YPC: forty-six percent of patients were resident in Wandsworth and 50% resided in neighbouring boroughs; 83% were born in the UK. Median age at menarche was 12 (range 8–15) and at first sex was 15 (range 7–17) including one reported sexual assault aged 7 years. Other socio-demographic characteristics are shown in Table 3.

Table 3

Socio-demographic characteristics of pregnant teenagers.

Demographic characteristics (n^a)	%
Living with: (n = 141)
Parents	80.9
Alone	4.3
Partner^b	3.5
In care	1.4
Other	9.9
History of mental health issues (n = 100)
Yes	7.0
No	93.0
History of social services involvement (n = 110)
Yes	23.6
No	76.4
History of non-consensual sex (n = 59)
Yes	16.9
No	83.1
Recreational drug use (n = 160)
Current	13.8
Past	6.3
Never	80.0
Smoking (n = 152)
Current	48.0
Past	6.6
Never	45.4
Alcohol use (n = 167)
Current	46.7
Past	9.0
Never	44.3

Refers to the number of teenagers for which variable was documented in patient records.

Three teenagers were married.

For the purposes of analysis, ethnicity was defined according to Greater London Authority (GLA) broad ethnic groups.¹⁸ Teenagers identified as ‘Black Other’ (which included ‘Mixed White-Black Caribbean’ and ‘Mixed White-Black African’) were over-represented in our cohort compared to both non-pregnant age-matched female clinic attendees and the population in Wandsworth as a whole,¹⁹ whereas those identifying as ‘White’ were under-represented (Figure 1).

Figure 1.

Ethnicity of pregnant teenagers compared to age-matched non-pregnant clinic attendees and local residents.

Where pre-pregnancy intentions were known (n = 260), only four (1.5%) pregnancies were reported to have been planned. At the time of presentation in clinic median gestation was 7 weeks (IQR 5–10). Where post-pregnancy intentions were known (n = 273), 64.4% intended to have a termination of pregnancy (TOP), 18.3% planned to continue with the pregnancy and 17.2% were undecided. Of 257 teenagers, 160 were directly referred for a TOP, 37/257 were offered further GUM follow-up, 25/257 were referred to Gynaecology and 23/257 for routine antenatal care. Fifty-four (23%) teenagers were known to have been pregnant before, 11 of these twice and 3 three times; 10/54 had one child and 2/54 had 2; 41/54 had had a previous TOP, 36 of these had had one termination and five had had two terminations.

Of 289 teenagers, 190 had previously accessed a GUM or contraception service, of whom 174 had attended our GUM service in the past. Ninety percent of these had had a documented discussion on contraception in the preceding year. In 40/281 pregnancies, no form of contraception was reported to have been used at all in the preceding year and 126/281 reported only intermittent condom use without additional contraception. Emergency contraception was used by 56/281. Hormonal contraception was reported to have been used consistently for any period of time in the preceding year in only 10 pregnancies.

One hundred and eighty teenagers had had a previous STI screen and 83 had previously been diagnosed with an STI (Table 4); 201/305 had an STI screen within 4 weeks of presentation and 53/201 were diagnosed with at least one STI (Table 4) leaving 104/305 unscreened. Of 305, 21 were documented to have declined screening and 2 of 305 had HIV tests only. Bacterial vaginosis was not considered an STI in this analysis.

Table 4

Frequency of sexually transmitted infections diagnosed in pregnant teenagers.

	Frequency of STIs previously diagnosed (n = 180)	Frequency of STIs diagnosed at presentation (n = 201)
Chlamydia	60	31
Gonorrhoea	16	13
PID/Cervicitis	9	0
Trichomonas	7	6
Herpes	6	4
Warts	5	9
Hepatitis B	0	1
Other	2	3

Of 269, 240 had a regular male partner who was reported to be the father of the baby in 210 cases. The median number of partners reported in the last 3 months was 1 (n = 204; range 0–50; IQR 1–1) as was the median number of lifetime partners (n = 121; range 1–50; IQR 1–2).

Discussion

Nationally-published teenage conception rates use a denominator of ‘total population in age group’ and thus include those who are sexually inactive. Young women attending GUM services are typically sexually active and therefore the conception rates that have been calculated are not directly comparable with nationally published rates. Nonetheless, teenagers attending our GUM service had a considerably higher risk of pregnancy than others their age in the general population. This risk was particularly marked in the under-16 age group, where the TPR of 85.8 per 1000 seen greatly exceeded the national average of 6.7 per 1000.²⁰ High TPRs have previously been observed in inner city GUM clinics.²¹ One recently published Scottish study found that 25% and 33% of teenage girls registering at GUM clinics at the ages of 13 and 15, respectively, subsequently became pregnant at least once within a 2-year study period.¹¹

We observed a one-third reduction in the clinic’s under-16 TPR across the two study periods. The significance of this is unclear, but appears to be in line with steadily falling rates both regionally and nationally. Local programmes aimed at preventing teenage pregnancy may have impacted the drop in pregnancy rates observed. However, in contrast to the 58% borough wide drop in under-18 TPR, no change was seen in the clinic’s under-18 TPR and reasons for this discrepancy are uncertain.

Two-thirds of patients had attended GUM services in the past and the vast majority of these were known to have discussed contraception. This finding is not unique. One English case-control study looking at 240 pregnant teenagers presenting to general practice found that 93% had consulted a health professional at least once in the year before conception, 71% had discussed contraception in this time and 50% had been prescribed oral contraception.²² Of those, 90% who had previously attended our service were documented to have had contraception discussed, and further research is needed into strategies to translate this advice into the effective use of contraception. This study’s dependence on written records may have underestimated the contraceptive advice given at previous clinic visit and there is no access to records from visits clients might have made to other providers offering similar advice such as primary care. GUM and contraceptive services in Wandsworth integrated in April 2012 and contraception is now routinely available from the general adult walk-in GUM clinics where the majority of young people present. We plan to examine the impact of these and other changes on subsequent teenage pregnancy trends and contraceptive uptake in the near future.

The main determinants of teenage pregnancy are known to be socio-economic. Our study was limited by its retrospective design meaning that information on socio-economic and other risk behaviours was incomplete and did not allow for multivariate analysis, which would have undoubtedly strengthened the analysis.

Median age at first sex was 15, a year younger than the age reported by the 2012 Natsal survey²³ and timing of intervention in relation to age also needs to be considered. Condom use was inconsistent and a significant proportion of women were not screened for STIs at pregnancy. STI prevalence was particularly high despite low reported numbers of recent and lifetime partners reflecting the need to ensure effective STI screening in this group regardless of onward referral. This finding also highlights the importance of partner testing and the need for more research into teenage fathers.

Teenagers of ‘Black Caribbean’ and ‘Black Other’ ethnicity were significantly over-represented in our pregnant cohort. This finding may to some extent be confounded by other factors such as differences in educational attainment or socio-economic status. National surveillance data²⁴ and other studies²⁵ however have consistently observed disproportionately poor sexual health and a higher TPR⁷ amongst this group who are also less likely than women of white ethnicity to use reliable methods of contraception.²⁶ Further research into ethnic variations in sexual health, particularly focusing on young people, may help to identify the sexual health support needs of specific ethnic communities.

Data from the Office for National Statistics estimated 59 conceptions in Wandsworth in under-16s in the 2009–2011 period.¹⁷ In that same 3-year period, 37 such pregnancies were seen at our GUM service. Whilst not all those attending our service were Wandsworth residents, this is still a surprisingly high proportion (63%) of the total number of Wandsworth pregnancies. These findings support the idea that GUM services appear to be reaching a large proportion of those at risk of teenage pregnancy and would be a logical place for policymakers to direct resources and target interventions. Better identifying those at higher risk of unintended pregnancy and intervening effectively when they first access services may have a significant impact on reducing unplanned teenage pregnancy and TOP.

Conclusion

Adolescents attending sexual health services are at high risk of pregnancy and STIs. Further research is needed into effective interventions to prevent unplanned pregnancies in this setting.

Footnotes

Conflict of interest

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Seven years of teenage pregnancy in an inner London genitourinary medicine service – a retrospective cohort study

Abstract

Summary

Keywords

Introduction

Methods

Results

Discussion

Conclusion

Footnotes

Conflict of interest

Funding

References