Teenage pregnancy rate of UK is highest in Europe, in other words UK is known as teenage pregnancy capital of Europe.1, 2 An underage pregnancy is one of the biggest problems being faced by Health Care Department and its prevention is thus one of the first line agenda with respect to the public health in UK. It not only affects the teenage parent but it also raises health and socio-economic problems for the new-borns. Also the chances of children born to teenage parent becoming themselves teenage parent in future is very high.3
To tackle with this, Government came up with National teenage pregnancy strategy in 1999 with the aim of lowering the statistic of teenage pregnancy to halve by 2010 and also to minimize the risk associated with the social exclusion of the teenage mother. All the local health authorities in UK were advised to develop individual strategies to meet 50% reduction in underage pregnancy by 2010 stating their main line of action. To meet the set targets, the strategy heavily relied on improving the sex-education in school and promoting the easy access of contraception.4
UNDERAGE PREGNANCY EPIDEMIOLOGY
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A teenage birth and abortion rate in UK leads the chart in Western Europe. It is as much as five times those in Holland.5 The data provided by Office for National Statistics (ONS) gives an insight on teenage birth and abortion rate in UK during time period of 1998 - 2008. According to the statistics as shown in table 1, in UK the conception rate under-18 dropped by 13.3% between 1998-2008. In 2008 almost 39,000 women less than 18 years of age became pregnant.6
Table 1: Under-18 Conceptions for England: 1998-2008
Under 18 conceptions
Percent leading to legal abortion
Source: Office for National Statistics and Teenage Pregnancy Unit, 20106
*per thousand females aged 15-17
2008 data are provisional
Figure 1: Under-18 conception rate for England: 1998-2008
Source: Office for National Statistics and Teenage Pregnancy Unit, 20106
Rate per thousand females aged 15-17
2008 data are provisional
The conception rate under-18 years of age varied significantly in different parts of the country during the period of 10 years. The recent figure shows the conception rate in the Tyne and Wear and in North east was 50.6 & 49.0 respectively in 2008 On the contrary, regions with low conception rate were south east (32.9) and south west (34.7) of England.7
In 1999, Government came up with National teenage strategy with an aim of achieving target conception rate of 23.3 by 2010 compared to that of 46.6 in 1998. East midlands public health observatory forecasted the teenage pregnancy results for 2010 using Holt's method. According to the data provided the strategy managed to achieve the conception rate of 40.4 (targeted conception rate 27.8) by 2008 which was far too less than expected.7
IMPACT OF UNDERAGE PREGNANCY ON PUBLIC HEALTH
Evidence has shown that teenage pregnancy raises serious social and economic problems which affect the public health. Teenage parent results from individual being themselves born to underage parent. This leads to resulting in various negative complications on the parent, the new-born and the society. These complications then can be; financial, poor health, deprived education or social exclusion.8, 9
As the teenage parent are not being able to afford basic necessities, increased risk of poverty is observed with the children born to teenage mother, this may lead to poor health and housing of the children and also chances of them being economically active in adult life becomes negligible.
The babies born to the older age mother is more likely to survive then those born to teenage mother. In other words, infant mortality rate is 60% higher for babies born to teenage mother.
The rate of post-natal depression is 3 times higher in teenage mother compared to older mothers thus developing higher chances of child suffering from poor mental health.
The instance of teenage mother breast feeding the child is less and also chances of teenage mothers smoking during pregnancy is high. These factors increase the rate of morbidity for the child.
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Teenage pregnancy also acts as a barrier in completing the education and thus rendering the teenage mother from deprived education and knowledge.
Underage pregnancy is common amongst the communities already suffering from social problems like poor housing, low income or unemployment etc. This increases the chances of negative consequences to the child born to the teenage mother from deprived community.8, 9
Teenage pregnancy has thus become a social exclusion and health care issue. But it has also raised economic and political concerns to tackle with the teenage pregnancy resulting in an increased burden on National Health Services (NHS) and local health care authorities.
The estimated cost to NHS for tackling with teenage pregnancy is £63m a year.
A total of £19000 - £2500 is estimated to be spent over the benefits to a teenage mother not employed in three years.
Type of local support such as employment, restarting the education, accommodation is required more by the teenage mother.
On the whole, on assessing longer duration of course (5 years) it is estimated that £4 is saved on every £1 spent on the strategy.9
STRATAGIES TO TACKLE UNDERAGE PREGNANCY
Rising of social and health care problems due to increase in number of underage pregnancy raised a matter of concern for government and the political agencies. The number of teenage pregnancy rose significantly by 1999. Thus, the priority of the public health in UK declined towards prevention of teenage pregnancies. With respect to this the government introduced a Teenage Pregnancy Strategy in 1999 on a National level. The primary aim of this strategy was to lower the number of conception rate to halve by 2010 and to decrease the risk of social exclusion associated with teenage pregnancy4, 10. UK relied on four major components of the strategy;
Media awareness campaign
-the campaign targeted the youth population via means of Radio, Magazines promoting awareness regarding the proper use of contraception and advising on sex and relationships.
Co-ordination between National and Local agencies
-this gave emphasize on mutual co-ordination between national and local health authorities. All the local health authorities were also been asked to place a 10 year teenage pregnancy strategy with appropriate medium and same level of target as being set on National level.
Educating people on sex
-this component concentrated on providing better Sex and Relationship Education(SRE) and access to health care services to the younger group of people specially targeting the primary schools.
Supporting teenage parents
-it involved encouraging and providing support to the teenage parents in re-starting their education and employment.4
Likewise, all the local health authorities in UK commenced a teenage pregnancy strategy primarily focusing on 4 proposed components of National teenage pregnancy strategy. All the local authorities made their strategies depending upon the region of improvement. For instance, Thurrock's teenage pregnancy strategy involved engagement of local sponsors and all the key partners like Public Care Trust (PCT), Children's education and family (CEF) as the main criteria. Liverpool's teenage pregnancy strategy gave emphasize on providing contraception and health services to the young people with ease. Whereas, Hackney's teenage pregnancy strategy focused on improving Sex and Relationship Education (SRE) and Personal Social and Health Education (PSHE).9
PUBLIC HEALTH INTERVENTIONS
Sex and relationship education (SRE)
Enhanced information and knowledge regarding sex and relationship along with contraceptive use helps to change the attitude of young lads towards early sex and helps them to be more responsible in reducing the teenage pregnancy rates.11 Evidence shows that Hackney teenage pregnancy strategy emphasized the implementation of SRE and PSHE by training the teachers of the schools in their area. The outcome of this being decrease in teenage pregnancy by 10% from 1998 - 2004.9
The very first emergency contraceptives were licensed in 1984 to be launched in UK. Since many years, NHS has been providing contraceptives for free on prescriptions. In 2000 Emergency Hormonal Contraceptive (EHC) was launched and became available to sell in pharmacies in 2001. One can get EHC free on NHS prescriptions where else have to buy it over the counter. EHC is made available through community pharmacies, family planning clinics, and school based health clinics and also from Accident and Emergency department (A&E). Easy access to EHC has help to prevent many pregnancies being cost-effective measure for public health. This important service is being provided in majority of pharmacies with highly skilled trained staff giving expert advice along with maintaining the confidentiality of the patient.11, 12, and 13
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It is scheme which provides free and confidential service to young individuals regarding sexual health. It provides free condoms and lubrication, advice on effective use of condoms thus making condoms easily accessible to young individuals. To use this service, individual (age 13-24) has to first get registered with the scheme. Upon registration, with the help of C-Card young individuals can claim free condoms from the pharmacies, NHS walk-in centres, GP practices and youth clubs. This scheme is beneficial in preventing Sexually Transmitted Diseases and unintended pregnancies.14, 15
It relies on young people's peer groups and approaches include which may be motivational, educational and skill based.16
Programmes promoting abstinence message (no sex) is safest contraception against STIs and pregnancy. They also provide information regarding the safe and effective use of contraception.16
Involving parents in the discussion with the children motivates and encourage them to undertake safe sexual activity. Evidence shows one of the most effective means to prevent health problems is to include teenager's parents in discussion and programmes.11
PHARMACY INTERVENTION IN UNDERAGE PREGNANCY
The role of pharmacist has been evolved greatly with the advancement of the technology and medical sciences. As a result of which it has created and increased the opportunities for pharmacies intervening the important aspect of public health. Teenage pregnancy is one of the serious issues of public health and with the help of extended role of pharmacist; the health care agencies have taken an extended step to deal with the situation. Under the new Pharmacy contract, EHC is provided by majority of community pharmacy as an enhanced service. This has enabled a wider access to EHC, saving the time of the patient as well as GP.17
The other advantage of it is being available at the nearest possible location and thus hindering the important time saving factor. This service has enabled pharmacist to give a deep insight into pharmacist-client relationship. Along with the advice on EHC, pharmacist can direct patients to Genito-Urinary Medicine (GUM) clinics and family planning service if the need arises.8, 18 To implant good practice in providing EHC to the patient, the pharmacists are provided some training sessions. As a part of this training they are asked to carry out certain role plays, improving their communication skills and being asked to complete centre for pharmacy post graduate education packages on contraception and EHC.19
Pharmacy is also an ideal place of spreading awareness regarding the importance of men being responsible in using contraception. Condoms are items which one can get without prescription as a result of which men find no need of seeking advice regarding the use of contraceptives from their GPs. The displayed posters and signs along with the leaflets given away in pharmacies encourage men to seek advice on use of contraception.8
These all factors help to give a safe and professional advice to the community and thus giving impetus in managing underage pregnancies.
Despite of the National Teenage Pregnancy Strategy being in place and all the necessary efforts thereby put in by the government, the data provided in table.1 shows that £280m strategy to halve the rate of conception under 18 years old by 2010 has failed. The future amendment by the government consists of introducing new action plan which involves one to one interaction with the use of contraception and sexual health for 16 years old.20