England's Teenage Pregnancy Strategy: a hard-won success
Authors: S Rachel Skinner, Jennifer L Marino
Journal: The Lancet (2016)

Teenage pregnancy is considered a key indicator of adolescent health for good reason.1Hindin MJ Tuncalp O Gerdts C Gipson JD Say L Monitoring adolescent sexual and reproductive health.Bull World Health Organ. 2016; 94: 159Crossref PubMed Scopus (13) Google Scholar The associations between teenage births and mortality, morbidity, and social and economic hardship for the mother and child are well established. Research over many decades has provided us with a good understanding of the underlying factors for the complex issue of teenage pregnancy and reasonable evidence for what strategies work to limit it. In The Lancet, Kaye Wellings and colleagues2Wellings K Palmer MJ Geary RS et al.Changes in conceptions in women younger than 18 years and the circumstances of young mothers in England in 2000–12: an observational study.Lancet. 2016; (published online May 23.)http://dx.doi.org/10.1016/S0140-6736(16)30449-4Google Scholar present the impact of the UK Teenage Pregnancy Strategy on rates of teenage abortions and births in England over the 13 years after its introduction in 2000.3Social Exclusion UnitTeenage pregnancy. Stationery Office, London1999Google Scholar The Teenage Pregnancy Strategy was a complex, intersectoral, and multicomponent intervention, informed by available evidence on likely effective strategies to reduce pregnancies, from inception throughout its funding period. There were three main components of the strategy. The first element was a whole-government approach to administration, headed by a cross-departmental ministerial task force (spanning the departments of health, education, and employment), monitored by an independent national advisory group and implemented by funded regional and local service coordinators and partnership boards. The second element was improved prevention efforts, including: high quality education about sex and relationships in schools; better access to effective contraception; enhanced efforts targeting the most at-risk groups, and young males; a media campaign with separate components for young people and parents; and a print and broadcast media campaign. The third element was better support for pregnant teenagers and teenage parents to ensure completion of education and access to secure housing with in-home support for mothers and their children. At the mid-course review in 2005, the UK's national conception rate had dropped 11% for those younger than 18 years and 15% for those younger than 16 years, but with variability, including reductions as substantial as 43% in one local authority.4Department for Education and SkillsTeenage pregnancy next steps: guidance for local authorities and primary care trusts on effective delivery of local strategies. Department for Education and Skills, London2006Google Scholar From this point, a more intensive approach to lower-performing authorities was adopted.5Scottish ParliamentInquiry into Teenage Pregnancy. Written testimony of Alison Hadley. Report on Inquiry into Teenage Pregnancy, fifth report, session 4, 2013, Scottish Parliament Health and Sport Committee.http://www.parliament.scot/S4_HealthandSportCommittee/TP065_-_Alison_Hadley_-_Teenage_Pregnancy_Knowledge_Exchange.pdfDate: 2013Google Scholar In the study by Wellings and colleagues,2Wellings K Palmer MJ Geary RS et al.Changes in conceptions in women younger than 18 years and the circumstances of young mothers in England in 2000–12: an observational study.Lancet. 2016; (published online May 23.)http://dx.doi.org/10.1016/S0140-6736(16)30449-4Google Scholar investigators combined routinely collected area-level data on abortions and births, deprivation, and Local Implementation Grant expenditures with individual-level risk factor information from the three waves of the National Surveys of Sexual Attitudes and Lifestyle (Natsal) to describe changes in conception, abortions, and maternities in individuals younger than 18 years in England from 2000 to 2013. The maternity rate of individuals younger than 18 years in England has decreased slowly but steadily from its peak in 1996–98, but much more rapidly from 2007 to 2013, along with a decline in the abortion rate, halving the conception rate overall. The most substantial reductions were in the most deprived areas, where rates were originally highest. Participation in work, education, or training by young women who became mothers before age 18 years doubled over the period of the Teenage Pregnancy Strategy. The authors also estimated an absolute decrease in conception rate of between 8·2 conceptions (95% CI 5·8–10·5; p<0·0001) and 11·5 conceptions (9·5–13·5; p<0·0001) per 1000 women aged 15–17 years per £100 Teenage Pregnancy Strategy spend per head. This translates to between about £8700 and £12 200 per conception prevention, which might seem expensive, but is less than a quarter the cost of child support for a teenage mother and her child, who are at high risk of lifelong intergenerational welfare dependence. As reported in the mid-course review,6Teenage Pregnancy Strategy Evaluation TeamTeenage pregnancy strategy evaluation: final report synthesis. Teenage Pregnancy Unit, London2005Google Scholar the net estimated welfare payment per teenage birth, over the 16 years for which the family would be eligible for child-contingent benefits, was £44 566 in 2005 (£61 947 in 2016). The authors present a convincing case that much of the reduction in teenage conception can be attributed to the Teenage Pregnancy Strategy. This is the first time we have seen a teenage pregnancy prevention programme reduce objectively measured teenage conceptions, and improve outcomes for teenage mothers over a sustained period of time at the national level. The programme had many components, and in the absence of a careful process assessment, we still don't know which were more effective than others, however the combination of sex and relationships education, increased access to contraception, and social inclusion strategies are likely to be necessary elements. Other multistrategy programmes (combining education and increased access to contraception) have also shown success in reducing self-reported pregnancies in study samples, mainly in the USA.7Oringanje C Meremikwu MM Eko H Esu E Meremikwu A Ehiri JE Interventions for preventing unintended pregnancies among adolescents.Cochrane Database of Syst Rev. 2016; 2 (CD005215.)PubMed Google Scholar The Teenage Pregnancy Strategy needed a full decade of implementation to show its capacity to effect change on this complex issue. At the mid-course review, rather than withdrawing funding in response to a modest 11% reduction in conceptions, the task force accelerated efforts. However, as happens often, a change in government in 2010 coincided with discontinuation of funding of the UK Teenage Pregnancy Strategy. In 2011, an investigation by The Guardian8Williams R Cuts threaten to undo progress on reducing teenage pregnancies.The Guardian. Aug 10, 2011; (accessed May 18, 2016).http://www.theguardian.com/society/2011/aug/09/cuts-undo-progress-teenage-pregnanciesGoogle Scholar reported that over a third of teenage pregnancy coordinator positions had been eliminated, and a parliamentary inquiry yielded no further information about disposition of coordination positions nationally.9UK ParliamentHansard, Parliamentary debates, answers to written questions, 6 May 2014: column 157W questioner: MP Luciana Berger, Answerer: MP and Parliamentary Under Secretary of State for Public Health Jane Ellison.http://www.publications.parliament.uk/pa/cm201314/cmhansrd/cm140506/text/140506w0006.htm#14050775000063Date: 2014Google Scholar The UK Teenage Pregnancy Strategy is an impressive example of how a sustained, multilevel, and multicomponent intervention, such as that advocated by the recent Lancet Commission on adolescent health,10Patton GC Sawyer SM Santelli JS et al.Our future: a Lancet commission on adolescent health and wellbeing.Lancet. 2016; (published online May 9.)http://dx.doi.org/10.1016/S0140-6736(16)00579-1Google Scholar can impact a complex health and social issue, with high cost-effectiveness. By way of comparison, the UK human papillomavirus (HPV) vaccination programme is another example of a complex health intervention programme, which has achieved similarly impressive success.11European Centre for Disease Prevention and ControlIntroduction of HPV vaccines in EU countries—an update. European Centre for Disease Prevention and Control, Stockholm2012Google Scholar, 12Smith M Update on HPV vaccination in Australia.Cancer Forum. 2014; 38: 207-208Google Scholar, 13Wagner K White J Saliba V Human papillomavirus (HPV) vaccine coverage in England, 2008/09 to 2013/14: a review of the full six years of the three-dose schedule. Public Health England, London2015Google Scholar Would the UK Government seriously consider defunding and devolving all responsibility for HPV vaccination programme implementation to local authorities and their budgets? Ongoing monitoring and support should be provided to local authorities to ensure that the key elements of the Teenage Pregnancy Strategy and low rates of teenage pregnancy remain a core goal for the UK. Teenage pregnancy is no longer a problem too hard to be solved: a country's teenage pregnancy rates can be lowered and, further, the association between intergenerational poverty and teenage pregnancy can be attenuated, long term. SRS's institution received funds from GlaxoSmithKline Biologicals to reimburse travel associated with travel to attend a human papillomavirus (HPV) vaccine investigator meeting in Belgium and funds from CSLBiotherapies for an investigator driven research project on HPV vaccine related knowledge in boys. JLM declares no competing interests. Teenage Pregnancy Strategy for EnglandWe very much welcome the Article by Kaye Wellings and colleagues1 that reports the changes in pregnancies in girls aged under 18 years in England since 2000. This careful analysis identifies some of the many and varied factors that affect this important outcome; amongst these factors are activities that were implemented as part of the Teenage Pregnancy Strategy. Given that country-level (or even regional-level) randomised controlled trials are not possible in such large and complex areas, the kind of detailed analyses described by Wellings and colleagues are immensely helpful in moving beyond simple associations and in lending support to the idea that the Strategy contributed substantially to this result. Full-Text PDF Changes in conceptions in women younger than 18 years and the circumstances of young mothers in England in 2000–12: an observational studyA sustained, multifaceted policy intervention involving health and education agencies, alongside other social and educational changes, has probably contributed to a substantial and accelerating decline in conceptions in women younger than 18 years in England since the late 1990s. Full-Text PDF Open AccessHow successful was the English teenage pregnancy strategy?Kaye Wellings and colleagues' paper (Aug 6, p 586)1 and accompanying Comment2 ascribe the fall in teenage pregnancies in England since 1998 to the Teenage Pregnancy Strategy published in 1999. Unlike the interim assessment by the same authors,3 the paper draws no parallels with other UK countries, but a comparison with trends in conceptions among 15–17 year olds in Wales and Scotland raises questions about how far the fall can be attributed to the strategy (figure).4,5 Full-Text PDF