Paul Greaves queries whether intervention really works

The senior house officer (SHO) covering the gynaecology clinic that morning returned to the nurses' room with an unusual request for advice from her registrar. After a morning filled with the usual speculums, pessaries, and smears, a young girl arrived with her father complaining of a missed period. Any attempt to find out how long this had been going on for was met with a shrug. An abdominal examination soon revealed the true extent of the problem - a swelling consistent with a pregnancy of at least 16 weeks.

"What happened?" There was the same response - a shrug. "When did you have sex?" "A couple of months ago." Asking the father to leave, believing that his presence could be inhibiting the girl, the SHO asked again. She'd been raped by "a friend's mate." Whether or not this was the truth, there was no doubting the reality of the situation. An ultrasound scan showed her to be more than 19 weeks pregnant-in three weeks' time there would be no choice but for her to have the child. What did she want to do? "Get rid of it."

There was no choice

Whatever the moral and ethical issues surrounding abortion under these circumstances, the tragedy of this situation was complicated by a telephone call, initially intended to find a second doctor to approve the termination. The girl no longer had the right to choose. The hospital trust would not undertake social abortions after 16 weeks and none were carried out on the NHS after 19 weeks. A private operation would have set her unemployed, single parent father back £600. So there was no choice. Whether she kept the child or had it adopted, by next spring this 14 year old girl would be a mother.

I was on the second week of my obstetrics and gynaecology attachment, and this event affected me more than anything I had had to face so far. That week I'd met far more teenage mums to be, albeit older and more happily expecting, than I'd ever anticipated. With numbers of teenage pregnancies on the increase nationally and a new drive on tackling teenage pregnancy under way, just how big is the problem and how effective can intervention be?

The United Kingdom is the well publicised leading nation for teenage pregnancies in Western Europe - 5.2% of teenagers become pregnant, compared with fewer than 4% in much of Europe.¹ Although far lower than in Eastern Europe or even America, where rates exceed 10%,² this still amounts to almost 100 000 teenagers a year. The case described is an unusual one, but 7000 under 16 year olds become pregnant each year, ¹ and it is for those that the impact on both mother and child is going to be the most devastating.

Public health measures had some effect

It has been worse. In 1971 the rate was almost twice today's figures. ³ After the trends over the following three decades it has become clear that public health measures, though often derided as being ineffectual, do seem to have some impact. In 1971 the contraceptive pill was made available to any woman who required it. Another revolution in the form of family planning clinics and the start of contraceptive and sex education coincided with the legalisation of abortion in 1967. By 1983 the number of teenage mothers had fallen to its lowest point since the 1950s.3 By 1990, though, the numbers had crept back up again. What has halted this decline?

Policymaking in the 1980s reflected a less forgiving public attitude to abortion and provision of contraception, with cuts in family planning clinics and tighter controls on the availability of terminations. This, combined with a scare on the safety of the pill in 1983, coincided with a reversal in the decline in the pregnancy rate.3 Again, it took a change of government policy to readdress the problem: there was increased funding to family planning clinics and a mandate to schools to provide sex education. Accordingly, attendance at clinics and general practice surgeries rose, and fewer teenagers became pregnant. And the early 1990s coincided with awareness of one of the biggest incentives to start using contraception - AIDS. In five years the proportion of young people using condoms at first intercourse doubled.³

So, where are we now? Sadly, teenage pregnancies are on the increase again. What is going wrong? It is essential to identify the reasons in order to understand where intervention can be effective. Despite the doubts that this is an area where money and political time are well spent, public health measures do have an influence and they are neglected at a cost. While American style evangelical preaching about the virtues of virginity, or the latest £60m government campaign, "It's OK to be a virgin,"⁴ may be ineffectual or simplistic, this does not mean that the problem is resistant to change. Surely pumping money into clinics and schools and raising public awareness is better than increasing the number of abortions or unwanted children.

This view may be simplistic and reflect inexperience in public health policymaking, but the successes of the past cannot be ignored. For this 14 year old any further measures come too late, but further measures are desperately needed.