Managing teenage pregnancies

GPs are the link between the services involved in caring for pregnant teenagers. By Dr Gillian Jenkins

Babies and children of teenage mothers tend to have higher health risks (Photograph: SPL)
Babies and children of teenage mothers tend to have higher health risks (Photograph: SPL)

The UK has the highest teenage birth and abortion rates in western Europe,1,2 up to five times higher than some of our European neighbours. Groups at risk of becoming teenage parents include school underachievers, children of teenage parents, those involved in crime or living in areas with higher social deprivation, those in or leaving care or who are homeless, as well as girls from certain ethnic groups (Caribbean, Pakistani or Bengali).3

Also, pregnant girls from socially disadvantaged areas are less likely to choose abortion, leaving girls from social class V around 10 times more likely to become teenage mothers than those from social class I.4

A 1998 10-year national strategy for England to halve the teenage pregnancy rate, developed by the Social Exclusion Unit's teenage pregnancy unit, only partly succeeded, reducing under-18 pregnancies by just 13.3% between 1998 and 2008.

For a GP, being presented with a pregnant teenager seeking help and advice can be complex and time-consuming. If she wants to continue with the pregnancy, you need to discuss issues including addressing her initial fears and concerns about the pregnancy, managing the higher health risks of teenage pregnancies, support and involvement of the baby's father (who may be a teenager) and her parents, and addressing her need for support in continuing education. Social support for housing and financial issues is vital, so contact with social services, with the input of a social worker, may need arranging.

Choosing termination
If your patient is uncertain about having a termination, needs counselling or support with her decision, or if she has already made that decision and is determined to go ahead, she will need referral to the appropriate local service. There are several UK-wide options including NHS family planning and pregnancy advisory services, as well as many local 'young & pregnant' initiatives and charities (see resources).

If a girl aged under 16 years is requesting referral for a termination, her GP must confirm and record that she is Gillick competent.

The Fraser guidelines (or Gillick competency) apply to all forms of medical care including abortion and require that those under the age of 16 can consent to medical treatment as long as they have sufficient maturity and judgment to enable them fully to understand what is proposed.

Contraception
Contraception is a vital part of post-abortion or postnatal care. An even higher burden befalls the teenage mother with several children, and better social and health outcomes are related to improved contraception in the postnatal period.

Whether this is through the GP, the clinic or hospital will be the mother's choice but it is usually the responsibility of the GP to maintain follow-up.

Long-acting contraception, such as the progestogen implant or injection, or an IUD, is ideal for the postnatal period when the teenage mother may be struggling to cope with the demands of her new and very responsible life.

Physical risks
Teenage mothers are at increased risk of many antenatal problems as a result of late presentation, dietary deficiency, anaemia and the consequences of lifestyle behaviours, such as drinking and smoking.

Babies and children of teenage mothers tend to have higher health risks including lower than average birthweight,5 increased likelihood of premature birth with all its sequelae, 60 per cent higher infant mortality than babies of older women,3 and more disabilities, such as cerebral palsy, learning difficulties and poor cognitive development. They are also 20-40% less likely to be breastfed.

They are more likely to belong to a lone parent family and are at increased risk of poverty, poor housing and poor nutrition. They are also more likely to become teenage parents themselves.5

Even as adults they are at risk, with research showing that low birthweight babies are at greater risk of long-term conditions, such as heart disease, diabetes and hypertension.6

An important part of the GP's role involves supporting the greater needs of the teenage parent. From regular contact around health advice to being the linchpin in support and communication between different services, such as health visitors, social services and education departments, the GP's role is vital.

Positive outcomes
A 2003 NHS Health Development Agency report highlighted evidence for many positive outcomes following health interventions in this group.7 For example, good antenatal care can improve health outcomes for mother and child and is cost effective, while home visiting, parental and psychological support can improve health and welfare outcomes, and may prevent repeat pregnancies.

The report also showed that improving housing increased health outcomes, and that support for young parents to continue education could improve educational and employment outcomes for parents, the mother/child interaction and social outcomes for children.

Early educational interventions for disadvantaged children were shown to improve long-term outcomes, and clinic-based healthcare programmes for mothers and their children improved health outcomes.

  • Dr Jenkins is a GP in Bristol

Resources

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Read up on Gillick competence and devise a checklist of things to consider when consulting with underage patients.
  • Investigate and review your local services or pathways available for teenagers seeking contraception or termination.
  • Read up on the causes and long-term sequelae of both low and high birthweight, and consider how this may affect your management of pregnant patients.

References
1. Avery L, Lazdane G. Eur J Contracept Reprod Health Care 2008; 13(1): 58-70.

2. United Nations Statistics Division. The World's Women reports. Table 2b: Indicators on childbearing.

3. Berthoud R. Population Trends 2001; 104: 12-17.

4. Lee E, Clements S, Ingham R et al. A matter of choice? Explaining national variation in teenage abortion and motherhood. York, Joseph Rowntree Foundation, 2004.

5. Botting B, Rosato M, Wood R. ONS Population Trends 1998; 93: 19-28.

6. Reyes L, Manalich R. Kidney Int Suppl 2005; 97: S107-11.

7. NHS Health Development Agency. Teenage pregnancy and parenthood: a review of reviews. Wetherby, HDA, 2003.

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