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Does access to contraception raise teenage pregnancy rates?

Nursing Times
24 March 2009

With the teenage pregnancy rate higher that it was a decade ago, David Paton asks whether easy access to contraceptive services is contributing to this problem

Since the government launched its Teenage Pregnancy Strategy in 1999, millions of pounds have been spent on access to ‘confidential sexual health services’ for young people.

Many nurses are uncomfortable with providing such services to children under 16, especially without parental knowledge, but do so believing that they are helping to reduce the risks of early pregnancy.

Unfortunately, the latest data shows that pregnancy and abortion rates for under-16s are higher now than when the strategy was published. Given this, nurses may be questioning whether they have been right to go along with this policy. It will be helpful to understand what the academic evidence says on the issue.

We have a wealth of evidence, from both randomised trials and population-level studies, indicating that access to contraception has little if any impact on teenage pregnancy rates. To take one example, a 2007 Obstetrics and Gynecology review of the evidence relating to emergency contraception concluded that ‘to date, no study has shown that increased access to [emergency contraception] reduces unintended pregnancy or abortion rates’.

When policy interventions have unexpected impacts that subvert the aim of the policy, economists often refer to the law of unintended consequences.

In this case, by lowering the pregnancy risk, easier access to birth control may encourage more young people to engage in sexual activity. If so, numbers of pregnancies decrease among those who would have had sex anyway, but increase among those who have sex when they otherwise would not have done. Overall, we end up with a similar number of pregnancies but with more underage youngsters being sexually active.

Many contraceptive methods offer no protection against sexually transmitted infections (STIs). Research published in Sex Education suggests that increased access to emergency contraception may be associated with higher teenage STI rates.

On the positive side, the academic evidence is clear that involving parents in decision-making is crucial. When the Gillick ruling was in effect in England and Wales in the 1980s, contraception could not be provided to underage girls without parental involvement. Take-up at family planning clinics dropped by about 30%, yet underage pregnancy rates actually decreased slightly relative to older teenagers. The ruling was overturned in 1985

Even more encouragingly, research published in the Journal of Health Economics and elsewhere reveals that laws requiring parental consent before an abortion is performed on a minor lead to significant decreases in teenage abortions and pregnancies.

It is unclear why it has taken so long for these findings to filter down to nurses working in the field.

Whatever the reason, nurses might remember that although the Fraser guidelines permit nurses to provide minors with access to abortion and contraception without parental knowledge if they are competent to make informed decisions, they do not require nurses to do so.

Furthermore, all health professionals – and, indeed, taxpayers – should question the wisdom of PCTs spending scarce resources on measures such as school-based provision of emergency contraception that, at best, are ineffective and, at worst, may actually be contributing to poor sexual health among teenagers.

David Paton, chair of industrial economics, Nottingham University Business School

References:
Levine, P.B. (2003) Parental involvement laws and fertility behavior. Journal of Health Economics; 22: 5, 861–878.

Paton, D. (2006) Random behaviour or rational choice? Family planning, teenage pregnancy and STIs. Sex Education: Sexuality, Society and Learning; 6: 3, 281–308.

Raymond, E.G. et al (2007) Population effect of increased access to emergency contraception pills: a systematic review. Obstetrics and Gynecology; 109: 1, 181–188.