The conception rate in girls aged 13-16 is about 1% and approximately half of these pregnancies are terminated. Overall over one third of all teenage pregnancies are terminated.

• Teenage pregnancies in the UK are the highest in Europe: Germany has half the pregnancy rate, France one third and the Netherlands one fifth. The UK comes second only to the USA in the developed world.
• Recent studies show that 18.7% of teenage women and 27.6% of teenage men had sexual intercourse before the age of 16.
• Another study in London reported that 1 in 5 children aged 13 years stated that they had already taken part in penetrative or oral intercourse. At this age they are far less likely to use contraception.
• Successful reduction is achieved where an open, tolerant, pragmatic attitude to sexuality is adopted with effective programmes of sex education and confidential contraceptive advice.¹
• The main concern of young people is that their interview should be confidential and fears over lack of confidentiality are the main reason for not attending the GP. For this reason, provision of the community family planning clinic may also be an important feature of an effective service.

Many teenagers who become pregnant have accessed contraceptive services at some point but do not continue to use the available services correctly. It is therefore very important to follow up this group after providing contraceptive services.

Adverse effects of teenage pregnancy

• Teenage pregnancy is a serious social problem. Having children at a young age can damage young women's health and well-being and severely limit their education and career prospects.²
• Children born to teenagers are much more likely to experience a range of negative outcomes in later life. Children born to teenage parents are also much more likely to become teenage parents themselves.²
• Abortion carries its medical and emotional adverse effects, whilst continuing pregnancy carries a higher risk of maternal and fetal disadvantage.
• Teenage pregnancies are more likely to suffer anaemia and pre-eclampsia. The fetus is at risk of high rates of perinatal mortality, low birth rate and higher incidence of congenital abnormalities.

Pregnancy risk factors

• Rates of teenage pregnancy vary widely within the UK with much higher rates in underprivileged areas. Teenage girls particularly at risk are those who:
  • Have been in care
  • Play truant from school
  • Are from a large family
  • Are themselves children of teenage mothers
• Fears that sex education will make them more likely to experiment have been shown to be unlikely. One Bristol study, in which schoolchildren aged 14-15 years were educated in the use of emergency contraception, showed no change in their sexual activity or use of the facility.³

Under-16s⁴

• Guidance from the British Medical Association and others states that 'the duty of confidentiality owed to a person under 16 is as great as that owed to any other person'.
• However, there is no right of confidentiality where issues such as child abuse and child protection are involved.
• Guidance also states that 'any competent young person, regardless of age, can independently seek medical advice and give valid consent to treatment'. See also separate article Consent to Treatment in Children (Mental Capacity and Mental Health Legislation).
• Contraceptive advice or treatment can be provided to a competent young person aged under 16 years without parental consent or knowledge using the Fraser criteria. A health professional needs to be satisfied that:
  • The young person could understand the advice and have sufficient maturity to understand what was involved in terms of the moral, social and emotional implications.
  • They could neither persuade the young person to inform the parents, nor to allow the health professional to inform them, that contraceptive advice was being sought.
  • The young person would be very likely to begin or to continue having sexual intercourse with or without contraceptive treatment.
  • Without contraceptive advice or treatment, the young person's physical or mental health or both would be likely to suffer.
  • The young person's best interests required the health professional to give contraceptive advice or treatment or both without parental consent.

Provision of advice or treatment

• If you are not the patient's usual doctor and the patient has significant medical problems, you may need to obtain permission from the patient to obtain medical and family history from their GP before treating.
• Allow adequate time for counselling with discussion about relationships, sexually transmitted infections and general health matters.
• It may help to provide information of all methods of contraception, their benefits and risks to allow informed choice. If the partner is present, involve them.
• Most reversible methods may be suitable for young, fit women.

Methods of contraception

Age alone should not limit contraceptive choices, including intrauterine methods.⁴ Provided that there are no medical contra-indications, young women should choose whichever method of contraception they prefer, but:

• Before menarche, condoms are preferred for contraception and to prevent sexually transmitted infections; hormonal methods of contraception are not advised.
• For young women using a hormonal or intrauterine contraceptive, condoms should also be used to prevent sexually transmitted infections.
• Vaginal ring: the combined contraceptive vaginal ring is not recommended for women below 18 years of age because safety and efficacy have only been established for women aged 18 to 40 years.

Oral contraceptives

• The low-dose combined oral contraceptive pill (COCP) offers non-contraceptive advantages in terms of irregular menstrual cycles, premenstrual symptoms and heavy or painful periods.
• Can also run treatment courses together to avoid menstruation during examinations, etc. Effectiveness depends upon taking the pill as instructed and in typical use associated with pregnancy rate of 3-20%.
• Teenagers are particularly at risk because of missed pills. Before prescribing, take the blood pressure. Cervical smears are not indicated in this age group although advice about human papillomavirus in cervical cancer is useful.
• COCPs may improve acne vulgaris. Co-cyprindiol (Dianette®) is indicated for severe acne which has not responded to oral antibiotics; however, it has a higher risk of venous thromboembolism.
• Progestogen-only pills are less suitable because of the need for them to be taken regularly, although Cerazette® may be the most appropriate for this group, as the missed pill rules are as for COCPs.

Depots and implants

• Depot injections are reliable and provide a contraceptive effect for 8-12 weeks. However, because of loss of bone mineral density, medroxyprogesterone acetate (Depo-Provera®) should be used in adolescents only when other methods of contraception are inappropriate.
• The etonogestrel-releasing implant (Nexplanon®) may be a suitable option and provides effective contraception for up to three years.

Intrauterine devices

• The copper-based intrauterine device (IUD) and the progestogen-releasing intrauterine system may be considered, although it may be difficult to insert a coil into a nulliparous uterus and there is no protection against sexually transmitted diseases.
• There is a small increase in risk of pelvic infection in the 20 days after IUD insertion, but there is no increased risk after the first 20 days.

Barrier methods

• A diaphragm may be suitable for some girls in stable relationships, but storing and transporting the device may be difficult if not telling parents.
• Male and female condoms are relatively unreliable if used alone.
• Condoms, if combined with other methods, enhance effectiveness and protect against sexually transmitted diseases.

Emergency contraception

• One study showed that a quarter of girls presented at a clinic for emergency contraception and many do not return for continuing contraceptive advice.
• They are a high-risk group for new unintended pregnancies.⁵

Document references

1. No authors listed; Contraception in teenagers. Drug Ther Bull. 2002 Dec;40(12):92-5. [abstract]
2. Teenage Pregnancy; Dept of Health
3. Graham A, Moore L, Sharp D, et al; Improving teenagers' knowledge of emergency contraception: cluster randomised controlled trial of a teacher led intervention. BMJ. 2002 May 18;324(7347):1179. [abstract]
4. Contraceptive Choices for Young People, Faculty of Sexual Health and Reproductive Healthcare (2010)
5. Falk G, Falk L, Hanson U, et al; Young women requesting emergency contraception are, despite contraceptive counseling, a high risk group for new unintended pregnancies. Contraception. 2001 Jul;64(1):23-7. [abstract]