Fertility levels in the UK have been below the replacement level for around 30 years. However, even without the effects of inward migration which is currently the main driver of UK population growth, demographic momentum – due to the large numbers of children produced in earlier cohorts (age bands) reaching childbearing years – would have prevented any population decline up to this century. For example, the large numbers of women resulting from the 1960s “baby boom” helped produce a rise in the number of births in the late 1980s and early 1990s (Population Trends 119, Spring 2005). The TFR peaked in 1964 at 2.95 children per woman, but this was followed by a rapid fall in the number of births per woman in the 1970s. In 2006 the TFR in the UK was 1.87 children, a rise from the previous year though still below the replacement rate. [1]. Around one in five women currently reaching the end of their fertile life are childless, compared to one in 10 women born in the mid-1940s.

Teenage pregnancies

Births to teenagers, aside from a few that are wanted and planned by young mothers in marriages or truly stable partnerships, have for a long time been a particular problem for the UK, for the OECD (Organisation for Economic Co-operation and Development) countries (Figure 5.2f below) and for the world as a whole. Teenage fertility rates in OECD countries vary considerably – from as few as four to as many as 45 births for every 1,000 girls aged 15 to 19. The UK is the third from the bottom of this list and last among all countries of Western Europe.

Why is the UK doing so poorly? In 2007 UNICEF published a Report Card No 7 [2] which used for 21 nations of the industrialised world the most recent available indicators that provide an assessment of the lives and well-being of children and young people. These background social considerations are highly relevant, given that there is no shortage of contraception in the UK. UNICEF found that the UK was bottom overall and also in the bottom third of rankings for five out of their six different measures of child welfare: material well-being, health and safety, education, peer and family relationships, behaviours and risks, and young people’s own subjective sense of well-being. Specifically and most relevantly for this discussion, the UK had the worst global score for all risk-taking behaviours; for early sexual debut (Figure 5.2d) and for the percentage who reported they had been drunk two or more times by ages 11,13 or 15 (Figure 5.2b). As a marker of contraceptive caution and safer sex, reported condom use at last intercourse was not quite the worst for the UK (Figure 5.2e); but given the potential for answers being given to please the researchers, this was hardly optimal anywhere and is obviously relevant to high unplanned conception rates among the teens of all the countries covered.

Disadvantages

An earlier study Report Card No 3 published by the UNICEF Innocenti Research Centre in 2001 showed clearly the later life outcomes of teenage mothers. Teenage maternity causes a wide range of disadvantages for the mother, for her child, for the planet’s environment, for society in general, and for taxpayers in particular. “The statistics suggest that a teenage mother is more likely to drop out of school, to have no or low qualifications, to be unemployed or low-paid, to live in poor housing conditions, to suffer from depression, and to live on welfare”.[3]

The norm to which most young people everywhere would probably aspire - if they got round to thinking about it - is, according to UNICEF in their 2007 report:

“an extended education, a career, a two-income household, delayed childbearing and a small family. And it is in this context that teenage pregnancy has become a significant problem: giving birth at too young an age is now associated with wide-ranging disadvantage for both mother and child – including a greater likelihood of dropping out of school, of having no or low qualifications, of being unemployed or low-paid, and of living in poor housing conditions. But as always, association is not the same as cause. Many girls who give birth in their teens have themselves grown up with the kind of poverty and disadvantage that would be likely to have negative consequences whether or not they wait until they are in their twenties before having children. Becoming pregnant while still a teenager may make these problems worse, but not becoming pregnant will not make them go away. Beyond the immediate problem, teenage fertility levels may also serve as an indicator of an aspect of young people’s lives that is otherwise hard to capture. To a young person with little sense of current well-being – unhappy and perhaps mistreated at home, miserable and under-achieving at school, and with only an unskilled and low-paid job to look forward to – having a baby to love and be loved by, with a small income from benefits and a home of her own, may seem a more attractive option than the alternatives. A teenager doing well at school and looking forward to an interesting and well-paid career, and who is surrounded by family and friends who have similarly high expectations, is likely to feel that giving birth would derail both present well-being and future hopes.” [2] (See also the last sentence of box A tale of two teenagers.)

A 2003 report based on the long-running British Cohort Study confirms these conclusions. [4] This followed all children born in a particular week in April 1970: the report used information collected in 2000 when they were 30. It showed that, compared to postponing childbearing into the 20s, the probability that a teenage mother’s partner does not have education beyond 16 is about 20 per cent higher and the probability that he has a job is about 20 per cent lower. The likelihood that with or without a partner she is a homeowner is also substantially reduced. The child of a teenage mother is also seriously disadvantaged. He or she “is more likely to live in poverty, to grow up without a father, to become a victim of neglect or abuse, to do less well at school, to become involved in crime, to abuse drugs and alcohol, and eventually to become a teenage parent and begin the cycle all over again”.[4 ]

Unplanned pregnancy

UK survey data show that 33-40 per cent of conceptions in all age groups were unplanned at conception, though often accepted later – rising to up to 90 per cent in teenagers. From an environmental perspective, the fact that so many births result from unintended conception and then, among teenagers, cause so much grief is plainly absurd. Each new UK birth, through the inevitable resource consumption and pollution that UK affluence generates throughout a lifetime, is responsible for on average about 160 times as much climate-related environmental damage as a new birth in Ethiopia or 35 times as much as a new birth in Bangladesh [5], a calculation that makes no allowance for Ethiopian or Bangladeshi citizens’ very obvious and reasonable wish for higher standards of living. This is compounded by the already unsustainable existing levels of population numbers and density in the UK.

However, this is but one of many reasons why moves to reduce unwanted teenage births can make a sensible contribution to population policy internationally and in the UK. The cacophony of contradictory advice in this area might lead one to conclude that the problem of teenage pregnancies can never be solved. The 2003 UNICEF report notes: “How teenage births might be reduced is a question to which everyone seems to have his or her favourite answer: more sex education or less sex education; abstinence education or free contraceptives in schools; dispensing ‘morning after’ pills or capping welfare benefits” [3].

The UK report Teenage Pregnancy (Social Exclusion Unit, 1999) [6] drew attention to the fact that, although teenage birth rates are the result of a complex pattern of forces that differ considerably from nation to nation, the teenage birth league clearly shows this is a problem that some developed countries have brought under control and others, including the UK, have not.

Can we learn from the instances of success? In 1999 the UK government set up a teenage pregnancy strategy, followed in 2000 by the Teenage Pregnancy Unit (TPU). It applies evidence not only from the more successful countries but also from a number of individual “best practice” projects and case studies from within the UK. Campaign messages focus on the themes of “taking control of your life”, the choices and personal responsibility themes embodied in the name of the website (http://www.ruthinking.co.uk) , with specific messages on peer pressure, the option of waiting for sex, sexually transmitted infections, using contraception and condoms. Advertisements focusing on the crucial issue of confidentiality have also been developed. The website and related endeavours are also aimed at problem groups that are often neglected, including boys and young men, young people from black and minority ethnic (BME) communities and those in care homes. All three groups are over-represented among teenage conceptions. TPU has also addressed young people with special needs, whether special educational needs or with physical disabilities.

The Teenage Pregnancy Unit (TPU)’s remit is ambitious, aiming to reduce conceptions under 18 by half by 2010 and provide better support, including contraceptives, for those teenagers who nevertheless become parents. Progress has been made on reducing under-18 and under-16 conception rates, to the point where both are now at their lowest level for 20 years. The England under-18 conception rate has fallen steadily, resulting in an 11.1 per cent decline between 1998 and 2004. The progress achieved nationally, however, masks significant variation in local area performance. Those areas which effectively implemented their strategies are seeing significant reductions of over 40 per cent.

In other areas, however, teenage pregnancy has not been given sufficient priority either within the area as a whole or among key parts of the delivery chain. If all areas were performing as well as the top quartile, the national reduction would be 23 per cent – more than double the reduction achieved. Therefore even the latest results remain a long way off the target and in 2006 the whole UK (England, Scotland, Wales and Northern Ireland) still had the highest number and rate of teenage pregnancies among the EU 25. This poor performance must be related in part to the disastrous trend in the modern NHS for primary care trusts to shut down community family planning clinics, where most service provision and training for the all-important long-acting reversible contraceptives(LARCs) is largely provided (see policies below).

(For the above statistics and more about the TPU, see its website.)

Future fertility policy - UK

In the UK some of the recommended policies – for example, the free availability of contraceptives, uniquely in this country without any cost to the user – are already fully implemented. Despite this, the high rate of unwanted teenage conceptions relative to most countries in continental Europe is proving highly resistant to reduction. Hence we should distinguish between fertility policies aimed at adults and those dealing with teenagers.

As already noted, the UK’s current total fertility rate (TFR) was 1.87 in 2006. Such a fertility rate, if it were allowed to continue (i.e. not following the trend of the past five years and rising further), would, in the absence of excess (net) immigration, lead to a gradual reduction in the UK population to a more sustainable level. Since this TFR equates to a little under 19 children in every 10 family units, it allows some degree of choice in family sizes: it means that the few who have three or more children rather than two are on average currently being balanced (with no instructions from government) by those who elect to have one or none.

However, for the future, a voluntary “stop at two” guideline should be encouraged for couples in the UK who want to adopt greener lifestyles. This could be achieved through education in schools and awareness campaigns by environmental organisations and the media: it would aim to set an example to couples worldwide of the value of limiting family size with environmental protection in mind.

There are special issues for teenagers, but for those aged 20 and above the major requirement in the UK is for the government to introduce an environmentally sustainable population policy. All responsible organisations need to counter pro-natalist pressures, notably pressure to increase the birth rate to improve the proportion of workers to non-workers – the age dependency ratio. This is hopelessly simplistic since more children now means yet more pensioners in 70 years time, greatly increasing the total population of the country while not, in the long term, improving the dependency ratio problem.

From an environmental standpoint, the number of unwanted new arrivals on the planet or in the UK should always be minimised. Since in the UK more unwanted conceptions occur among teenagers than any other age-group, it is sensible to develop policies for this particular group.

A major obstacle is the length of time for which all young people now need to contracept, since rising levels of education, more career choice for women, the perception that contraception is now so effective and changing preferences, have raised the average age at first birth in all developed countries. Yet there is evidence (Figure 5.2b) that in the UK sexual debut is slightly earlier than elsewhere while at the same time the responses by UK young people to questions about whether any form of contraception was used at last coitus show a lower rate. [7] This combination, of the trend to earlier sexual debut during adolescence and the societal advantages of delaying the first birth to well beyond one’s teens, means that the need to avoid maternity lasts longer than ever before.

Policies and activities are best described under three main headings – together with a fourth that has been inadequately addressed to date.

1. Joined-up action by government agencies. There is a need to engage and co-ordinate all the many stakeholders, to avoid both wasteful duplications and gaping omissions. The well thought-out though not always successful endeavours of the government’s Teenage Pregnancy Unit (TPU) in this area are described above and on its Teenage Pregnancy.

2. New guidelines for the portrayal of sex and fertility issues by broadcasters, print media and internet service providers. These could be drawn up through consultation with industry, government, health agencies such as the TPU and relevant NGOs . They would be aimed at

• countering the glamorisation of sex and motherhood among vulnerable groups, and
• stressing personal and social responsibility.

Action already taken over smoking, fatty food and advertising to children recognises the power of the media to influence attitudes and behaviour; statistics on teenage pregnancies, sexually transmitted infections and AIDS suggest that this is too important a subject to be left to the market-place. Critics may object that this is another example of the nanny state in action – but when the whole of society pays the price, some judicious nannying is surely a highly appropriate function for the state to exercise on behalf of its citizens and the natural world. The guidelines could cover:

• Motivational programmes that target young men as well as young women.
• Avoiding the portrayal of teenage sex/pregnancy in advertising to promote teenage products such as jeans, perfume, jewellery, make-up and cosmetics.
• Less use of teenage pregnancies in the story-lines of TV soaps whenever they tend to glamorise the outcome.
• Promotion of sexually responsible behaviour through positive character portrayal in soaps. This could include: safer sex, using condoms; the use of effective contraception including the morning-after pill; and the option of sexual abstinence (see below).
• Programmes involving young people that demonstrate: how demanding a baby is of its mother; the sheer drudgery sometimes involved; and how effectively it prevents normal teenage social life. For example, the trials shown on BBC Television’s Video Nation series used a highly realistic “virtual baby” [8] which cries repeatedly and can only be silenced by the “mother’s” immediate attention.
• Story-lines that demonstrate how teenage motherhood blights future educational and earning prospects.
• Environment programmes that advocate using contraception to avoid unwanted babies and depict this as integral to being “green” – no less relevant, for example, than saving energy or recycling or bicycling.

3. Improved sex and relationships education (SRE) and access to family planning and sexual health (FPSH) Services.

• This terminology (“sex and relationships education”, SRE) should always be used, as a matter of policy. The term “sex education” is unhelpful, both because it omits the crucial word “relationships” and because it allows opponents to allege that this means “educating” or encouraging young people to have sex before they otherwise would - an allegation that is widely believed, though not supported by the facts.
• “Someone with a smile would be your best bet…” This was the conclusion from a focus group of young people to the question “Who would you like to advise you about sex, relationships and contraception?” – something of an indictment of the providers those young people had previously encountered.
• Confidentiality is crucial -“here to listen, not to tell” - in making appointments and at contraceptive consultations, for all young people, not only for girls.
• Midwives, social workers and probation officers as well as teachers and school nurses, whose positive influence can be immense, should see it as their duty to raise issues of sex and contraception opportunistically with their contacts. Knowledge in this embarrassing area is greatly empowering.
• SRE programmes should present all choices in contraception even including what is sometimes termed “saving sex” – not having sex yet. There is no reason why this very safe option should not be offered as one of the choices, though it is unrealistic to insist on abstinence as the sole path for all to follow.
• Since contraceptives so often fail the user - or, more commonly the user fails the contraceptive - it is unsurprising that teenage conception rates tend to be high, especially in the UK. This is a disadvantage of pills for contraception, which have the wrong “default” state – conception. By contrast, the long-acting reversible contraceptives (LARCs) have the built-in advantage of being forgettable.
• LARCs such as contraceptive implants, injections and the intrauterine methods should be made much more readily available to young people, since, as noted, they have the virtue of forgettability and have been shown to be far more effective in typical use than the contraceptive pill – as emphasised in a 2005 report by NICE.[9] Indeed, achievement of the government’s teenage conception reduction targets of between 40-60 per cent by 2010, from their 1999 level, is probably out of the question without a major increase in the uptake of the LARCs.
• Given that both service provision and training for the LARCs in the UK is largely provided by community family planning clinics, it is a calamity that contraception services are so undervalued in so many primary care trusts in the UK, leading to a steady attrition of their staff and facilities [10]. This trend must be reversed with great urgency.
• The impact of emergency contraception (EC, the “morning after” pill) has been disappointing, despite wide publicity and improved availability. It is calculated that it prevents up to 90 per cent of conceptions but about 90 per cent of UK women requesting termination of pregnancy did not use EC in the appropriate cycle, so the message is not being taken on board [11]. Although it must be publicised and made available, not least on the radio and in the shops of the slums of developing countries, the expectations of EC are a long way from being fulfilled.
• Parents in the UK need more support and education for their vital and neglected role of providing good SRE for their own children, so that the learning process for young people – about their bodies, their sexuality and their relationships as well as contraception and sexually-transmitted infections (STIs) – can begin at home, matter-of-factly, at the moments the questions are asked. The Parentlineplus website implements the TPU-linked “Time to Talk” initiative, aimed at helping parents develop confidence and skills in talking to their own children about sex and relationships.

Policies and Recommendations Checklist

• Every country would benefit from an environmentally sustainable population policy.
• Fertility rates at or slightly below replacement level should be welcomed.
• Efforts to encourage, voluntarily, small families by education and through the media – “stop at two or have one less” – should be maintained and promoted.
• Fiscal incentives to encourage women to have large families should be opposed.
• Women’s empowerment in reproductive and sexual health should be given the highest priority.
• New guidelines should be developed for the portrayal of sex and fertility issues by broadcasters, print media and internet service providers.
• Obstacles to birth control should be removed, contraception and safer sex services prioritised.
• Challenges of the global youthquake should be recognised, with a special emphasis on preventing teenage pregnancies, in the UK and worldwide, and particularly in the slums of the planet’s new mega-cities.

References

1. Office of National Statistics at http://www.statistics.gov.uk
2. Child poverty in perspective: An overview of child well-being in rich countries, Innocenti Report Card 7, 2007 UNICEF Innocenti Research Centre, Florence. The United Nations Children’s Fund, 2007. http://www.unicef-icdc.org
3. A league table of teenage births in rich nations, Innocenti Report Card No. 3, July 2001, UNICEF Innocenti Research Centre, Florence. http://www.unicef-icdc.org
4. British Cohort Study Report 2003, Institute of Social and Economic Research http://www.esds.ac.uk/longitudinal/access/bcs70/l33229.asp
5. How many is too many? Leaflet published by the Optimum Population Trust 2006.
6. Teenage Pregnancy (Social Exclusion Unit). Report for Parliament (Cmd 4332, The Stationery Office, London, 1999.)
7. Teenage Pregnancy Strategy Evaluation Summary 2005. This is available to download (with other relevant reports) from the Teenage Pregnancy Unit website: http://www.everychildmatters.gov.uk/teenagepregnancy.
8. http://www.bbc.co.uk/threecounties/read_this/2003/12/virtual_mummy.shtml
   http://www.virtualparenting.com.au/infantsimulators_realcarebaby.htm
9. The effective and appropriate use of long-acting reversible contraception. National Institute for Health and Clinical Excellence. London: RCOG, October 2005.
10. Ma, Richard. It’s about sex, but not sexy enough! British Medical Journal 2006;333:1227.
11. Lakha F, Glasier A. Unintended pregnancy and use of emergency contraception among a large cohort of women attending for antenatal care or abortion in Scotland. Lancet 2006 2006; 368;1782-7.