Family Planning: Teenage Pregnancy
The author plans to critically appraise the role of the family planning nurse in relation to unplanned teenage pregnancy. This area was chosen for a number of reasons. Firstly the UK has the highest number of teenage conceptions in Western Europe (Social Exclusion Unit 1999) and this has driven the Government to implement measures to decrease the number of teenage pregnancies. They have set targets and devised strategies nation-wide to address the issue and the targets are being achieved. The Health of the Nation report (Department of Health 1992) highlights sexual health as a key area including the recording of teenage conceptions. Teenage health is an area that the Scottish Executive (2003) is also interested in promoting through its Improving Health in Scotland document.
The issue of teenage pregnancy is a topical subject, which gets lots of media coverage, however it is usually shown in poor light or sensationalised (Coleman and Roker 1998).
The report will address three main areas: covering 1) sex education and influences on young people, 2) access to sexual health services and associated problems and finally 3) how the family planning nurse addresses these issues. The author will analyse both negative and positive aspects throughout and provide a personal evaluation.
Education and Influences
There has been much debate over the reasons why the UK has the highest teenage conceptions rate in Europe (Department of Health 1992). There is also much blaming as it is felt by others that there are enough services directed at young people for them to make the right choices in regards to having sex and using contraception (Sherman-Jones 2003). However it may not be as simple as that. Factors such as sexual knowledge, media and peer pressure, deprivation or family relations and expectations can all contribute to sexual activity and subsequent pregnancy.
There is pressure placed on young people who have physically developed but lack the emotional maturity to go with this (Chapin 2000). Not understanding how their body works can prevent teenagers from realising they are in need of advice. Knowledge of their own fertility and body changes is required as this can help the individuals to adapt as the changes happen (Winn et al 1998). Education is needed at an earlier age than other generations because the average onset of puberty is one month earlier per decade of this century (Coleman and Roker 1998). They not only need educated about their own bodies but also on contraception and how to use it. According to Green and Tones (2000) in adolescents, contraception use is seen as priority over protection from HIV. Kane et al (2003) describe how young people might not know how to ask for information but this does not mean they do not want to know. In order for young people to make informed choices they have to have knowledge as, according to Winn et al (1998) this enables teenagers to protect themselves. Knowledge is also a useful tool for assessing and evaluating education programmes and services (Naidoo and Wills 2000). Being educated about relationships, love, assertiveness, sexually transmitted infections (STI's), pregnancy and abortion should lead to delaying the onset of sexual activity and an increase in contraceptive use. Glasier and Gebbie (2000) propose this should promote equality and minimise prejudice.
Many problems come from peer pressure. Often young people feel they have to have sex to fit in with the crowd, though they may not fully understand the implications, they proceed because they believe the exaggeration of others (Winn et al 1998). There are so many myths surrounding sex and pregnancy that its not surprising young women end up becoming pregnant. The age of first sexual intercourse correlates to contraceptive use (Wellings and Mitchell 1998), which increases the risk not only of pregnancy but STI's.
Other influences come from the media who are continually advertising the sexualisation of girls. Girl's magazines are full of make-up tips, how to appeal to a sexy guy and make a sexy T-shirt. Boy's magazines on the other hand are full of football tips and playstation cheats. Girls are probably more aware of the implications of this one sided aspect than boys, who are still seen as the dominant sex but do not have the same knowledge (Chapin 2000). The perception is that for boys, sex in the media is innuendo and smutty jokes but little actual fact. They are not actively targeted the same as girls and early sexual activity is seen as manly. Therefore information should be aimed equally at boys and girls, as health professionals believe that sex education and services are often viewed specifically as women's issues (Kiddy 2002, Sherman-Jones 2003).
The view is that young people prefer to get advice from professionals within the same age group and of the same sex, meaning boys often only have their GP to talk to (Sherman-Jones 2003).
Certain teenagers feel there is little hope for them to get a good education or decent job and feel they need somebody to love who will love them unconditionally in return. Perhaps this is why such a high number of girls leaving local authority care find themselves in this situation (Department of Health 2001). Poor prospects and poverty contribute to why significant numbers come from deprived areas (Flowerdew 2003). Some youngsters mirror their parents and being the daughter of a teen mum means they are more likely to become a teen mum too (Glasier and Gebbie 2000). There is little talk of teenage fathers even though the majority of young people do attend to register the birth of their child together (One Parent Families Scotland 2001).
Teenage pregnancy is often viewed negatively by the media as they sensationalise many teenage health articles with headlines such as ' Teen mums told - stay in school' and 'Teen lifestyle health timebomb' (BBC 2003a and 2003b). This ignites much of the blame culture with unfounded opinions (Kiddy 2002). What is not reported is the majority of teenagers' who appear to be extremely responsible, by waiting until they are older to have first sexual intercourse. The average age of first sex is 17 which is still above the legal limit of 16 years and approximately only 3% of all pregnancies in England and Wales occur in under 16's (National Statistics Office 2001). However defining teenage pregnancy is difficult because many people have different interpretations of it, some feel that it refers specifically to those under 16 or under 18, or even under 20 as the title implies. The issue of whether to include abortion in the definition is also debated. The government defines teenage pregnancy as under 18 and under 16 and includes live or still birth and legal abortions in their conception data (Teenage Pregnancy Unit 2002).
There are ongoing debates about changing the age of consent to adapt to changing sexual health needs (BBC 2001, Sawyer 2003), however critics believe that rebellious teenagers are always going to do whatever they have been told not to.
Access and Services
Much research is being commenced to find out what problems young people actually experience and how these can be overcome (Counterpoint 2001, Kane et al 2003, Sherman-Jones 2003).
One major area is confidentiality which is an aspect both the professionals and the teenagers pinpoint (Sherman-Jones 2003). The Royal Society of General Practitioners (RCGP) (2001) introduced the Confidentiality Toolkit to clarify some of the problems surrounding confidentiality. It seeks to invent a national minimum standard for dealing with teens and those under the age of consent. Young people need confirmation of what is actually confidential. They want to see it in black and white and have it reinforced by the professional to put them at ease. However it appears that young people are beginning to believe that confidential information stays that way and their main concern now is discretion. Being seen in a clinic is now a problem as teenagers feel their privacy could be breached if they are recognised or staff discusses their case (RCGP 2001, Sherman-Jones 2003). Those under the legal age of consent have an added disadvantage when seeking advice, they often feel they cannot access advice or services because its illegal or their parent will be informed. This however is not the case, in 1985 the Fraser Guidelines were introduced in England and Wales following a ruling against Victoria Gillick enabling young people to receive medical treatment if deemed capable of understanding what is proposed (RCGP 2001). In Scotland those under16 are able to consent to treatment under the Legal Age of Capacity (Scotland) Act 1991 if the professional treating them feels they understand the implications (RCGP 2001).
According to Sherman Jones (2003) adolescents felt that issues with discretion could be overcome through siting clinics within health centres or better still having facilities purely for young people in a discreet easily accessible place. There is little point having a teen clinic available weekday mornings when they will be at school. The preference is for early evenings and Saturday mornings. Flexibility is what is required not only in opening times but also by making it a drop-in service. It is the teenagers' experience that making appointments can be time wasting, difficult to arrange and embarrassing to make. However any service that is provided should be advertised adequately. This could be done with the co-operation of schools by incorporating talks from local teen sexual health advisors or from school nurses. Also advertising of services perhaps inside toilet doors at school like they do in some universities or an online service that can help them to realise they need advice and where to get it.
Kane et al (2003) found that young people attending sexual health services needed verbal information backed up by written information. Information in the form of leaflets was found to be most beneficial when it is specifically designed for the target audience using language they can understand and advice on where to obtain further assistance. It was felt that professionals assumed the teenagers had a more in depth understanding of sexual health issues than was actually the case.
For a practitioner to be able to address the issues above she needs to be aware of the young peoples' perceptions in the first place. In order to work out an approach the practitioner should review all available literature to see where weaknesses lie in her area. She must be a knowledgeable practitioner not only of fertility, contraception, termination and sexual health issues but also what young people need from their service.
Communication and the Role of the Family Planning Nurse
Staff dealing with teens should have a young outlook to better relate to the teenagers as older staff it was felt disapproved of them having sex. It has been noted from studies (Counterpoint 2001, Sherman-Jones 2003) that they feel more at ease with a young practitioner who does not judge them, in an environment where they are free to talk in their own language. The professional must be able to discuss issues in a way they understand.
To be able to communicate effectively practitioners must be able to use language the young person understands and refrain from using jargon or going to the other extreme of using street language she is uncomfortable with. Communication is probably the one main skill the family planning practitioner should have. The nurse needs to be able to assess and collect information. To do this she needs to promote am atmosphere of trust enabling the young person to discuss her worries. Closed questions are useful for gaining specific information. Many young people who do seek help are very embarrassed and often not forthcoming with information, but by asking yes/ no questions the nurse is able to learn more facts. However the nurse should not probe if it's felt that the teenager does not want to divulge information (Jolley 2002).
Using an open posture, leaning towards the client and not sitting behind a desk helps the teenager to relax, but don't invade her personal space. She has to be aware of the tone of voice she uses. Most young people expect to get a row when they seek advice, so it is therefore important to be reassuring that they are doing the right thing. Try to maintain eye contact without entering a staring competition. The non-verbal communication skills the nurse possesses can be more important than the verbal skills.
It is important to take a thorough sexual history to ensure that any advice given will be appropriate. Inappropriate advice could result in a loss of trust between the nurse and the young person or a loss of autonomy and choice (Betts 2002).
Sherman-Jones (2003) debates that although most young people relate better with a younger nurse, a young practitioner is not always available so somebody with a young outlook would be just as good. But it's not only the nurses that the teenagers would like to see a young outlook in. They say that the environment of the facility would benefit from being modernised to cater for their taste. Young peoples' magazine in the waiting room, bright colours and pop music make them feel like its somewhere that they are welcome.
Training staff from nurses to receptionists on how to promote confidentiality should be an ongoing process and a priority with new staff. To ensure that all members of staff are up to date with current policy and have refreshers to keep the importance of this issue at the forefront of their mind.
Unplanned pregnancy does not only affect teens, even the Prime Minister and his wife had an unplanned pregnancy. It is also not just an issue that concerns females, the Government addresses this through its sexual health policies and guidelines (Department of Health 2003, Social Exclusion Unit 1999). Mayer (2001) proposes that the government is promoting sex education for boys as they now realise males could assist in the solution to the teen pregnancy problem rather than be viewed as the cause.
Recent research has shown that although peer pressure, media, social and family expectations can contribute to teenage pregnancy what the young people really want is support and advice to help them make informed choices (Reeve 2002).
Finding out she has conceived, having to take on board advice and make decisions that go with an unplanned pregnancy is not easy for a woman of any age. The added emotional and physical burden of puberty demands that teenagers are given a high level of support tailored to meet their precise needs.
Even if the individual has had the courage to seek help they are often not very willing to give up information easily. It is therefore important to remember that all women have the right to facts, choice and advice in a confidential environment from non-judgemental professionals (Sutherland 2001).
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