Teenage pregnancy and reproductive health: summary review

Teenage pregnancy, by and large unplanned, has become one of the major public health issues of our time. Despite the widespread and improved availability of contraception, the problem is unresolved and in some areas is increasing. Both live births and abortions in teenagers in England are among the highest in Europe. The circumstances of teenage pregnancy in the UK, including medical, social and public health implications have been examined by the RCOG Study Group and their findings are given in a comprehensive volume of proceedings, of which this is a summary. Recent headlines point to a teenage sex health crisis fuelled by drink and drugs, as well as confused messages from role models, and the lack of a coordinated national approach. Yet there is some hope of a way forward. The Study Group reveals the factors associated with success, including locally coordinated strategies, comprehensive education programmes, accessible contraceptive services, as well as wider social issues such as workforce training and recognition of vulnerable groups. I recommend this Summary Review to all concerned about this issue, and this must surely include all of us. I want to thank and congratulate the organisers and contributors to the Study Group for a fine piece of work and for sound advice. Allan Templeton President, Royal College of Obstetricians and Gynaecologist

Forming new sex partnerships while overseas: findings from the third British national survey of sexual attitudes & lifestyles (Natsal-3)

Objectives: Travelling away from home presents opportunities for new sexual partnerships, which may be associated with sexually transmitted infection (STI) risk. We examined the prevalence of, and factors associated with, reporting new sexual partner(s) while overseas, and whether this differed by partners’ region of residence. Methods: We analysed data from 12 530 men and women aged 16–74 years reporting ≥1 sexual partner(s) in the past 5 years in Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a probability survey undertaken 2010–2012. Results: 9.2% (95% CI 8.3% to 10.1%) of men and 5.3% (4.8% to 5.8%) of women reported new sexual partner(s) while overseas in the past 5 years. This was strongly associated with higher partner numbers and other sexual and health risk behaviours. Among those with new partners while overseas, 72% of men and 58% of women reported partner(s) who were not UK residents. Compared with those having only UK partners while abroad, these people were more likely to identify as ‘White Other’ or ‘Non-White’ (vs White British ethnicity), report higher partner numbers, new partners from outside the UK while in the UK and paying for sex (men only) all in the past 5 years. There was no difference in reporting STI diagnosis/es during this time period. Conclusions: Reporting new partners while overseas was associated with a range of sexual risk behaviours. Advice on sexual health should be included as part of holistic health advice for all travellers, regardless of age, destination or reason for travel

Epidemiology of Mycoplasma genitalium in British men and women aged 16–44 years: evidence from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: There are currently no large general population epidemiological studies of Mycoplasma genitalium (MG), which include prevalence, risk factors, symptoms and co-infection in men and women across a broad age range. METHODS: In 2010-–12, we conducted the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a probability sample survey in Britain. Urine from 4507 sexually-experienced participants, aged 16–44 years, was tested for MG. RESULTS: MG prevalence was 1.2% [95% confidence interval (CI): 0.7–1.8%] in men and 1.3% (0.9–1.9%) in women. There were no positive MG tests in men aged 16–19, and prevalence peaked at 2.1% (1.2–3.7%) in men aged 25–34 years. In women, prevalence was highest in 16–19 year olds, at 2.4% (1.2–4.8%), and decreased with age. Men of Black ethnicity were more likely to test positive for MG [adjusted odds ratio (AOR) 12.1; 95% CI: 3.7–39.4). For both men and women, MG was strongly associated with reporting sexual risk behaviours (increasing number of total and new partners, and unsafe sex, in the past year). Women with MG were more likely to report post-coital bleeding (AOR 5.8; 95%CI 1.4–23.3). However, the majority of men (94.4%), and over half of women (56.2%) with MG did not report any sexually transmitted infection (STI) symptoms. Men with MG were more likely to report previously diagnosed gonorrhoea, syphilis or non-specific urethritis, and women previous trichomoniasis. CONCLUSIONS: This study strengthens evidence that MG is an STI. MG was identified in over 1% of the population, including in men with high-risk behaviours in older age groups that are often not included in STI prevention measures

Is chlamydia screening and testing in Britain reaching young adults at risk of infection? Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: In the context of widespread opportunistic chlamydia screening among young adults, we aimed to quantify chlamydia testing and diagnosis among 16-24 year olds in Britain in relation to risk factors for prevalent chlamydia infection. METHODS: Using data from sexually experienced (≥1 lifetime sexual partner) 16-year-old to 24-year-old participants in Britain's third National Survey of Sexual Attitudes and Lifestyles (conducted 2010-2012), we explored socio-demographic and behavioural factors associated with prevalent chlamydia infection (detected in urine; n=1832), self-reported testing and self-reported diagnosis in the last year (both n=3115). RESULTS: Chlamydia prevalence was 3.1% (95% CI 2.2% to 4.3%) in women and 2.3% (1.5% to 3.4%) in men. A total of 12.3% of women and 5.3% men had a previous chlamydia diagnosis. Factors associated with prevalent infection were also associated with testing and diagnosis (eg, increasing numbers of sexual partners), with some exceptions. For example, chlamydia prevalence was higher in women living in more deprived areas, whereas testing was not. In men, prevalence was higher in 20-24 than 16-19 year olds but testing was lower. Thirty per cent of women and 53.7% of men with ≥2 new sexual partners in the last year had not recently tested. CONCLUSIONS: In 2010-2012 in Britain, the proportion of young adults reporting chlamydia testing was generally higher in those reporting factors associated with chlamydia. However, many of those with risk factors had not been recently tested, leaving potential for undiagnosed infections. Greater screening and prevention efforts among individuals in deprived areas and those reporting risk factors for chlamydia may reduce undiagnosed prevalence and transmission

Abstracts from the NIHR INVOLVE Conference 2017

n/

Genomic investigations of unexplained acute hepatitis in children

Since its first identification in Scotland, over 1,000 cases of unexplained paediatric hepatitis in children have been reported worldwide, including 278 cases in the UK1. Here we report an investigation of 38 cases, 66 age-matched immunocompetent controls and 21 immunocompromised comparator participants, using a combination of genomic, transcriptomic, proteomic and immunohistochemical methods. We detected high levels of adeno-associated virus 2 (AAV2) DNA in the liver, blood, plasma or stool from 27 of 28 cases. We found low levels of adenovirus (HAdV) and human herpesvirus 6B (HHV-6B) in 23 of 31 and 16 of 23, respectively, of the cases tested. By contrast, AAV2 was infrequently detected and at low titre in the blood or the liver from control children with HAdV, even when profoundly immunosuppressed. AAV2, HAdV and HHV-6 phylogeny excluded the emergence of novel strains in cases. Histological analyses of explanted livers showed enrichment for T cells and B lineage cells. Proteomic comparison of liver tissue from cases and healthy controls identified increased expression of HLA class 2, immunoglobulin variable regions and complement proteins. HAdV and AAV2 proteins were not detected in the livers. Instead, we identified AAV2 DNA complexes reflecting both HAdV-mediated and HHV-6B-mediated replication. We hypothesize that high levels of abnormal AAV2 replication products aided by HAdV and, in severe cases, HHV-6B may have triggered immune-mediated hepatic disease in genetically and immunologically predisposed children

Teenage pregnancy and reproductive health: consensus views

Descriptive research 1.There is an urgent need for comparative, up-to-date, age-specific data on conceptions, births and abortions from European and other developed countries, disaggregated by ethnicity, socio-economic status and marital/cohabitation status. Research aimed at improving young women and men's sexual health 1.Insights into young people's attitudes to contraceptive and sexual health services - including barriers to use and how they might be removed – should be obtained to inform public education campaigns and commissioning of services. 2. Greater understanding is needed of the perceived risks associated with various contraceptive methods, and their influence on decision making. Interventions to improve effective contraceptive decisions need to be developed. 3.The impact on practitioners and young people of public health strategies seeking to encourage delay in onset of sexual activity needs to be assessed. Rigorous evaluation is needed of the impact on teenage pregnancy of school- based programmes aimed at raising career and life aspirations. 4.Research is needed into the norms and aspirations of young men and the social influences on these, with a view to guiding interventions aimed at helping them develop the competence and confidence to form mutually respectful relationships. 5. Local needs assessments should be carried out to develop culture- and faith-sensitive sexual health services and programmes, and their feasibility, transferability and effectiveness should be evaluated. Research aimed at supporting teenage parents 1.The government should identify and resolve any contradictory policies that obstruct young parents being able to engage in learning. 2.Research is required to identify and evaluate the best methods for supporting young parents to maximise their social wellbeing and health and that of their children. Research aimed at determining the specific effects of maternal age on health outcomes for mother and child 1.Research is needed to explore the independent impact of young maternal age on adverse health outcomes (e.g. low birthweight, prematurity, infant mortality and maternal health), using designs capable of dealing with confounding factors. 2.The effects of becoming pregnant at a very young age (e.g. before 16 years) for both mother and baby need to be explored using large multicentre studies. Policy Policies aimed at preventing unplanned teenage pregnancy 1.The government should continue to prioritise teenage pregnancy to ensure that the progress of the Teenage Pregnancy Strategy is accelerated to 2010. The public service agreement (PSA) should remain jointly held by the Department for Education and Skills (DfES) and the Department of Health (DH) and be retained in the next comprehensive spending review. 2.Research findings should inform forthcoming revisions of the strategy to support teenage parents, referenced in Teenage Pregnancy: Accelerating the Strategy to 2010 . 3.Factors contributing to the success of some areas in reducing teenage pregnancy rates should be incorporated, where feasible, in others areas. Further evaluation, and monitoring of these areas should be undertaken through performance management arrangements of the DfES and the DH, _ with a close focus on areas at risk of failing to meet their 2010 target. 4.Local data on teenage conceptions should be used in commissioning by Children's Trusts to ensure effective and targeted delivery of teenage pregnancy strategies. Primary care trusts should be actively involved. 5.National and local implementation of the Teenage Pregnancy Strategy must link to policies and programmes addressing the underlying causes of early pregnancy: socio-economic inequalities, poor educational attainment, and low self-esteem and aspirations. 6.Policies and interventions, including Sex and Relationship Education (SRE), aimed at reducing teenage pregnancy and supporting teenage parents should be developed and implemented in a context of respect for young people, an acceptance of teenage sexuality, and the promotion of responsible and mutually consensual relationships. 7.Strategies to reduce teenage pregnancy must continue to be universally targeted, but efforts should be strengthened among groups and in areas in which risk is higher. The focus should be on risky situations, rather than risky individuals. 8.All individuals working with children and young people should be trained and equipped with the knowledge and skills to address issues of health and emotional wellbeing. 9.The health of children and young people should be prioritised in the NHS and the revised Quality and Outcomes Framework to ensure the provision of accessible young-people-centred services that include contraception and sexual health. 10. Health promotion and ill-health prevention should be incentivised to ensure delivery in a healthcare system driven by payment by results (PbR). 11.Personal, Social and Health Education (PSHE), which includes SRE, should be made a statutory foundation subject in schools at all stages of education, starting at 4 years until 18 years, and based on the features of good SRE identified by pupils and research. 12.Ofsted inspections should include provision of PSHE as part of a school's requirement to meet the Every Child Matters five outcomes, and should ensure that PSHE provision meets the Qualification and Curriculum Authority (QCA) end of Key Stage assessments and the needs of pupils. Policies aimed at supporting teenage parents 1.Revisions of the Teenage Pregnancy Strategy to support teenage parents should focus on improving outcomes for teenage parents and their children, and the most crucial of these should be measured in order to assess improvement. The current target of 60 % of 16- to 19-year-old mothers in education, training or employment should be modified such that reference is to those mothers with a child over the age of 1 year. Practice Prevention of teenage pregnancy 1.Both single and mixed gender SRE work should be offered in both schools and community settings. 2. Following evaluation of the Young People Development Pilots (March 2007), areas should commission personal development programmes for young people most at risk of teenage pregnancy. 3.The tension between the principle of confidentiality vital to delivery of effective services to young people and the duty of professionals to safeguard their physical and emotional wellbeing needs to be carefully managed. Information sharing between key agencies such as social services and the police is unavoidable. Multi-agency training is needed to increase the confidence of professionals to work across agencies. 4. Youth-friendly contraceptive services which meet the DH ‘You're Welcome' quality criteria should be universally available to all young people, with targeted work to ensure teenagers at greatest risk have services they trust and can access easily. 5.•Local areas should explore, with young people, innovative ways of providing services that are less medicalised and more in keeping with their lifestyles, for example, condom schemes in leisure settings and drop-in services in high street stores. 6. Healthy Schools, Extended Schools and colleges of further education (FE) should include on-site access to contraceptive and sexual health advice, as part of generic health advice services. Support of young parents and their children 1.Early access to a ‘teen-focused’ maternity healthcare package should be provided to ensure earlier access to medical and midwifery care. 2. Maternity services aimed at the young should be staffed by midwives and healthcare professionals specially trained to avoid judgemental and stigmatising attitudes. 3.To prevent unplanned repeat pregnancies, help should be given to all teenagers who have been pregnant to choose and use an effective method of contraception. 4.Every pregnant teenager, teenage mother and teenage father should have access to a dedicated personal adviser provided through Children’s Trusts. Individual needs should be assessed and a package of support coordinated, linked to specialist education, health and housing services, and continued until the young person is able to conduct his or her affairs independently. To ensure continuity of care, maternity services should provide advisers with details of teenage parents (with their consent). 5.Increased attention should be given to the development and evaluation of programmes that enable young parents to continue education and career development. The Care to Learn childcare programme should continue to be evaluated to ensure it addresses any barriers to learning. 6.Agencies working with teenage parents and their babies should identify housing difficulties and ensure contact with appropriate local social, housing or teenage parent support services that may offer assistance. 7.Flexible childcare provision should be available for school-age parents and those in their late teens and early 20s to ensure full participation in education and to mitigate social isolation and depression

Teenage pregnancy and reproductive health

Teenage pregnancy, by and large unplanned, has become one of the major public health issues of our time. Despite the widespread and improved availability of contraception, the problem is unresolved and in some areas is increasing. Both live births and abortions in teenagers in England are among the highest in Europe. The circumstances of teenage pregnancy in the UK, including medical, social and public health implications have been examined by the RCOG Study Group and their findings are given in a comprehensive volume of proceedings, of which this is a summary. Recent headlines point to a teenage sex health crisis fuelled by drink and drugs, as well as confused messages from role models, and the lack of a coordinated national approach. Yet there is some hope of a way forward. The Study Group reveals the factors associated with success, including locally coordinated strategies, comprehensive education programmes, accessible contraceptive services, as well as wider social issues such as workforce training and recognition of vulnerable groups. I recommend this Summary Review to all concerned about this issue, and this must surely include all of us. I want to thank and congratulate the organisers and contributors to the Study Group for a fine piece of work and for sound advice