Termination of pregnancy in under-16s: a review of the service provided by the Sandyford Initiative during the financial year 2012-2013
Sophie Whiteway
4th Year Medical Student
University of Glasgow
24th November 2013
Introduction
The Sandyford Initiative provides a termination of pregnancy assessment and referral (TOPAR) service to the Greater Glasgow and Clyde area. In the financial year 2012-2013, a total of 52 patients under the age of 16 attended a consultation at the TOPAR service. During my five week attachment I studied the cases of these patients to identify any patterns in those seeking this service, and whether this reflects the trends in teenage pregnancy and abortion seen across Scotland. I also aimed to identify any possible flaws in the service being provided to these young people.
Teenage pregnancy in Scotland
Although the teenage pregnancy rate has been in decline over recent years, Scotland still has one of the highest rates across Western Europe. In 2011, the teenage pregnancy rate was 5.7 per 1000 in under-16s, 30.6 per 1000 in under-18s and 45.2 per 1000 in under-20s. Figure 1 shows the decreasing trend over recent years, particularly in the under-18 and under-20 age groups. The teenage pregnancy rate is based upon both live and still birth registrations and induced abortions1.
Termination of pregnancy in Scotland
Termination of pregnancy has been legal in the UK (except Northern Ireland) for over 40 years, following implementation of the 1967 Abortion Act. The grounds for which an abortion may be legally carried out in accordance with the Abortion Act are split into seven categories (A-G); the majority of terminations carried out in Scotland fall under category C (>90% in 2012). Category C states that “the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman”2.
From implementation of the Act in 1967 to 1971 the number of terminations carried out in Scotland rose dramatically from 1500 to over 7500, and continued to rise at a steadier rate thereafter. A peak of 13,904 was reached in 2008 with a decline over the last four years (Figure 2)2.
In 1991, medical methods of termination became licensed in the UK and an upper limit of 24 weeks (for most reasons) was placed; these changes were represented in the Abortion (Scotland) Regulations 1991. Since the introduction of medical termination, its use has risen compared to surgical methods (Figure 3)2.
Termination of pregnancy in Scottish teenagers
The rate of termination in under-16s has remained fairly steady over the last 10 years, ranging from a peak of 3.9 per 1000 in 2009 to a low of 2.9 per 1000 in 2012 (Figure 4)2.
It is well understood that socioeconomic factors have a significant influence on both pregnancy rates and the number of terminations in the teenage age group. The conception rate amongst teenagers from deprived areas has been found to be up to six times more frequent compared to their more affluent counterparts. Young women from socially disadvantaged areas are less likely to opt for termination than those from more affluent areas3,4.
Motherhood may seem more desirable for those whose life lacks stability and who feel being a mother could change their life in a positive way. However, those who have plans for further education or employment are less likely to continue their pregnancy4.
The above graph shows a change in the delivery: termination ratio of under-16 pregnancies; before 2001 a greater proportion of pregnancies were continued, but since 2001 a greater proportion of teenagers have opted for termination. There’s no solid evidence to determine exactly why this is, but it could be speculated than there have been changes to young peoples’ aspirations over more recent years. Perhaps fewer teenagers are seeing motherhood as an “escape route” from their current lives, or perhaps it’s a logistics reason, with termination services being made more accessible.
Under-16s attending a consultation at the termination of pregnancy assessment and referral (TOPAR) service provided by the Sandyford Initiative
As stated earlier, 52 patients under the age of 16 attended a TOPAR consultation during the financial year 2012-2013. These included one 13 year old, ten 14 year olds and forty one 15 year olds. A further three patients DNA’d their TOPAR appointment, and there was email correspondence with a teenager living in the Outer Hebrides, though as none of these attended a TOPAR consultation they weren’t included in my analysis.
For those attending TOPAR, all had a positive pregnancy test at the time of their consultation and none had undergone a previous termination of pregnancy. 23 had previously attended for a different service at the Sandyford (44%). This is of interest as research has found that most teenagers becoming pregnant had attended some form of contraceptive service during the previous year5.
When patients attend for TOPAR they’re routinely screened for Chlamydia Trachomatis infection by taking a self-taken vaginal swab. 2 of the 52 under-16s were positive for this sexually transmitted infection (3.8%) at the time of their TOPAR consultation; however they may have tested positive at other Sandyford consultations previously.
The use of interpreters is becoming more frequent in many areas of healthcare, and their service is available if required for TOPAR consultation. 2 of the 52 patients had an interpreter during their consultation; reflecting the diverse population that accesses the service.
Young Person’s Risk Assessment Forms
As patients under 16 may be more vulnerable than their older counterparts and there may be legality/abuse concerns, a “Young Person’s Risk Assessment” (YPRA) form should be filled in for each under-16 using the Sandyford services (including TOPAR) and updated with any changes in circumstances at further consultations. This form, as well as other clinical details, may be shared with other parties such as social work or the Archway counselling service if deemed necessary. Every under-16 who attended TOPAR had a YPRA form filled in or updated.
Although 8 patients were recorded as receiving some form of social work involvement in their lives, it was only noted that 1 had her YPRA form and other details shared with her social worker. Another patient (without previous social work involvement) had her YPRA and other details shared with both the Archway counselling service and the police as her pregnancy was the result of an alleged sexual assault. This patient also attended a special needs school and may have had other input not recorded in the notes.
Deprivation amongst patients attending the TOPAR service
As mentioned previously, deprivation plays a significant factor in both teenage conceptions and terminations of pregnancy; there is a higher rate of both in deprived areas.
The teenagers accessing the TOPAR service were significantly more likely (p<0.001) to be from a deprived area (Scottish Multiple Index of Deprivation quintile 1 or 2). This reflects the trend of higher rates of abortion in these quintiles across Scotland (see Figures 6 and 7). We can also see from Figure 6 that although termination rates are higher in more deprived areas, a greater proportion of teenage pregnancies in these areas continue to delivery than in the more affluent areas.
At what gestation do patients present?
Ultrasound is used at the TOPAR service to determine gestation and viability for induced abortion, and to confirm the pregnancy is intrauterine. At this stage in the consultation, it was revealed that 3 patients had suffered an early pregnancy failure. Knowing the gestation of the pregnancy is vital in determining the viable methods of termination; only those with a gestation of 7-15 weeks have the option of surgical termination. Although surgical dilatation and evacuation can be carried out after 15 weeks, this method is no longer regularly used. Early medical termination can be carried out up to 9 weeks, after which it becomes a late medical termination.
Half of the patients (24) had presented before their 7th week of pregnancy. The earliest presentation was 4+2 weeks and the latest presentation 17+6 weeks (Figure 8). After 18 weeks, patients are referred via BPAS to England as Scotland doesn’t provide a termination service for gestations over 18 weeks. The patient presenting at 17+6 weeks actually chose to continue her pregnancy, and no other patients were at a gestation that required a BPAS referral.
Outcome after TOPAR consultation
Although 52 patients attended the TOPAR service, only 44 proceeded to termination. Of the remaining 8, 5 patients decided to continue their pregnancy and 3 had an early pregnancy failure (miscarriage).
32 patients underwent a medical termination and 12 chose a surgical termination. Of those opting for medical methods, there were 20 early medical terminations performed (up to 9 weeks) and 12 late medical terminations performed (over 9 weeks). Figure 9 demonstrates the outcome of patients undergoing a termination and also those who didn’t proceed to termination.
Who knows about these pregnancies, and who is attending with them to appointments?
Teenagers are often very secretive about their pregnancy and usually reluctant to tell their parents for many reasons. Those who presented to the TOPAR service were more likely to tell their partner than their parents; as shown by Figure 10. However, it must be noted that this graph only represents what is recorded in the clinical notes. Also, although they may not have informed their GP, currently discharge letters may be emailed to them due to a flaw in the introduction of a new IT tracking system.
Although these patients were more likely to inform their partner about the pregnancy (Figure 10), they were more likely to attend TOPAR with a parent or another family member (Figure 11). Three patients attended TOPAR alone, though no patients attended their termination without an escort.
They were also more likely to have their parent present (50% vs 21%) during the termination as well (Figure 12). All patients are required to have an escort home from the hospital after the procedure, and patients attending for surgical termination are required to have someone over 18. Of those attending for surgical termination, 75% had a parent present and 25% had another family member present. All patients had somebody to escort them home.
Contraception
Before their TOPAR consultation, the majority of patients were either using male condoms (24) or no contraception (17). 9 were using the combined oral contraceptive pill and 1 used the progestogen only pill; although these methods have a greater reliability, this is reliant upon them being taken properly. 1 patient had a contraceptive implant in place at her TOPAR consultation, however there was a pregnancy prior to the implant fitting (Figure 13).
Of the 22 who had previously attended the Sandyford service: 9 were using condoms, 7 were using the COC, 1 was using the POP, 1 had an implant and 4 were using no contraception at all.
Of the 44 patients who proceeded with termination, the two main methods of contraception chosen after the procedure were the contraceptive implant (48%) and the combined oral contraceptive pill (39%). However, it is interesting that 7% still opted not to use contraception after their termination (Figure 14).
Conclusions
After reviewing the TOPAR service provided to under-16s, I feel that the Sandyford is providing an excellent service to these young people. However, this review has highlighted a few possible areas for improvement and for future review.
Areas for improvement:
1. Aim to decrease the number of sexually active under-16s leaving the Sandyford without a reliable form of contraception
2. Ensure that all under-16s have contraception given at the hospital after their termination; with greater encouragement for the use of LARC
3. Further promotion of the contraceptive services available to under-16s, particularly to more deprived areas
Future review:
1. Comparison of service given to under-16s to that given to older patients: are they receiving the same standard of care? Are they treated differently?
2. Review of the hospital notes for under-16s presenting during previous years, to establish the local risk of complications in under-16s and enable more accurate information-giving to this age group at TOPAR consultations.
3. Review of the patients’ perspectives on the care they’re given, both at TOPAR and at the hospital. Are they happy with the service? Are medical staff judgemental in their care-giving?
Word Count: 1998 (minus textboxes and references)
References:
1. ISD Scotland, Teenage pregnancy [Internet] [cited 24th October 2013, published 25th June 2013] Available from: http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/2013-06-25/2013-06-25-TeenPreg-Report.pdf?54717653990
2. ISD Scotland, Abortion Statistics [Internet] [cited 24th October 2013, published 28th May 2013] Available from: http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/2013-05-28/2013-05-28-Abortions-Report.pdf?31579226256
3. Smith T “Influence of socioeconomic factors on attaining targets for reducing teenage pregnancies” British Medical Journal. Vol. 306, pp1232-1235
4. McLeod A “Changing patterns of teenage pregnancy: population based study of small areas” British Medical Journal, Vol.323, pp199-203 28th July 2001
5. Lee E, Clements S, Ingham R, Stone N. A matter of choice? Explaining national variation in teenage abortion and motherhood. York, Joseph Rowntree Foundation. 2004. ISBN: 1859351824. Available from www.jrf.org.uk
6. Churchill D, Allen J, Pringle M, HippisleyCox J, Ebdon D, Macpherson M, et al. Consultation patterns and provision of contraception in general practice before teenage pregnancy: casecontrol study. BMJ 2000;321:4869.
Diagrams
(1, 5)ISD Scotland, Teenage pregnancy [Internet] [cited 24th October 2013, published 25th June 2013] Available from: http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/2013-06-25/2013-06-25-TeenPreg-Report.pdf?54717653990
(2,3, 4 & 7) ISD Scotland, Abortion Statistics [Internet] [cited 24th October 2013, published 28th May 2013] Available from: http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/2013-05-28/2013-05-28-Abortions-Report.pdf?31579226256
(6, 8, 9, 10, 11, 12, 13, 14) Diagrams produced on Microsoft Excel myself.
Sophie Whiteway Page 1