Being poor affects health. This concept has been explored in Chapters 1 and 2 and runs through many of the chapters of this book. Being poor also affects sexual health. There are proven links between social deprivation and sexually transmitted infections (STIs), abortions and teenage conceptions, with girls from the poorest backgrounds being 10 times more likely to become teenage mothers than girls from wealthier backgrounds.
One of the ultimate outcomes of poor sexual health is unplanned pregnancy, and this is particularly problematic for teenagers.
Throughout the developed world, teenage pregnancy occurs most frequently among those young people who have been disadvant- aged in childhood themselves. For example, they have grown up
Sexual Health 101 in poverty and have poor expectations of education and low aspirations in relation to employment (Botting et al.1998). Teenage parents are far less likely to continue with their education and often come from the most deprived parts of the country. If you are a socially excluded teenager you are more likely to become a teenage parent and if you become a parent while in your teens, you are more likely to become socially excluded. The issue is both a cause and a symptom of social exclusion. Children born to teenage mothers generally face greater disadvantage than those born to older parents and are more likely to become teenage parents them- selves, thus perpetuating the cycle of early parenthood and social exclusion (Department for Education and Skills 2006).
Although there is a great deal of work being undertaken around prevention and support for teenagers who become pregnant (see page 77 for national policy), the UK still has the highest rate of teenage pregnancy in Europe, with rates that are twice as high as Germany, three times as high as France and six times as high as the Netherlands (DoH 1999). Unintended pregnancies increase the risk of poor social, economic and health prospects for both mother and child. In 2003, 42 173 under 18-year-olds in the UK conceived.
This equates to a rate of 42.3 conceptions per 1000 young women aged 15–17 in 2003. Approximately two-fifths of these pregnanc- ies resulted in an abortion (Office for National Statistics 2005).
Analysis has also highlighted that the younger a woman is, the more likely she is to have a termination. In 2002, 61% of concep- tions to 14-year-olds resulted in legal abortions with 55% of 15- year-old girls opting to terminate their pregnancy (ONS 2004).
These figures would suggest that pregnancy was unplanned and therefore sexual health may have been compromised in many cases. This idea is supported by research undertaken by the Health Education Authority, which suggested that there has been an increase in risky sexual behaviour, and that there is still ignorance about the possible consequences.
There has also been a noticeable drop in the age at which young people start having sex. Forty years ago, the average age at which people started having sex was 21. Today it is 17. Worryingly, between a third and a half of teenagers do not use contraception at first intercourse. Research by Dawe and Meltzer found that over a quarter of 14–15 year olds thought that the contraceptive pill protects against infection and most people questioned did not know what chlamydia was (Dawe and Meltzer 1999).
People of all ages from more deprived backgrounds are more likely to experience poor sexual health. The highest rates of sexually transmitted infections are found in women, particularly
102 Essential Midwifery Practice: Public Health
young women, gay men, teenagers, young adults and black and minority ethnic groups (Hughes et al. 2000). A recent summary factsheet on sexual health from the Department of Health (DoH 2006a) stated that sexually transmitted infections dispropor- tionately affect young people and are more prevalent in deprived areas with poor educational attainment and low aspiration. The sheet also stated that people living in London are dispropor- tionately affected by poor sexual health. HIV disproportionately affects young gay men (under 40); those with lower educational attainment; and those from black African communities.
It is well documented that those living in deprivation are more likely to experience lower levels of education attainment. A recent study by Rutherford et al. (2006) examined whether or not there are links between low levels of literacy and sexual behaviour and knowledge. Their study concluded that there is a link and more- over that those in the lower literacy group were significantly more likely to:
•
have been under 16 years of age the first time they had sex•
be significantly less likely to know when the most fertile time is during the menstrual cycle•
be significantly less likely to be able to identify sexually trans- mitted infections•
be significantly less likely to be aware that infections can be transmitted through both oral and anal sex•
be more likely to have difficulties understanding health liter- ature distributed in clinics.Example of good practice
As part of the original Sure Start Plus project, Liverpool Women’s NHS Foundation Trust seconded a midwife to support young women who became pregnant, working closely with the Teenage Pregnancy Co- ordinator, Sure Start Plus and Connexions. When the Sure Start Plus ended this post was mainstreamed by the Trust with some financial support from the Teenage Pregnancy Co-ordinator.
This midwife provides outreach support for all young pregnant women and their partners and families and includes teenage friends.
She undertook her Family Planning Certificate and now offers the full range of contraceptive advice to extended groups. Working along- side a supportive consultant obstetrician, she administers long-acting reversible contraception (LARC), condoms and offers some screening
Sexual Health 103 options to young women. She also uses the opportunity to advise non-pregnant friends about safe sex and refers them for appropriate screening and contraception.