Originally written for The Guardian, condensed version can be seen there.
In 2008, over 5,000 UK women under the age of 20 had an abortion that was not their first. As was made clear by the alarmist headlines following the publication of those numbers, this is a big concern for the public.
A woman’s reproductive life often spans 30+ years. Around 1/2 of all pregnancies in the US and UK are unplanned. Contraception isn’t used or used properly. It fails sometimes even in perfect use. Female fertility peaks between the ages of 19 and 24: the reason we tend to see the most abortions (and pregnancies) in that group is because it is the most fertile group having the most sex. (Piccinino, LJ, Mosher, WD. Trends in contraceptive method use in the United States: 1982-1994. 1998. Family Planning Perspectives. Vol. 30(1): 4-10 & 6, Table 1) The UK teen pregnancy rate is the highest in Western Europe: six times higher than the Netherlands, nearly three times higher than France and more than twice the rate in Germany.
In 2008, nearly 33% of all UK terminations were not first-time procedures. Under 18’s had 1,452 “repeat” terminations. Women 18-24 had 21,443 terminations that were a second or third; those 20-29, 16,734 repeats, and for women over 30, 23,804. As it is in the US, the group with the highest rate of repeats is women over 30. As it is in the states, half those women are likely already mothers.
I don’t get the concern about abortions, specifically. No matter what choices we make with it, pregnancy has the capacity to radically change our health and life. Pregnancy itself is a potentially dangerous health event: 40% of all pregnant women have some sort of health risk. 15% of those risks are potentially life-threatening. The rate of risk and complication with delivery is 8-10 times higher (and higher still for the youngest women) than for legal, first-trimester abortion. The maternal mortality rate in New York state dropped 45% after abortion was legalized in the U.S. Safe, legal abortion isn’t the health issue: unintended pregnancy is.
We should all have women becoming unwantedly pregnant as our deepest concern, no matter how a pregnancy ends.
What most influences unplanned pregnancy? People shagging in ways that matchmake sperm and egg, which most do and historically will have done by the age of 19 or 20. Whether reliable contraception is used correctly and consistently. Poverty is a huge factor, as is the sense of reduced self that often results from poverty, like the sense or reality that motherhood is an attainable goal while other goals are not within reach. Rape and other sexual abuses and unhealthy relationships, also whoppers.
What can be done? The UK plans to respond to this in exactly some of the ways I'd suggest. Lucky Brits! When I think the U.S. government should respond a certain way, they have an uncanny habit of doing the opposite.
Provide better sex education, information about and access to contraception: The 2008/2009 Opinions Survey Report shows only 57% of UK women 16–19 using contraception, a lower rate than all other ages. Only 11% of young people in the Netherlands don’t use contraception: their rate of STIs and unwanted pregnancies is impressively low. 11% vs. 43%: that’s major.
Women need access to comprehensive, unbiased information about all contraceptive methods, addressing all as viable while making clear the differences in effectiveness and proper use. Women need that information at school, at home, in the media and from healthcare providers, including those providing care with pregnancy, whether it ends in abortion, miscarriage or birth. The youngest women use family planning services less than older women, and are often scared to ask for them. It’s vital they’re offered these services without finger-wagging. Women need information about and access to contraception before they need to use it, not after.
Many women won’t know about all options, how to use them properly, or which methods will suit them best without thorough information that puts an emphasis on them as individuals. For instance, young women nearly always ask for (or are rotely given by healthcare providers) the pill, but oral contraceptives are less effective for teen women than for older women: some data shows a failure rate as high as 20% for young women, with a risk of failure as much as 55% higher for those under 20 as those older. (LM Dinerman et al, Archives of Pediatrics and Adolescent Med, 149(9):967-72, Sept 1995. MD Hayward and J Yogi, "Contraceptive Failure Rate in the US: Estimates from the 1982 National Survey of Family Growth," Family Perspectives, Vol 18, No. 5, Sept/Oct 1986, p. 204; J Trussell, B Vaughan, Contraceptive Failure, Method-Related Discontinuation And Resumption of Use: Results from the 1995 National Survey of Family Growth, Family Planning Perspectives, 1999, 31)
We must work hard to provide marginalized women contraceptive information and overall support services: the poorest women, the youngest women, women of color, refugee women, homeless women, abused women. These women have a higher risk of unplanned pregnancy because they are the least well-served and the least visible.
Assure thorough information is provided during an abortion visit: Women who don’t want to become pregnant again should be offered an in-depth contraception consult during their abortion visit. Women can often start reversible long-acting methods – an injection, implant or IUD – before they leave the clinic. Providers should make clear women can easily become pregnant post-abortion and ask about the dynamics of their sexual relationships. IPV rates in the UK are high: women in abusive, controlling relationships, particularly the youngest women, have higher rates of repeat unwanted pregnancies.
Talk about combining methods: Combining two forms of contraception provides no less than 92% protection from pregnancy in typical use and no less than 98% in perfect use. If we want to cut the rate of sexually transmitted infections and unplanned pregnancy, we must make clear that consistently backing up any method with condoms radically reduces both STI and pregnancy risks.
Increase awareness about emergency contraception: Only 14% of UK women 16-19 reported using emergency contraception in 2008. Less than 1% of women knew it could be used up to 5 days after a risk; only 49% knew it could be used up to 72 hours. 6% of UK women thought one dose of EC could prevent pregnancy until the next menstrual period (it can’t). Many young women do not know they can get emergency contraception through the NHS, not just family planning clinics.
Men need accurate information on contraception, too. Partner contraceptive non-cooperation is a problem, particularly for the youngest women who are still working on their dump-that-chump-skills. Beyond the impact abusive or careless partners have, even caring men can inadvertently sabotage contraceptive efficacy or use. That Opinions Survey Report included a study on male knowledge that makes clear men need more contraceptive education. Only around 30% knew long-acting contraceptives were more effective than other methods.
UK men reported they always used a condom only 3% of the time. To be an effective sole or backup method, condoms must be used correctly and consistently. Make sure men know that they also are entitled to prevent pregnancies they do not want, and have methods they can use themselves to exercise their reproductive rights. We need to do a better job making sure boys and men understand they are as responsible for their sexual choices, including prevention of unwanted pregnancy, as women are. We don’t do women or men any favors by accepting or enabling double-standards to the contrary.
Think (and talk) differently about teen sexuality: Most young people will -- as they always have -- be sexual with partners. The approaches to teen sexuality with the best outcomes accept this rather than trying to deny or eradicate it.
When we give young people a message their sexuality is something shameful they need to fear or hide, they hear it. They become afraid and less inclined to ask questions or for help, to be honest about what they need and what’s really going on with them. In the Netherlands (last time, I promise): they don’t treat teen sexuality as we do in the UK and the US. They don’t present young people’s sexual partnerships as a terrifying if but as an acceptable when. When reared with a clear cultural expectation they will seek out sexual partnership and an equally clear expectation they will handle sexual partnership ably, young people often will, in fact, do just that.
Just like anything else, all of sexuality has a learning curve. As with, say, cooking, driving a car or writing pieces on huge topics in less than 1,000 words, few begin their sex lives savants. We can’t expect young people to magically be better at this than the rest of us, especially without our help and support. Should we want them to be better at it all than we were or are, we can’t keep doing the same things we know full well have always failed them.