From MIDWIFERY MATTERS, Issue No.93, Summer 2002
Exhuming the Social Exclusion Report
Alison Perry
"So, in this case," I, the student midwife asked, "who will talk to her about contraception?"
"Oh, I don't know.." pondered the midwife from the Neonatal Unit as we drove away. "I suppose someone should, really, shouldn't they?"
Having been ready to rattle off the pros and cons of implants versus barriers, I wondered why it wouldn't be us...
Our home visit had been with an eighteen-year old teenage mum who had given birth to her second unplanned and, questionably, unwanted baby, fifty-three days before. Born prematurely, her baby had only recently learned how to regulate his own temperature and how to breathe consistently. He was now at home. However, nobody, including the midwives, nurses, doctors and social services seemed sure that this was best. Indeed, the psycho-social and socio-economic factors pertaining to teenage pregnancy are complex and emotive. In spite of this and also because of this, it seemed to me that a very obvious opportunity to dole out some contraceptive advice had been missed. Midwives, after all, have an intimate window into a woman's sexual and reproductive life. We go there armed with our education, knowledge and experience and yet we were electing not to bother. The question, 'Is contraceptive advice the role of the midwife?' has been asked increasingly over recent years and continues to be relevant. As a Canadian international student, I've considered whether, as a foreigner, I'm missing something. To me the answer is obvious. 'Of course it is,' effortlessly rolls off my tongue. More completely, however, it needs to be a team responsibility of all those involved in family and community health and education. Indeed, it is a societal responsibility. From the midwifery perspective, it seems that supplying women, such as the young mother above, with postnatal contraceptive advice is the minimum of the potential influence that midwives could have on this issue.
In the distant wake of the findings of the Social Exclusion Unit (1999), much political and media attention has been paid to the issue of teenage pregnancy. Perhaps this should have begun a timely inauguration of midwives extended involvement with young people in the community, as well as reinforcing our commitment to the pregnant women with whom we already work. However, it is important first to grasp that the extended role of the midwife in sex education is only a part of the solution to teenage pregnancy. Indeed, to equate contraceptive information giving by midwives with the eradication of teenage pregnancy is to miss the complexities of the issue, the intricacies of which far exceed the scope of this article. This article will instead touch upon the issues which characterise teenage preg-nancy in this country, while factoring in the potential role of the midwife.
Teenage pregnancy itself is perceived by our society as a deviation from normal. It has been placed alongside drug abuse and crime on Government initiative agendas (Mowlam, 2000; Gilham, 1997). This overt pathologisation reinforces a culture of disapproval of teenage pregnancy; having babies when you are young is seen as a bad thing (Baker, 1999). It is ironic that having babies during the time that doctors insist is the optimal time physiologically (aged 18-25) no longer coincides with society's more modem priorities and expectations. These include education, career life, and experience. Indeed, the time at which individual women have babies is very much influenced by complex factors involving both their particular social class and culture.
When delving into teenage pregnancy, one soon realises that no hard and fast lines can be drawn. The stereotypes are inconsistent. The public's general tendency is to paint the picture of victimised young women without agency. However, it is important to counter this impression and point out that some of these young women have actively chosen to become mothers (Mander, 1999). For the midwife becoming involved in this arena, it is important to note that despite the language used by many teenagers, such as, "I fell pregnant", which connotes a passive role in the process, there are also teenage mothers who consciously planned their pregnancies (Baker, 1999). One study has shown no increased risks of perinatal outcomes among teenagers having their first baby (Kaufman, 2001). In reality, the generic term teenage mother includes a spectrum of young women in a variety of situations. This can be seen in the differences between a vulnerable, unsupported thirteen year old and a well-supported seventeen year old highlighted in recent teen pregnancy audits (Baker, 1999). While there are unique aspects of teenage pregnancy which bind it as an issue, it is important for the midwife to extricate the individual women from the blanket term teenage mother. It is undoubtedly true that a significant number of young women make an active choice to become mothers (MacKeith and Phillipson in Kargar and Hunt, 1997). Although these women may inevitably find joy in their choice to bear children, it is not this choice that defines teenage pregnancy. It is the striking absence of choice around childbearing that relegates it to the ranks of the disadvantaged.
The most compelling characteristic of the teenage pregnancy profile is that of social exclusion. If the midwife is to play an effective part in sexual health education, she must be familiar with the larger issues. The Department of Health's report on teenage pregnancy has generalised some risk factors associated with teenage pregnancy, including poverty. The so-called risk of becoming a teenage mother is thought to be ten times higher among young women from families dependent upon unskilled labour than those from professional families. Also, children in foster care or who have left care are more likely to become teenage mothers. Teenage pregnancy is also linked with low educational achievement, non-participation in education, training or employment, sexual abuse, mental health problems and crime (Social Exclusion Unit, 1999). The predisposing causes of many of these circumstances are linked to class disparity and the division of wealth. However, there is no exclusive causal link between low education and teenage pregnancy. It is part of a broad based socio-political web of issues. At the core of this, the UK stands apart from other comparable European countries as it is characterised by high levels of income inequality (Social Exclusion Unit, 1999). Much of the reality of this profile exceeds the realm of the midwife's influence. Nevertheless, this important knowledge must be taken into the family planning arena. This knowledge should be the foundation upon which midwives are trained to become sexual health educators. The factors which influence teenage pregnancy rates far exceed the knowledge of how to use a condom correctly. However, comparative studies highlight that the UK fares poorly on this front, also. It is the details of these findings, around which the midwife is well suited to harness her practical skills. It is important to note that not all UK teenagers are experimenting with sex at comparatively younger ages. However, of those that are, between one-half and one-third use no contraception at all the first time. This rate is significantly higher than many European countries (Social Exclusion Unit, 1999). The reasons for this difference are partially woven into the cultural maxims of the UK itself. However, outwardly there is a measurable link to lack of information on contraception, and lack of access to contraception, itself.
In theory, the official role of the midwife already encompasses giving contraceptive advice. The Midwives Code of Conduct states that:
She has an important task in health counselling and education, not onlyfor the women, but also within the family and the community. The work should involve antenatal education and preparation for parenthood and extends to certain areas ofgynaecology, family planning and childcare. She may practise in hospitals, clinics, health units, domiciliary conditions or in any otherservice (UKCC, 1998).
In practice, however, this role seems rarely utilised. Comparative educational systems are testimony that the actualisation of this role is overdue. Contrary to conservative debate, research shows that sexual education does not lead to participation in sex at a younger age. The Netherlands have long had comprehensive sex education and an accessible family planning service with high priority given to confidentiality. There is a general acceptance of teenage sexuality. The accompanying low pregnancy rates attest the effectiveness of this open ideology (MacKeith and Phillipson in Kargar and Hunt, 1997). Similarly, Finland also has extremely low teenage pregnancy rates. It provides a comprehensive sexual education curriculum, which is taught to children age eight to nine and is led by a health care worker. In Finnish schools, the emergency contraception pill can be administered. Exemplary systems in western Europe should provide ideas for innovation and change within the UK (Hudson, 1997).In contrast, the UK has had sex education in all secondary schools only since the Education Act (1993) and there are still no clear guidelines on who should teach it (Dolby, 1998). The high teenage pregnancy rates are no doubt testimony of this. Indeed, the current system for sex education is inadequate in many ways. Parents are given little advice on how to talk with their children about sex and school-based sex education is patchy and often under-developed and inconsistent. As a result there is a considerable amount of misinformation and ignorance among youths about sex, and how to cope with puberty and adolescence (Social Exclusion Unit, 1999). It is here that the community health and education systems could overlap in a team approach, to benefit young people. In many ways the midwife is already well suited to speak about sexual health within the school curriculum. She has a firm grasp on reproductive anatomy and physiology. She has up-to-date information on sexually transmitted infections, prevention and treatment. She is familiar with some of the psycho-social aspects of sexuality. Perhaps most importantly, she is comfortable with the language to use around reproductive issues and is presumably sensitive to the tact and insight required in discussing these issues. She is not a teacher in the school system cornered into teaching sex education with which she may not be comfortable. The fact that she would be viewed as separate from the staff is of benefit to the students as the issue of confidentiality was indeed cited as important to youth in the Social Exclusion Report (1999).
The outreach of community based midwives into schools is a logical development in an increasingly community-based approach to health care for all (Akker, Lees and Murphy, 1999). It has been noted that midwives seem well placed to take on this role, but due to the psycho-social complexity as has been touched on above, they should not be expected to do so without specific training which expands upon the issues mentioned above (Hawkey, 1997). Although standard midwifery training includes reproductive and sexual health, the scope of the issues around contraception and teenage pregnancy necessitate more depth. Most literature around this suggestion proposes the specialist role of the midwife (Hawkey, 1997). However, perhaps it should be prioritised within the current education scheme, as the erosion of holistic midwifery through the development of the so-called specialist midwife is already of concern to many. When direct-entry midwifery moves toward universal degree qualification, perhaps sexual health counselling could be an elective component within the program. It is arguably a loss to consider the training for this extended role as an extension of training itself. Though some of the particular information may be additional, the skills for candid and sensitive dialogue, personal discussion, and tactful honesty with sexual issues should also be central to the traditional role of the midwife. However, these skills are not necessarily basic to traditional midwifery as was confirmed by the midwife in the anecdote that began this article.
Although, significant numbers of young mothers may take an active part in deciding to have a baby, it can also be said that many young parents admit to having underestimated the full involvement of parenthood (Baker, 1999; Gilham, 1997). Here again, the midwife may be instrumental in lessening the gap between fantasy and reality by discussing the realities of caring for a baby in a preventative forum such as in schools or by invitation to parent education classes (Baker, 1999). The midwife is well positioned to liaise with community services and also to arrange guest speakers with first hand knowledge of interest to teenagers. Importantly, it has been audited that teenagers will respond to educational systems in which they have had significant input (MacKeith, I999). This must also be taken into account. More directly, the midwife has the opportunity to affect the teenage pregnancy rate through dialogue with the childbearing women she encounters in her current practice. Though at first glance some might perceive speaking to pregnant women in the midwifery environment as closing the proverbial barn door after the horse has bolted, this is not completely accurate. This perception misses the cyclical nature of teenage pregnancy as highlighted by the Social Exclusion Report. The daughters of teenage mothers are themselves one and a half times more likely to become teenage mothers than are the daughters of older mothers (Social Exclusion Unit, 1999). The sociological factors which account for the influence of cultural and familial role models are complex, but the midwife can contribute to countering this effect with empowerment through the provision of information. Discussing issues around family planning and sexuality during pregnancy and the postnatal period may equip some women with the information they need to take control of their contraceptive needs and to plan their family as they like, rather than simply as they have seen. So, there is a potential for midwives to extend their role into the community and there is also an overdue need for midwives to fulfil the role, which they have already taken on.
As with most midwifery issues, continuity of care will greatly enhance the midwife's ability to give individualised information and appropriate advice on contraception. Personal understanding of the woman will give the midwife insight into her particular needs. For example, if the midwife knows that a woman's life is stable, routine and the continuation of breastfeeding is a priority for her, than she may be a good candidate for the mini pill. Conversely, if she is a teenager worried about her parents knowing about her sex life, the inconspicuous injection might be more suitable. Also, continuity usually affords a trust between the midwife and her client, which is beneficial for effective dialogue.
Akker 0, Lees T and Murphy T (1999). Adolescent sexual behaviour and knowledge , British Journal of Midwifery, 7, 765-769.
Baker K (1999). Young, pregnant...and pleased , Practising Midwife,2, 14-16.
Dolby L (1998). Is sex education in the Netherlands better organised than in Britain? British Journal of Midwifery, 6, 96-99.
Gilham, Bill (1997). The Facts About Teenage Pregnancy, Cassell, London.
Hawkey M (1997). Contraceptive advice: Ajob for mid-wives? British Journal of Midwifery, 5, 623.
Hudson P (1997). Contraceptive advice for teenagers in Finland, Midwives, 110, 222-223.
Kaufman T (2001). Teenage pregnancy: How can we help? RCM Midwives Journal, 4, 322.
Kaufman T (1999). Teenage pregnancy , RCM Midwives Journal, 2, 214.
MacKeith P and Phillipson R (1997). Young mothers , In: Kargar I and Hunt S (Eds). Challenges in Midwifery Care, MacMillan Press, London.
MacKereth C (1998). Sexual health messages: Working with young people , Community Practitioner, 71, 412-414.
Mander R (1999). Teenage pregnancy: A challenge or a problem for whom? RCMMidwivesJournal, 2, 280-281.
Mowlam M (2000). Count me in , Nursing Standard, 14, 21.
Social Exclusion Unit (1999). Teenage Pregnancy Report by the Social Exclusion Unit, HMSO, London.
UKCC (1998). Midwives Rules and Code of Practice, London.
Edwards G (2000). Teenage pregnancies a baseline audit , Practising Midwife, 3, 10-13.
Edwards G (2000). Teenage pregnancies 2: Comparative outcomes, Practising Midwife, 3, 12-15.
RCM editorial (2001). Teenage conception rates fall , RCM Midwives Journal, 4, 134.
LW updated February 4, 2005