Political support at all levels, long-term commitment and changes to social norms behind success of public health strategy

Rates of teenage pregnancy in the UK have halved in the past two decades and are now at their lowest levels since record-keeping began in the late 1960s.

It is a dramatic turnaround: in 1998, England had one of the highest teenage pregnancy rates in western Europe. Last week, the Office for National Statistics released data revealing the fall in the conception rate among females aged 15 to 19 as the standout success story in the public health field: just 14.5 per 1,000 births were to women in their teens, with drops in all age groups under 25.

“It’s the result of an unusually long-term and ambitious strategy launched by the Labour government in 1999,” said Alison Hadley, director of the Teenage Pregnancy Knowledge Exchange at the University of Bedfordshire. “The drive to reduce teenage pregnancy was given 10 years to achieve a 50% fall in under-18 conception rates. Unusually for government schemes, efforts really were sustained for the full 10 years and ambitions weren’t lowered, despite difficulties and slow progress at the start.”

Hadley, who led the implementation of the teenage pregnancy strategy for England, said: “We realised that teenage pregnancy was everyone’s business, from health to education, to social care and youth services. Local areas agreed individual targets and if progress was slow, they were directly contacted by the [then] children and health ministers – Beverley Hughes and Caroline Flint – and helped to get back on track.”

High-quality relationships and sex education was introduced, with welcoming health services – in the right place, open at the right time – and friendly nonjudgmental staff to help young people delay having sex until they were ready, at which point they knew how to use contraception effectively.

The teenage conception rate in England still remains higher than a number of other western European countries, however, and reductions at council level vary from 30% to 70% – including stark differences between areas with similar demographics.

Lisa Fontanelle, 20, has been a peer mentor for the sexual health charity Brook since she was 14. “I’ve mentored young people all over the country and I see differences in conception rates that have nothing to do with deprivation and inequality,” she said. “The biggest reasons are cultural, lack of education and stigma: people still think that if you give young people sex and relationship education, they’re going to go crazy.

“The two things that would make the biggest difference to regional differences in conception rates are making sex and relationship education compulsory in schools, and engaging with parents. Schools are vital but they can’t do it all. Parents have to be engaged for rates to go down.”

Fontanelle conducted a survey recently among young people in Kent. “I was really surprised that the biggest issue was consent. Young men and women didn’t know they had the right to say no to sex. They also felt embarrassed to access condoms,” she said.

Cornwall county council has helped to halve the under-18 conception rate in the county since 1998. Among other programmes in Cornwall, Brook delivers relationship and sex education to secondary schools and offers tailored support to those who need it, while Clear, a local charity, offers a six-week intensive healthy relationship programme.

“Because we had support at every political level, we were able to challenge the status quo and introduce training and programmes for everyone who works with young people,” said Alexa Gainsbury , Cornwall’s teenage pregnancy and sexual health coordinator.

“We found that young people were craving information. That the problem was that we hadn’t been making it easy for them to access the reliable information they wanted.”

Kaye Wellings is the author of the report England’s Teenage Pregnancy Strategy: a Hard-won Success, which was published in the Lancet in May. She believes there are wider reasons for the fall in teenage conceptions.

“The conclusion of our paper was that there was a fair wind behind the teenage pregnancy strategy because all over the world rates were dropping,” she said. “The strategy made a big difference but the underlying trend towards fewer early pregnancies has been attributed to increased education, later completion of education and increased access to reliable contraception: long-acting, reversible methods which don’t depend on the reliability of the user.”

She added: “Social norms have also changed. In early 2000s, a lot of young female role models were getting pregnant. Among some young women it was a mark of status to get pregnant. Now it’s considered totally uncool.”

This “fair wind” gives Wellings confidence that rates will continue their decline, even if the government, under the new prime minister, Theresa May, turns its attention elsewhere. ‘“It’s my guess we will never again see the levels of teenage pregnancy we had at the turn of the century,” she said.

The new challenge for society, said Clare Murphy, director of external affairs at the British Pregnancy Advisory Service, is to redesign services to answer the needs of today’s young women.

“Emergency contraception services are still very much focused on preventing teenage pregnancy,” she said. “But the difficulties of modern life mean young women of all ages want and need help controlling their fertility.

“If you’re working or juggling childcare, you don’t have time to wait hours to be seen in a crowded walk-in clinic and we all know how hard it is to get an appointment at a GP. The cost of emergency contraception in a pharmacy is between £30 and £45. Those prices have nothing to do with the cost of production: in Europe, the same contraception costs between €7 and €19.”

Murphy said free emergency contraception should be made available from pharmacies. “We’ve done so well for teenagers but have managed to put up as many barriers as possible for other women seeking emergency contraception. And yet it’s simple and it’s safe. Why wouldn’t we do it?”