General Practice

Consultation patterns and provision of contraception in general practice before teenage pregnancy: case-control study

Dick Churchill, clinical lecturer ^a, Jane Allen, researcher ^a, Mike Pringle, professor ^a, Julia Hippisley-Cox, senior lecturer ^a, Dave Ebdon, lecturer ^b, Marion Macpherson, consultant ^c, Sue Bradley, lecturer ^d. 

^a Division of General Practice, University of Nottingham Medical School, Queen's Medical Centre, Nottingham NG7 2UH, ^b Department of Geography, University of Nottingham, Nottingham NG7 2RD, ^c Department of Obstetrics and Gynaecology, Queens Medical Centre, Nottingham, ^d School of Nursing, Queen's Medical Centre, Nottingham

Correspondence to: R Churchill dick.churchill{at}nottingham.ac.uk

	Abstract

Top Abstract Introduction Subjects and methods Results Discussion References

Objectives: To determine patterns of consultation in general practice and provision of contraception before teenage pregnancy.
Design: Case-control study, with retrospective analysis of case notes.
Setting: 14 general practices in Trent region.
Subjects: 240 registered patients (cases) with a recorded conception before the age of 20. Three controls per case were matched by age and practice.
Main outcome measures: Consultations in general practice and provision of contraception in the 12 months before conception and recorded provision of contraception at any time before conception.
Results: Overall, 223 cases (93%) had consulted a health professional at least once in the year before conception, 171 (71%) had discussed contraception in this time, and 121 (50%) had been prescribed oral contraception. Cases were more likely to have consulted in the year before conception than controls (odds ratio 2.70, 95% confidence interval 1.56 to 4.66). Most of the difference was owing to consultation for contraception. Overall, 53 cases (22%) resulted in a termination of pregnancy. Cases whose pregnancy ended in a termination were more likely to have received emergency contraception than either their controls (3.21, 1.32 to 7.79) or cases resulting in other outcomes (3.01, 1.06 to 8.51).
Conclusions: Most teenagers who became pregnant attended general practice in the year before pregnancy, and many had sought contraceptive advice. The reluctance of teenagers to attend general practice for contraception may be less than previously supposed. The association between provision of emergency contraception and pregnancy ending in termination emphasises the need for continuing follow up of teenagers consulting for this form of contraception.

	Introduction

Top Abstract Introduction Subjects and methods Results Discussion References

The United Kingdom has the highest teenage pregnancy rate among 15-19 year olds in western Europe,¹ and associated problems have recently been highlighted.² Around 35% of teenage pregnancies result in a termination, and continued pregnancy is associated with physical, psychosocial, and educational complications for both the mother and the child.² Teenage pregnancy has been identified as a target for health improvement by successive governments. ^{2 3}

Improving access to health education and contraceptive services is seen as the principal way to reduce teenage pregnancy.⁴ General practice is one source of provision of contraception, but it has been suggested that teenagers are reluctant to seek advice because of difficulty in gaining access and fears about confidentiality.⁵ However, there is little published evidence concerning the actual use made of general practice services by teenagers who subsequently become pregnant.

We aimed to determine the extent to which teenagers who become pregnant have utilised general practice services before the pregnancy, and also whether there are differences between those whose pregnancy ends in termination (as a proxy for unintended pregnancy) and others. The results might allow identification of potential opportunities for preventing teenage pregnancy.

	Subjects and methods

Top Abstract Introduction Subjects and methods Results Discussion References

We conducted a case-control study in which characteristics of cases who conceived as teenagers were compared with those of controls matched by age and practice. The study was performed in 14 general practices from the Trent Focus Collaborative Research Network.

Identification of subjects
Cases were registered patients who had a recorded termination, delivery, or miscarriage resulting from conception before the age of 20, between 1 January 1995 and 1 January 1998. Cases were identified from computer records, maternity books, and the knowledge of practice staff. If cases had more than one pregnancy during the study period then the earliest was selected as the index pregnancy. Date of conception was based on the date of the last menstrual period when recorded or estimated from the date of outcome.

Data extraction
Data on demography, consultation, and contraception were extracted from medical records by a member of each practice (usually the practice nurse) after standardised training. Data on consultations were recorded for the same 12 month period before the estimated date of conception for both the case and matched controls. Data on clinical consultations were then categorised and coded by one of us (DC).

Analysis
Data were entered on to an EpiInfo 6.01 database. Principal analyses and calculations of odds ratios were performed with STATA 5.0, and descriptive analyses were performed with SPSS for Windows 8.0.

	Results

Top Abstract Introduction Subjects and methods Results Discussion References

Overall, 240 cases, and 719 matched controls, were identified. Overall, 70% of index pregnancies resulted in delivery, 22% in termination, and 8% in miscarriage. The median age of cases at conception was 17 years (range 13 to 19 years). Thirty four cases (14%) were less than 16 years. Forty eight cases (20%) had been pregnant at least once previously.

The median number of consultations by cases in the year before conception was 4 (range 0 to 29). Table 1 shows the proportion of cases consulting and also recorded provision of contraception both in the index year and at any time before conception. Of the 92 cases who had not consulted for contraception in the year before conception, 76 (83%) had consulted for another reason at least once and 24 (26%) had consulted on four or more occasions.

Townsend scores were available for 232 cases (97%) and 657 controls (91%). The mean score was 3.2 for cases (SD 3.4) and 2.4 for controls (SD 3.3), with the difference between cases and aggregated matched controls being significant (t=4.866, df=231, P<0.001), indicating that cases were resident in more deprived areas. More cases than controls lived within two miles of the surgery, although the difference only just attained significance (table 1).

In the year before conception, cases were more likely than controls to have consulted any health professional at least once, to have consulted a general practitioner, to have consulted frequently (four or more times), and to have consulted for purposes both related to contraception and not related to contraception (table 1). After multivariate analysis, in the year before pregnancy the only significant association was in relation to consultation for contraception (odds ratio 1.78, 95% confidence interval 1.22 to 2.60; P=0.003). Cases were more likely to have consulted for contraception at any time before conception and specifically to have been provided with oral contraception, injectable progestogens, or condoms (table 1).

Table 2 shows consultation rates and uptake of contraception by cases whose pregnancy ended in termination. Of the 27 cases who had not consulted for contraception, all but two (7%) had consulted at least once, and seven (26%) had consulted on four or more occasions in the previous year. There were no significant differences between cases whose pregnancy ended in termination and their 159 matched controls for overall consultation rate, consultations with a general practitioner, or consultations related to contraception or not related to contraception. Cases were less likely than controls to have consulted a practice nurse, although the difference did not attain significance. Cases resulting in termination of pregnancy were significantly more likely to have been provided with emergency contraception or condoms at any time before conception.

Consultation rates of cases whose pregnancies ended in termination were compared with those with other outcomes. There were no significant differences in terms of overall consultation rate or the proportion consulting any health professional at least once, consulting the general practitioner at least once, or consulting frequently. Cases resulting in a termination were, however, half as likely to have consulted the practice nurse than others, with seven (13%) having done so compared with 49 (26%) others (²=3.899, df=1, P=0.048).

The use of contraception by teenagers whose pregnancy resulted in a termination was compared with that of other outcomes (table 3). Cases resulting in a termination of the pregnancy were less likely to have consulted for contraception and less likely to have been prescribed oral contraception at any time but were more likely to have been prescribed emergency contraception.

	Discussion

Top Abstract Introduction Subjects and methods Results Discussion References

This is the first study to compare the consultation patterns of teenagers who become pregnant with those of age matched peers. There is little published research about the uptake of services for contraception in general practice by teenagers before pregnancy. Such research is difficult to undertake and is subject to ethical constraints.

Our study involved general practices from the Trent Focus Collaborative Research Network. Although research practices may potentially provide different standards of care for teenage patients, pregnancy rates in the study practices were similar to those of other practices in the region. The proportion of pregnancies resulting in a termination in this study (22%) was lower than expected from national data (35% among teenagers aged 15-19 in 1994²) suggesting that we may not have identified all such cases, particularly if the terminations were performed in the private sector or referred directly from family planning services without notifying the general practitioner.

Our data were based solely on general practice records. This was appropriate since our interest was in the use made of general practice services. Our results therefore provide an underestimate of the total provision of contraception to teenagers because a proportion access family planning or specific teenage services. The extent of use of other services is likely to vary with locality, but one study found that 60% of pregnant teenagers had accessed services for contraception in general practice compared with 30% who had attended family planning clinics.⁶

Consultation patterns before pregnancy
Our results show that most teenagers who become pregnant do access general practice for both general medical services and contraceptive advice before their pregnancy. This suggests that for most teenagers fears about confidentiality and embarrassment is less of a barrier than previously supposed.⁵ These issues may, however, still be important for the minority who did not consult.

Unintended pregnancy
A separate analysis was performed on cases whose pregnancy ended in a termination, as this group excludes those teenagers in whom the pregnancy was planned or wanted. Most teenagers in this group were still likely to have consulted in general practice in the year before pregnancy, and half had discussed contraception during this time.

	Acknowledgments

We thank the practices from the Trent Focus Research Network and their staff who took part. Since this paper was written, Dave Ebdon has died.

Contributors: All authors were part of the project team. DC developed the original idea by MP, had major input into the study design, performed data coding and analysis, interpreted the results, and wrote the paper; he will act as guarantor for the paper. JA contributed to the design of the study, undertook the literature review, provided training for practices undertaking data collection, performed data entry, and commented on the analysis and the paper. MP conceived the original idea for the project and contributed to the design, interpretation of results, and writing of the paper. JH-C contributed to the development of core ideas, study design, data analysis, interpretation of results, and the paper. DE analysed postcode data for deprivation and spatial analysis. MM and SB commented on the design, interpretation of results, and the paper. Data collection was performed by staff in participating practices. Carol Coupland provided advice on statistical analysis.

	Footnotes

Funding: Trent NHS Executive.

Competing interests: None declared.

	References

Top Abstract Introduction Subjects and methods Results Discussion References

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(Accepted 5 July 2000)