Journal of Public Health Advance Access originally published online on November 9, 2006
Journal of Public Health 2006 28(4):304-308; doi:10.1093/pubmed/fdl069
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Life as a league table bottom dweller: teenage pregnancy in Lambeth
Abdu Mohiddin, Consultant in Public Health
Lucinda Cawley, Teenage Pregnancy Strategy Coordinator
Yimmy Chow, Specialist Registrar in Public Health, London Deanery
Ruth Wallis, Director of Public Health
Directorate of Public Health, Lambeth Primary Care Trust/London Borough of Lambeth, 2nd Floor, 1 Lower Marsh, SE1 7NT, London, UK
Address correspondence to Abdu Mohiddin, E-mail: abdu.mohiddin{at}lambethpct.nhs.uk
In mid-2004, the lead for tackling teenage pregnancy in Lambeth moved from the Council to Public Health in the coterminous Primary Care Trust. Lambeth is a deprived inner-city London borough with a culturally rich and diverse population. The under-18 teenage conception rate had risen by 19% over the 5-year period (1998–2003) following the launch of the National Teenage Pregnancy Strategy. There was considerable pressure from local and national agencies to reduce this high rate (then standing at twice the English average). This article describes how we attempted to do this.
Keywords: sexual health, strategy, teenage pregnancy
Teenage pregnancy and Lambeth sometimes seem synonymous; locals and many Londoners know that we are—notoriously—the place with the highest teenage pregnancy rate in all of Western Europe. The under-18 conception rate rose by 19% over the 5-year period (1998–2003) following the launch of the National Teenage Pregnancy Strategy, a multimillion pound high-profile initiative.1 Lambeth also has high rates of sexually transmitted infections and HIV, all pointing to a borough with a high sexual ill-health burden.
Linked to the National teenage pregnancy strategy is a Public Service Agreement target to reduce the under-18 conception rate by 50% by 2010 from a 1998 baseline. In Lambeth, this target was set locally at a 60% reduction by 2010. This is a jointly owned target between the Primary Care Trust (PCT) and local authorities, and in mid-2004, following a Teenage Pregnancy Unit report, the lead for tackling teenage pregnancy moved from Social Services in the Council to Public Health in the coterminous PCT. This coincided with the appointment of a new Teenage Pregnancy Co-ordinator and the start of a new teenage pregnancy and parenthood team. This article describes our experience. We began with a needs assessment.
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The Lambeth picture: sex n drugs n race n ‘rithmetic? Or more... |
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 TOP The Lambeth picture: sex... Convincing our own side:...Trial by mediaPerformance managementMountaintop or foothillCompeting interestsAcknowledgementsReferences |
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Lambeth is an inner-city London borough, with a resident population of 266 170 persons, which is culturally rich and diverse with well-established Black and Irish communities (34% Black and minority ethnic groups and >130 languages spoken). It is a deprived borough and has a higher than average proportion of young people between 20 and 40 years of age.
Part of the Lambeth picture is the many local anecdotes that attempt to explain why Lambeth has high teenage pregnancy rates. In recent decades, Lambeth has tended to have a high teenage pregnancy rate, and stories have grown around this (Table 1). We found that some individuals vocalized these anecdotes forcefully and that some of them were quite widespread. Naturally, whilst there may be some truth in such anecdotal evidence, we were cautious, as there may be some red herrings too. What is interesting about these anecdotes are their variety and themes around ethnicity and culture.
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But were these anecdotes reflected in the literature? There are many risk factors associated with teenage pregnancy, several of them found in Lambeth in excess of national and London averages.2,3 For example, the looked after children rate is 112 per 10000 in Lambeth compared with 75 in London (2004). Educational attainment in Lambeth (e.g. five GCSEs) was lower and substance misuse prevalence was higher than found nationally. The National Surveys of Sexual Attitudes and Lifestyles indicate that some risky sexual behaviour is higher in London compared with other regions and that levels have increased over time and are most common amongst those aged 16–24 years.4,5 To illustrate, a higher average number of heterosexual sex partners in the past 5 years was reported by men (4.5 partners) and women (2.7 partners) in London than elsewhere in Britain (3.7 and 2.3 partners, respectively). Furthermore, individuals with two or more relationships at the same time (in the past year) were also more common in London (18% men and 12% women in London compared with 14% and 
9% outside London, respectively). Black Caribbean and Black African men report the highest number of lifetime sexual partners of all ethnic groups.
We felt that shedding light on some of the anecdotes and the risk factors meant investigating further the epidemiology of teenage pregnancy was the next step and one that relied initially on routinely available and predominantly health data. The challenges of partnership working meant that sharing of relevant data took both time and effort. For example, getting information on say, the number of looked after young people who are parents or are pregnant; or, agreeing to collect a common data set across agencies.
An initial look at the available routine data revealed an under-18 conception rate from 1998 (the national strategy baseline) that is rising and diverging compared with the London and national experience (Fig. 1). This meant a conception in 1 in 10 teenage girls under 18 resident in Lambeth in 2003. The under-16 rate increased too (from 18.7 to 24.6 per 1000). All Lambeth’s wards have an under-18 rate at, or above, the national average with some 3-fold variation between the highest and the lowest wards.
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A closer look at the conception rate components reveals more insights. The profile of teenage parents in Lambeth suggests that Lambeth teenage mothers are over-represented in the Black Caribbean, Mixed Black Caribbean–White minority ethnic groups than the proportion of such groups in the general Lambeth population of teenage women. Compared with England, Lambeth teenage mothers tended to live alone and are less qualified. For terminations, there is an under-representation of White British and an over-representation of Black Caribbean women.
The scatterplot in Fig. 2 shows the conception rate by borough against a deprivation score (the Index of Multiple Deprivation), and it further emphasizes the outlying position that Lambeth’s conception rate represents. The square dot is Lambeth, and its statistical neighbours (boroughs with similar socioeconomic and demographic profiles) are shown in diamond dots. The best-fit curve indicates that 71% of the variation in conception rate between boroughs can be explained by deprivation. Whilst Lambeth is amongst the most deprived boroughs, its conception rate is clearly higher than both other boroughs of similar deprivation and its statistical neighbours. There is a proportion of the conception rate in Lambeth that is not explained by deprivation (almost half). These observations require explanation and show how different Lambeth is. Explanations may include complex social and cultural factors, e.g. ‘estate’ and ‘gang’ cultures, access to services, effectiveness of sex and relationship education and a mobile population.7
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Lambeth has considerable population mobility, and people may move to access services such as abortion providers locally. Data from the 2001 census show that 18% of Lambeth’s population were migrants in that year compared with 12% in England and that ward migration figures vary from 4 to 16% in females aged 16 or 17 years (defined as a person with a different address 1 year before the census to that on the census day).
The intergenerational influence of teenage motherhood increases the likelihood of the next generation of teenage mothers. This effect is enhanced in Lambeth given its historically high rates of teenage motherhood in previous decades.
This initial look at the data revealed quite a complex picture: an inner-city borough with a large young population, high Black and minority ethnic groups, considerable mobility, low incomes, a high prevalence of substance misuse and sexually transmitted infections including HIV. All these influences and others may act in a synergistic way on the conception rate, and a more thorough investigation was needed.
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Convincing our own side: do you have a strategy? |
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TOPThe Lambeth picture: sex...Convincing our own side:...Trial by mediaPerformance managementMountaintop or foothillCompeting interestsAcknowledgementsReferences |
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Given the conception rate trajectory since 1998, there was considerable local pressure to reduce the rate. Allied to this was a measure of scepticism about the adequacy of existing local efforts and a need to explain the performance of the local strategy over the last few years. The tasks for us were to review and revitalize the local work, to convince our Local Strategic Partnership and related forums that we did have a plan and to lobby for more resources. But as existing members of the local teenage pregnancy Board, we were under scrutiny too. All this was compounded by the propensity—perhaps unique to teenage pregnancy—for individuals, including eminent ones, to have their own strong convictions on what teenage pregnancy is really about and how to deal with it. Added to this was the sensitivity of talking about the realities of teenage pregnancy in an ethnically diverse borough.
As part of a needs assessment, we reviewed the local strategy establishing that it had focussed more on supporting parents than on prevention (Teenage Pregnancy Unit guidance helped inform this review). We were plunged into a series of seemingly endless and frustrating presentations to the Local Strategic Partnership and partners in which we found the communication of the complexity of teenage pregnancy—its causes, technical solutions, etc.—very difficult. Perhaps this was because some audiences tended to have a linear and mechanistic view of the issue: more resources put in equals an immediate result of a lowered conception rate.
We discovered that the complexity of teenage pregnancy in Lambeth was best represented through a picture—in this case, the scatterplot (Fig. 2). Audiences immediately recognized Lambeth as a significant outlier even compared with similar sociodemographic boroughs and were more open to reasons for this and discussion about solutions. Maybe too, this picture helped provide more plausible ‘excuses’ for our performance.
We were able to secure Neighbourhood Renewal Funding for a year, and this doubled our budget. These resources were prioritized at prevention (both primary and secondary) and at better information and understanding the local context. For instance, we are strengthening considerably sex and relationship education and training in and out of schools, and we have commissioned qualitative work with young people and men. We now have the public health director co-chairing the teenage pregnancy Board along with the assistant director of Youth Services from the borough. We also began reviewing our sexual health services and contraception, and this was strengthened by the PCT and borough prioritizing sexual health and by the involvement of a local charity that invests in health issues (The Guy’s and St Thomas’ Charitable Foundation).
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Trial by media |
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TOPThe Lambeth picture: sex...Convincing our own side:...Trial by mediaPerformance managementMountaintop or foothillCompeting interestsAcknowledgementsReferences |
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Teenage pregnancy is a media-genic subject, one that generates much interest and strong feeling. As a league table bottom dweller on teenage pregnancy, all paths beat to our door—we faced a lot of press interest from local, national and international agencies—print, radio and television (Fig. 3). Sometimes, these were sparked off by the routine national release of conception rate data, although the busiest time was in summer 2005 following reports by the national media of two teenage sisters becoming pregnant (not Lambeth residents) after which we had
30 enquiries in a few days. The enquiries were nearly all critical wanting explanations for ‘failure’ and access to young parents. Some media enquiries were outlandish like a request for pregnant teenagers to take part in a ‘Big Brother’ style house for television.
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We faced again the challenge of communicating the complexity of teenage pregnancy to demanding press audiences and trying to avoid the stigmatization of teenage parents or a particular ethnic group. Agreeing a common message with all our partnership Board members was not easy particularly in the acute heat of media interest, let alone summarizing our position on teenage pregnancy into a convincing sound bite. Press releases and briefings were issued, and the chief executive went on television. A silver lining was the inclusion of Lambeth in a national photography project on teenage pregnancy by a renowned international photojournalist. The photographer works with young parents to illustrate their lives in a realistic way, and parents have found this a positive experience.
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Performance management |
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TOPThe Lambeth picture: sex...Convincing our own side:...Trial by mediaPerformance managementMountaintop or foothillCompeting interestsAcknowledgementsReferences |
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The poor conception rate performance of Lambeth did not escape the attention of government. It was clear that we had a lot to do to make the case and reassure those who performance manage local government and PCTs. Three separate government agencies (the Department for Education and Skills, Department of Health and the Government Office for London) scrutinized us in a 12-month period (to add to this, we also had the Borough health scrutiny committee to appear before and a central government ministerial visit).
Each visit involved a series of meetings—one-to-ones and groups with senior managers and practitioners from a wide range of partner agencies. There was a general assumption that poor outcomes mean poor inputs when it may also mean that it is a complex issue. We had to produce and disseminate reports and briefings. We had to present our strategy and plans and found that inviting a national teenage pregnancy expert (for one visit) was particularly helpful, not least in reassuring others that teenage pregnancy is not a simple, quick fix and suggesting ideas and best practice. Although each visit yielded something of value, there was some disruption associated. A more joined up approach and an appreciation of the contextual differences and challenges between different areas of the country would be helpful.
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Mountaintop or foothill |
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TOPThe Lambeth picture: sex...Convincing our own side:...Trial by mediaPerformance managementMountaintop or foothillCompeting interestsAcknowledgementsReferences |
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At the time of writing (August 2006), Lambeth’s latest under-18 conception rate has fallen from 101.5 to 84 per 1000 with absolute numbers of 415 pregnancies in 2003 and 352 in 2004. This has been cautiously welcomed, as it is a provisional estimate (final figures are awaited). However, we hope that it is the beginning of a downward trend. Alert readers will have noted that these new conception rates relate to 2004, and we took over the lead halfway through the year—had the decline already started or did we initiate it? Or is there a stack of notification forms stuck en route to the Office for National Statistics?
Time will tell...
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Competing interests |
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TOPThe Lambeth picture: sex...Convincing our own side:...Trial by mediaPerformance managementMountaintop or foothillCompeting interestsAcknowledgementsReferences |
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All authors declare that they have no competing interests.
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Acknowledgements |
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TOPThe Lambeth picture: sex...Convincing our own side:...Trial by mediaPerformance managementMountaintop or foothillCompeting interestsAcknowledgementsReferences |
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We thank Barbara James, Lynn Snowden, Mary Rogers, Lambert Allman and Jane Ramsey for their considerable support and guidance.
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References |
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TOPThe Lambeth picture: sex...Convincing our own side:...Trial by mediaPerformance managementMountaintop or foothillCompeting interestsAcknowledgementsReferences |
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- Social Exclusion Unit. Report on Teenage Pregnancy. http://www.dfes.gov.uk/teenagepregnancy/dsp_content.cfm?pageID=84 (17 August 2006, date last accessed).
- Health Development Agency. Teenage Pregnancy: An Overview of the Research Evidence. http://www.nice.org.uk/page.aspx?o=502705 (16 August 2006, date last accessed).
- Swann C, Bowe K, McCormick G, Kosmin M. Teenage Pregnancy and Parenthood: A Review of Reviews. London: Health Development Agency, 2003. http://www.nice.org.uk/page.aspx?o=502529 (17 August 2006, date last accessed).
- Johnson AM, Mercer CH, Erens B et al. Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviours. Lancet 2001;358:1835–42.[CrossRef][ISI][Medline]
- Fenton KA, Mercer CH, McManus S et al. Ethnic variations in sexual behaviour in Great Britain and risk of sexually transmitted infections: a probability survey. Lancet 2005;365:1246–55.[CrossRef][ISI][Medline]
- Conception rate trend analysis. Teenage Pregnancy Unit, London, 2005.
- Bradshaw J, Finch N, Miles JN. Deprivation and variations in teenage conceptions and abortions in England. J Fam Plann Reprod Health Care 2005;31(1):15–9.[CrossRef][ISI][Medline]
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