SRE0463

Written evidence submitted by Professor David Paton

Executive Summary

ES.1 Recent data from England make clear that proposed policy changes such as statutory provision for Sex and Relationships Education (SRE) in schools and removing the right of parental opt-out from SRE are not a pre-requisite for achieving reductions in teenage pregnancy rates.

ES.2 The peer-reviewed evidence similarly provides little evidence that school-based SRE has any significant effect on unwanted pregnancy amongst adolescents.

ES.3 This evidence as well as the experience in other countries suggests that, rather than looking for uniformity in the provision of SRE, there should be scope for schools and other groups to engage with parents in identifying SRE-related material and input that is appropriate for the particular needs of diverse groups of children.

ES.4 There seems no sound reason to introduce statutory SRE in schools or to end the right to parents/carers to opt their children out of school-based SRE.

Supplement Oct 2014: ES.5: Recent research suggests that improvements to educational outcomes and demographic change explain much of the recent decreases in teenage pregnancy rates, whilst increased promotion of long acting reversible contraception appears to have had very little impact (see section 2.4a for details).

1. Introduction

1.1 This submission is based on research that I have conducted for a number of years on sexual health policy in my capacity as a professor of economics at Nottingham University Business School.  A brief bibliography of peer-reviewed articles which I have authored or co-authored is in the Appendix.  By way of further background, I have long experience as the Link Governor for Sex and Relationships Education (SRE) at a comprehensive school.  I am also a member of the Society for the Protection of Unborn Children.  This statement is submitted in a personal capacity.

1.2 My intention in this submission is to examine how recent data and peer-reviewed research might inform the questions identified by the Committee.  Following this introduction, I provide an overview of trends in teenage pregnancy and abortion in England along with associated policy interventions.  I then go on to outline the findings of the peer-reviewed evidence on SRE.  In the final section, I respond directly to the specific questions posed by the Committee.

2. Teenage pregnancy and abortion in the UK: trends and policy interventions

2.1 There is considerable agreement in the peer-reviewed literature that teenage pregnancy rates are strongly correlated with underlying socio-economic factors such as poverty, educational achievement, religious practice and family stability.  There is less agreement over the impact of policies aimed directly at reducing unwanted pregnancy and, in particular, the role of school-based sex education (SRE) and access to family planning services.

2.2 Teenage conceptions and abortions have decreased significantly since 2008.  Although some commentators have suggested that measures introduced under the previous Government’s Teenage Pregnancy Strategy (TPS) may lie behind the declines, neither an inspection of the aggregate data nor more formal peer-reviewed research provides much support for this hypothesis.

2.3 The TPS was announced in 1999 and ended in 2010.  Over that period, several hundred million pounds was spent on a number of measures aimed at reducing teenage conceptions including significant investment in adolescent family planning services.  Figure 1 reports annual expenditure on the TPS and under-18 conception/abortion rates in England over the period.  It is hard to discern any consistent correlation.  In the early years of the Strategy, expenditure increased rapidly, whilst pregnancy and abortion rates changed only marginally.  Indeed, the under-18 abortion rate was higher in 2008 than it was at the start of the TPS.  Significant decreases in conception and abortion rates started only from 2008.  Notably, they have continued (and even accelerated) after the end of the Strategy. These reductions have been achieved despite significant cuts to teenage pregnancy-related interventions in many areas dating from even before that point.

2.4 There are a number of possible reasons for the decline since 2008.  These include demographic change, improvements in educational outcomes (particularly amongst groups at high risk of early pregnancy) and a shift away from reliance on the pill and condoms in favour of long acting reversible contraception (LARC).  A further potential explanation may lie in a more fundamental (and largely unexplained) reduction in risky behaviour amongst young people as evidenced by declines in smoking, drug-taking and alcohol use amongst teenagers over the same period.  To date, there have been no formal tests of these alternative explanations and this is an important area for future research.

Supplement 2.4a Further to the original submission of this evidence, research examining a number of different explanations of the recent fall in teenage pregnancy rates in England has now been completed (Paton and Girma (2014) and is available at http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2462432 .  This paper finds that recent improvements in educational outcomes and, to a lesser extent, increases in the non-white proportion of the population have been associated with large and statistically significant reductions in teenage pregnancy in England.  In contrast, increased promotion of LARCs seems to explain little or none of the recent decrease.

2.5 Looking more specifically at school-based sex and relationships education (SRE), it is noteworthy that recent reductions in teenage pregnancy have been achieved without implementing policy changes such as statutory SRE or ending the parental opt-out.

2.6 It is important to note that national trends may be affected by a range of other factors and so any review of the aggregate data should be accompanied by an examination of the peer-reviewed literature.

3. Peer reviewed evidence on SRE

3.1 There is conflicting evidence on the effect that school-based SRE has on adolescent pregnancies or abortions. For example, Oettinger (1999) finds that, amongst some sub-groups, teenagers who were exposed to school-based SRE experienced slightly higher pregnancy rates than those who were not exposed.  In contrast, Kohler et al. (2008) find that SRE is associated with lower self-reported pregnancy rates amongst teenagers.  Other researchers conclude that SRE has no significant on adolescent pregnancy (Sabia, 2006) or birth rates (Cavazos-Rehg, 2012).  Research that examines the effect of innovative or enhanced or peer-delivered SRE programmes has generally found little evidence of any effect on unwanted pregnancy rates (e.g., Stephenson et al., 2008; Henderson et al., 2007; Wilkinson et al., 2006; DiCenso et al., 2002).[1]

3.2 On the specific issue of so-called ‘abstinence education’, the current state of the evidence is mixed, with some studies finding abstinence-based education is no more effective than ‘conventional’ approaches in terms of reducing unwanted pregnancy rates (e.g. DiCenso et al, 2002), whilst other studies are more optimistic (e.g. Cabezon et al., 2005, Cannonier, 2011).

3.3 There is little or no peer-reviewed evidence on the effect of starting SRE in primary schools on subsequent teenage pregnancy.

3.4 The experience of the Netherlands is frequently cited as evidence in favour of making changes to SRE policy in the UK.  However, the view that low teenage pregnancy rates in the Netherlands can be explained by earlier and more explicit sex education is not supported by the available evidence.  SRE in the Netherlands is compulsory only in secondary school (Eurydice/NFER, 2009).  As Dutch secondary education generally starts one year later than in UK, this means that school SRE is compulsory one year later than in the UK.  Further, in practice SRE in the Netherlands is commonly taught only from the final year of primary school (Van Loon, 2003) i.e. at least one year later than is typical in England.  Finally, there is no statutory content to SRE in the Netherlands.  Rather schools can decide about both the content and approach and these decisions are highly influenced by parental views.  As a result, SRE in the Netherlands varies widely in terms of content, delivery and timing.

3.5 Recent Government advice about SRE provision has focused on the integration of and signposting to family planning services by schools.  The evidence on the impact of such measures is not encouraging.  For example, Wilkinson et al. (2006) evaluate the impact of the TPS.  Although they find that those local authorities that had been allocated more money experienced larger reductions in under-18 conception rates, looking at specific factors within this overall finding, they find that those areas with higher quality contraceptive services and with better access to services experienced lower reductions in conception rates than others.  Although such associations should not necessarily be interpreted as a causal effect, their findings are consistent with a range of population-level studies and evaluations of randomised controlled trials (RCTs) from both the USA and the UK (e.g. Paton, 2002; DiCenso et al., 2002; Imamura et al, 2007) and which provide little or no evidence that access to family planning has a significant impact on teenage pregnancy rates.

3.6 The evidence-base is perhaps strongest on the impact of increased access to emergency birth control (EBC).  An exhaustive review of RCT evidence on this question concluded that “to date, no study has shown that increased access to [EBC] reduces unintended pregnancy or abortion rates on a population level” (Raymond et al., 2007, p.184).  This is complemented by population-level studies from the U.S. and U.K. (Girma and Paton, 2006, 2011; Durrance, 2013) which also all find no evidence that access to EBC leads to reductions in teenage pregnancy or abortion rates.

3.7 Some commentators have suggested that access to family planning may reduce underage pregnancy and abortion rates when combined with other measures as part of a multi-faceted approach.  To date, the peer-reviewed evidence does not support such a conclusion.  For example, Wiggins et al. (2009) report that a comprehensive intervention (including SRE and access to family planning services) led to a number of adverse outcomes amongst the intervention group including significantly higher rates of teenage pregnancy.  More recently, Blackman (2013) also finds that dedicated planning and commissioning of services aimed at tackling high teenage conception services “appears to make things worse” (p.69)

3.8 In summary, the peer-reviewed evidence provides little evidence that school-based SRE (including providing easier access to adolescent birth control services) has a significant effect on unwanted pregnancy amongst adolescents.

3.9 It is important to be clear that this does not mean that schools have no role in the delivery of SRE.  Sex education is not just aimed at reducing teenage pregnancy rates and there is certainly some excellent work being done by schools and some external groups in this area.  However, given the evidence to date, it is important not to overstate the likelihood that innovations to SRE policy (such as compulsory SRE at primary school level, a statutory SRE curriculum or removing the right of parental opt-out from SRE) will help to improve sexual health amongst young people.

3.10 Given the peer-reviewed evidence and also the fact that teenage pregnancy rates have decreased significantly over the past few years (despite there being no major shift in national policy on SRE), policy makers should be very cautious about contemplating a more centralised or interventionist approach towards SRE policy in schools.

4. Summary

4.1 Data from England over the past three decades suggests no clear relationship between conventional policy interventions (such as easier access to family planning for teenagers) and changes in underage pregnancy or abortion rates.

4.2 There is no evidence to date that the current parental opt-out of school SRE contributes to adverse sexual health amongst adolescents.

4.3 There is no evidence to date that the lack of a statutory curriculum for SRE in secondary schools contributes to adverse sexual health amongst adolescents.

4.4 There is no evidence to date that the current policy of permitting primary schools to decide whether or not to provide SRE contributes to adverse sexual health amongst adolescents.

4.5 The peer-reviewed evidence as well as the experience in other countries suggests that, rather than looking for uniformity in the provision of SRE, there should be scope for schools and other groups to engage with parents in identifying SRE-related material and input that is appropriate for the particular needs of diverse groups of children.

Responses to some of the specific questions raised by the Committee

Question 1: Whether PSHE ought to be statutory, either as part of the National Curriculum or through some other means of entitlement.

Response: making PSHE statutory would be a retrograde step.  Aside from material which is essential for curricula in subject areas such as biology and RE/Ethics, decisions over whether to provide further aspects of SRE within PSHE should broadly be left to the individual school.  In particular, the current ability for parents to withdraw their children from aspects of SRE which they deem to be inappropriate should be retained.  The proportion of parents who avail themselves of this opportunity is very small, but the awareness that this right is available should the need arise provides significant reassurance to parents.

4.4 Question 2:  Whether the current accountability system is sufficient to ensure that schools focus on PSHE.

Response: the current system works reasonably well, but more could be done to ensure that Schools are aware of the need to consult fully with parents about the provision of SRE.  In particular, more direction could be given to Schools that any materials used in SRE (videos, handouts etc) should be made easily available to parents to view.

4.5 Question 3: The overall provision of Sex and Relationships Education in schools and the quality of its teaching, including in primary schools and academies.

Response: clearly the provision of SRE varies in its quality across schools and changing the statutory status of SRE will not change this.  Although it might be argued that mandating a common curriculum across all schools will lead to more consistency of provision, this is not necessarily a desirable outcome.  By its nature, some aspects of SRE provision are very sensitive in nature.  Pupils vary significantly in terms of their needs across and within age groups and in terms of the cultural and religious context.  Given this, a “one-size fits all” approach imposed from central Government may lead to negative outcomes for individual children.

4.7 Question 5: How the effectiveness of SRE should be measured

Response: although surveys of pupils will provide some useful information, data might also be collected on the satisfaction of parents and also more systematic information on the numbers of parents who request that their children are removed from SRE classes.  Note, however, that such requests by parents should not necessarily be seen as a failure in provision by schools.  In cases where a parent wishes to take responsibility to deliver this material to their child, this may be a very positive outcome.

References

Blackman, T. (2013). Exploring explanations for local reductions in teenage pregnancy rates in England: an approach using qualitative comparative analysis. Social Policy and Society, 12 (1): 61-72.

Cabezon C, P Vigil, I Rojas, et al. (2005), ‘Adolescent pregnancy prevention: an abstinence-centered randomized controlled intervention in a Chilean public high school’, Journal of Adolescent Health, 36: 64-9.

Cannonier, C. (2001) ‘State abstinence education programs and teen birthrates in the US’, Review of Economics of the Household, 2011.

Cavazos-Rehg, PA, MJ Krauss, EL Spitznagel et al. (2012), ‘Associations between sexuality education in schools and adolescent birthrates: a state-level longitudinal model’, Archives of Pediatric Adolescent Medicine, 166(2): 134-40.

DiCenso A, G Gordon, W Andrew and L Griffith (2002), ‘Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials’, British Medical Journal, 324(15, June): 1426-34.

Durrance, C (2013), ‘The effects of increased access to emergency contraception on sexually transmitted disease and abortion rates’, Economic Inquiry, 51 (3): 1682-95.

Eurydice/NFER (2009), SRE education in other countries www.inca.org.uk/Sex_and_relationships_education_December_2009_.pdf  accessed 19th October 2010.

Girma S and D Paton (2006), ‘Matching Estimates of the Impact of Over-the-Counter Emergency Birth Control on Teenage Pregnancy’, Health Economics, 15(Sept): 1021- 32.

Girma, S and Paton, D (2011) ‘The impact of emergency birth control on teen pregnancy and STIs’, Journal of Health Economics, 30: 373-80.

Supplement: Girma, S and Paton, D (2014) ‘Is Education the Best Contraception? The Case of Declining Teenage Pregnancy in England’, Nottingham University Business School Research Paper, 2014-04, http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2462432

Henderson M, D Wight, GM Raab et al. (2007), ‘Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations: final results of cluster randomised trial, BMJ, 334(Jan): 133-137.

Imamura, M., Tucker, J., Hannaford, P. et al (2007), Factors associated with teenage pregnancy in the European Union countries: a systematic review. European Journal of Public Health, 17 (6, March): 630-6.

Kohler PK, LE Manhart and WE Lafferty (2008), ‘Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy’ Journal of Adolescent Health, 42: 344-51.

Oettinger GS (1999), ‘The effects of sex education on teen sexual activity and teen pregnancy’, Journal of Political Economy, 107(3): 606-44.

Paton D (2002), ‘The economics of abortion, family planning and underage conceptions’, Journal of Health Economics, 21(2): 27-45.

Raymond EG, J Trussell and CB Polis (2007), ‘Population effect of increased access to emergency contraceptive pills: a systematic review’, Obstetrics & Gynecology, 109(1, Jan): 181-8.

Sabia JJ (2006), ‘Does sex education affect adolescent sexual behaviors and health?’, Journal of Policy Analysis and Management, 25(4): 783-802.

Stephenson J, V Strange, E Allen et al. (2008), ‘The long-term effects of a peer-led sex education programme (RIPPLE): a cluster randomised trial in schools in England’, PLoS Medicine, 5(11, Nov): 1579-90.

Van Loon J (2003), Deconstructing the Dutch Utopia: sex education and teenage pregnancy in the Netherlands, London: FET.

Supplement: Wellings, K, KG Jones, CH Mercer et al (2013), ‘The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)’, The Lancet, 382 (Nov): 1807-16.

Wiggins M, C Bonell, M Sawtell et al. (2009) ‘Health outcomes of youth development programme in England: prospective matched comparison study’, BMJ, 339 (July) b2534.

Wilkinson P, R French, R Kane et al. (2006), ‘Teenage conceptions, abortions and births in England: 19894-2003, and the national teenage pregnancy strategy’ Lancet, 368 (Nov): 1879-86.

Appendix: relevant peer-reviewed articles authored or co-authored by Professor Paton

Girma S and D Paton (2006), ‘Matching Estimates of the Impact of Over-the-Counter Emergency Birth Control on Teenage Pregnancy’, Health Economics, 15(Sept): 1021- 32.

Girma, S and Paton, D (2011) ‘The impact of emergency birth control on teen pregnancy and STIs’, Journal of Health Economics, 30: 373-80.

Paton D (2002), ‘The economics of abortion, family planning and underage conceptions’, Journal of Health Economics, 21(2): 27-45.

Paton, D. (2012), ‘Underage conceptions and abortions in England and Wales: the role of public policy’, Education and Health, 30 (2): 22-4.

Girma, S. and D Paton (2013), ‘Does parental consent for birth control affect underage pregnancy Rates?  The case of Texas’, Demography, 50 (6):2105–28

Paton, D. (2012), ‘Underage conceptions and abortions in England and Wales: the role of public policy’, Education and Health, 30 (2): 22-4.

Paton, D (2006), ‘Random Behaviour or Rational Choice? Family Planning, Teenage Pregnancy and STIs ‘, Sex Education: sexuality, society and learning, 6 (3, Aug): 281-308.

Paton, D (2009), ‘Exploring the evidence on strategies to reduce teenage pregnancy rates’, Nursing Times, 105 (42, 22nd Oct): 22-25.

October 2014