Providing specialist sexual health advice within adolescent diabetes services

In 1999, the Government launched a strategy to reduce teenage pregnancy rates by half in relation to the 1998 baseline conception figures by 2010, and to increase the proportion of teenage parents in education, training or employment to 60% by 2010 (Social Exclusion Unit, 1999). 

Current teenage conception rates for England are 41.7 per 1000 girls aged 15–17, which represents an overall decline of 10.7% since 1998. The 2007 conception rate for girls under 16 years of age in England was 8.3 per 1000 girls aged from 13–15 years.  This is 6.4% lower than the teenage pregnancy strategy’s 1998 baseline rate of 8.8 conceptions per 1000 girls aged 13–15 years (Office for National Statistics and Teenage Pregnancy Unit, 2009). 

Teenage pregnancy is associated with a range of poor outcomes for both child and mother (Box 1). The National Service Framework for Children, Young People and Maternity Services (Department of Health and Department for Education and Skills, 2004) requires PCTs and local authorities to ensure that interventions to improve young people’s sexual health and reduce teenage pregnancy are included in local health promotion strategies. 

Why manage diabetes in pregnancy?
The 2005 Confidential Enquiry into Maternal and Child Health (CEMACH, 2005) report was the largest ever enquiry into diabetes and pregnancy undertaken in the UK. It examined the outcomes of 3733 women, accounting for 3808 pregnancies between 1 March 2002 and 28 February 2003. It found that a woman with diabetes is much more likely to (CEMACH, 2005):

• Deliver the baby early.
• Require an induction of labour.
• Deliver by Caesarean section.

It was also found that babies of women with diabetes are: 

• Five times as likely to be stillborn compared with babies from mothers without diabetes.
• Three times as likely to die in their first few months of life compared with babies from mothers without diabetes.
• Twice as likely to have a major congenital anomaly compared with babies from mothers without diabetes.

The management of pregnancy in an individual with diabetes is a highly intensive and interventional process, with the requirement of multiple injections and blood tests every day to maintain near normoglycaemia. Other medications have to be reviewed as they can cause fetal abnormalities, and high-dose folic acid is to be taken to help prevent neuro-tubal defects (CEMACH, 2005). With planning and specialist support services, a woman with diabetes can reduce these risks and have a normal birth (Department of Health, 2001). 

In England and Wales there are approximately 650000 births each year, of which 2–5% are complicated by diabetes. Of those births associated with diabetes, 7.5% are by women with type 1 diabetes and 5% by women with type 2 diabetes (NICE, 2008). One of the key elements to a successful outcome for a pregnancy complicated by diabetes is pre-conceptual care with screening for complications such as diabetic retinopathy and nephropathy, along with medication review and establishing good glycaemic control prior to conception. Unplanned pregnancies should be avoided (NICE, 2008).

Teenagers with diabetes
As one in 15 of all births are to women under age of 20 years old (Department for Children, Schools and Families, 2009), it is imperative that those providing a service to all teenagers with diabetes actively address the sexual health of the individuals that they care for and follow national guidance. The importance of the avoidance of unplanned pregnancies should be an essential component of adolescent diabetes education. 

The young person’s intentions regarding pregnancy and contraceptive use should also be documented at each contact with their diabetes care team (NICE, 2008). This may prove difficult for teams to achieve if they do not have designated adolescent services. There may also be a lack of ability to have confidential conversations with the young person in some paediatric diabetes clinics. However, in view of the HbA_1c target for pregnancy of 6.1% (43 mmol/mol), and the recommendation that those with an HbA_1c level >10% (86 mmol/mol) should avoid pregnancy, many adolescents with diabetes have suboptimal control for pregnancy, and therefore need information and access to adequate contraception (NICE, 2008). 

The Sexual Offences Act (2003) does not prevent healthcare professional from giving confidential advice and treatment to young people under 16 years of age. This includes contraception if acting to protect that young person from sexually transmitted infections, preventing pregnancy, promoting emotional wellbeing and ensuring physical safety. The healthcare professional should be well versed with local safeguarding policies and take into account the young person’s ability to consent to treatment and the Gillick competency using Fraser guidelines (Atherton, 2009).

Teenagers tend to be later in accessing maternity care than older individuals, with the average gestational age at booking being 16 weeks (Department for Children, Schools and Families, 2009). Often this is because they do not realise they are pregnant, or actively conceal the pregnancy while they try to come to terms with being pregnant, and their fear of others’ reactions to the pregnancy (Department for Children, Schools and Families, 2009). NICE (2008) recommends that joint antenatal and diabetes care should start as soon as pregnancy is suspected, with booking ideally by 10 weeks at the latest; paediatric and adolescent healthcare teams therefore need to facilitate this early presentation.

In the author’s local area, a sexual health advisor with additional training in diabetes attends the young persons’ diabetes clinic working as part of the adolescent diabetes team to provide an integrated, confidential sexual health service to the young people attending the clinic. This is funded on a sessional basis from the acute paediatric budget. This person can facilitate referral into a wider network of sexual health services as and when required by the young person with diabetes. Their role and responsibilities are outlined in Box 2, with an example of practice in Box 3. Although the young person in the example did become pregnant, her ability to access specialist services enabled her to receive prompt specialist advice when she required it, and empowered her to address her own sexual health needs at the time.

This example is one of many ways that sexual health services can be integrated into adolescent diabetes services, but the author recognises that this model of care is not duplicated throughout the country. Local Authorities have made it a priority to develop comprehensive programmes of sex and relationship education in schools, with training for professional partners, such as Connexions, and youth and social workers. In every area there should be well publicised young-person-centred contraception and sexual health services (Department for Education and Skills, 2006), which young people can be signposted to from diabetes clinics. 

Some school health services offer “Clinic in a Box” services that can also be used. “Clinic in a Box” is a mobile sexual-health service that is offered to young people in a confidential setting, often at lunchtime in school. Initiated in North Staffordshire, and adopted in other areas, this service offers relationship and sexual health advice and support, condoms, pregnancy testing, emergency contraception, chlamydia and gonorrhoea screening (Atherton, 2009).

Conclusion
Sexual health advice and the need for planned pregnancies should be fully integrated into any paediatric and adolescent diabetes service, as the statistics show that young people within the age group we serve do conceive with all the associated risks of an unplanned teenage diabetes pregnancy.