Teenage Pregnancy: great progress but more to do Alison Hadley, Director, Teenage Pregnancy Knowledge Exchange, University of Bedfordshire

A reminder of the reasons for a Teenage Pregnancy Strategy Poor outcomes for young parents and their children 50% under 18 conceptions end in abortion A key public health issue of health and educational inequalities Historically high rates compared with similar Western European countries and no sustained downward trend

Teenage Pregnancy Strategy: the goals Halve the under 18 conception rate from 1998-2010 to bring the rate in line with Western European countries Improve outcomes for teenage parents and their children, measured by increasing proportion of 16-19 mothers in education, employment or training 10 year strategies in each of the 150 local government areas with a local 2010 reduction target. If all areas met the target the 50% national goal would be achieved

Progress on reducing teenage pregnancy - and trends in chlamydia diagnosis

England progress: 1998-2012 41% reduction in under 18 conception rate – from 46.6/1000 15-17s in 1998 to 27.7/1000 in 2012. Lowest rate since 1969 when conception data collection began Both maternity and abortion rates now declining but steeper overall reduction in births of 46% ..but still higher than levels experienced by young people in comparable Western European countries 5

Under 18 conception rate | 1998-2012 Presentation title - edit in Header and Footer

Percentage change in under 18 conception rate 1998-2012 Variation in local authority reductions: 1998-2012 Progress of LAs in South Midlands and Herts Public Health England Centre Percentage change in under 18 conception rate 1998-2012

Under 18 conception rates* 2012 and % reduction since 1998 England 27.7 -41% Milton Keynes 25.5 -50% …but 2012 data showed an increase from 2011 and and Q1 2013 data also showing an increase *Number of conceptions per 1000 females aged 15/17 8

Number of under 18 conceptions, % ending in abortion and number of maternities: 2012 Number % abortion no. of maternities England 26,157 49% 13,340 Milton Keynes 115 50% 57 9

‘Hidden’ high rate wards in Milton Keynes (2009-11 data) Woughton 63/1000 Campbell Park 60/1000 Eaton Manor 55/1000 Denbigh 49/1000 Stantonbury 41/1000 Stony Stratford 41/1000 *Latest ward data is for 2009-11

Chlamydia: aims of the National Chlamydia Screening Programme A high level of diagnosis: 2,300 per 100,000 15-24 year olds Universal screening to reach large numbers of sexually active 15-24 year olds 15-24 year olds screened annually or on change of partner - including young parents Recent NATSAL data found two thirds of young people with chlamydia only had one partner in the last year - - 11

Local chlamydia data: diagnostic rate 2013 Aim: 2,300 positive tests per 100,1000 15-24s 2013 data (published 17 June) England: 2,016 positive tests per 100,000 15-24 year olds Milton Keynes: 2,700 positive tests per 100,000 15-24s - - 12

Reducing teenage pregnancy: a reminder of the evidence Provision of high quality SRE, (Kirby 2007) and improved use of contraception (Santelli 2008) are areas where strongest empirical evidence exists on impact on teenage pregnancy rates Universal and targeted. SRE and contraception provision for all, with more intensive support for young people at risk, combined with additional motivation to delay early pregnancy – ‘means and motivation’ No evidence that alternative approaches (e.g abstinence-only education or benefit conditionality) are effective

Translating evidence into a ‘whole systems’ approach: ten factors for an effective local strategy Strategic leadership accountability & SRE in schools and colleges Youth friendly contraceptive/SH services and condom schemes Targeted prevention for young people at risk Support for parents to discuss relationships and sexual health Training on relationships and sexual health for health and non-health professionals Advice and access to contraception in non-health youth settings Consistent messages to young people, parents and practitioners Dedicated support for teenage parents – including SRE and contraception Strong use of data for commissioning and monitoring of progress

Why the work needs to continue  Rates remain higher than levels experienced by young people in similar Western European countries Progress varies significantly between – and within – Local Authorities  Outcomes for young parents and their children are improving but remain disproportionately poor  Rates remain higher 15

A continuing priority: the national policy context ▪ A Framework for Sexual Health Improvement in England: - continue to reduce the rate of under 16 and under 18 conceptions one of four priorities Child Poverty Strategy: - under 18 conception rate a measure of national and local progress Troubled Families: overlapping risk factors for teenage pregnancy Raising the Participation Age: - from 2013 all 17 year olds in education, training or work based learning and all 18 year olds – until their 18th birthday - from 2015 Healthy Child Programme and School Nurse Development Programme Safeguarding and Child Sexual Exploitation Children’s Centres core purpose Public Health Outcomes Framework: - under 18 conception rate + other indicators disproportionately affecting teenage parents and their children 16

The pregnancy pathway and improving support for young parents 17

Poor child health outcomes 21% higher risk of preterm birth and 93% higher risk for second pregnancies 25% higher risk of low birth weight 41% higher rates of infant mortality (reduced from 60% in 2000) Affected by … Late booking for antenatal care (on average 16 weeks) Three times higher rate of smoking during pregnancy A third lower rate of breastfeeding Poor maternal nutrition

Poor emotional health and well being Three times the rate of post-natal depression of older mothers Higher rates of poor mental health for up to 3 years after the birth Higher risk of partnership breakdown and isolation More likely to live in poor quality housing Affecting the well being of their children and contributing to: Higher accident rates - such as from falls and swallowing substances More behavioural problems - conduct, emotional and hyperactivity problems

Poor economic well being 21% of estimated number of 16-18 year old young women not in education, training or employment are teenage mothers By age 30, 22% more likely to be living in poverty than mothers giving birth aged 24 or over Much less likely to be employed or living with a partner Young fathers twice as likely to be unemployed at age 30 – even after taking account of deprivation Which also affects the economic well being of their children who have: 63% higher risk of living in child poverty Lower academic attainment A higher risk of unemployment and low income in later life

(63% higher risk for children born to women under 20)(1) Fingertips Sexual and Reproductive Health Profiles and LA Child Health Profiles: Children in poverty (63% higher risk for children born to women under 20)(1) Rates of adolescents not in education, employment or training (NEET) (21% of the estimated number of female NEETs 16-18 are teenage mothers)(2) Infant mortality rate (41% higher risk for babies born to women under 20)(3) Incidence of low birth weight of term babies (25% higher risk for babies born to women under 20) (4) Maternal smoking prevalence (including during pregnancy) (Mothers under 20 are twice as likely to smoke before and during pregnancy and three times more likely to smoke throughout pregnancy)(5) Breastfeeding initiation and prevalence at 6-8 weeks (Mothers under 20 are third less likely to initiate breastfeeding and half as likely to be breastfeeding at 6-8 weeks)(6) 21

..but poor outcomes are not inevitable with the right support in place Family Nurse Partnership: intensive support for young parents from family nurse, from no later than 28 weeks of pregnancy until child reaches two. Randomised controlled trial reporting in 2014 Evidence from Sure Start Plus programme found key ingredients of effective support are: early identification in the antenatal period, dedicated support from a lead professional – coordinating and drawing in specialist services as necessary from education, social care, housing voluntary sector – and health services Provided in a young people friendly, non-judgemental and supportive environment – to address young parents’ waryness of professional support and fears that asking for advice makes them a bad parent. .

The importance of involving young fathers  75% of babies to teenage mothers are jointly registered with the father; only 20% are sole registrations Young fathers have a strong influence over young mothers’ attitudes and decisions about smoking and breastfeeding A good relationship with the baby’s father and supportive behaviour by him is a protective factor for postnatal depression Highly involved fathers (even if the couple don’t remain together) is associated with better outcomes for the child - emotional, behavioural and educational

The importance of partnership work: recommendations from Ofsted “’In too many cases: there had been insufficient support for young parents‘  Young teenage parents need to be supported in an environment in which they feel comfortable and supported. Adult centred services may not achieve this without additional teenage focused services  Both parents need to be supported. The father is as important as the mother and they need support to help them become good parents  There should be a joined up (multi-agency) approach to teenage pregnancy and teenage parents with every agency understanding their role within it.  Planned and coordinated transfer of care between midwifery services, health visitors and GPs is critical

Is there a joined up care pathway in your area? Free well publicised pregnancy testing and unbiased* advice on pregnancy options If abortion is the chosen option Swift referral to accessible NHS funded abortion service Pre-abortion: access to accurate, unbiased information and a trained counsellor if required, chlamydia screening and support with post abortion contraception Post abortion: access to trained counsellor if required, follow up support on contraception * Education for Choice and Telegraph reports on Pregnancy Crisis Centres

Is there a joined up care pathway in your area? If continuing the pregnancy is the chosen option - Swift referral to antenatal booking + information to support healthy early pregnancy - folic acid & healthy start Careful pre-birth assessment in maternity services to identify and address any problems early Tailored antenatal care and preparation for parenthood for teenage mothers and young fathers, including contraception and sexual health advice – including chlamydia screening

Is there a joined up care pathway in your area? Clear referral pathway between maternity services and children’s centres, HVs and general practice Dedicated adviser, co-ordinating support on health, education, housing, benefits and parenting – with more intensive help for the most vulnerable, and inclusive of young fathers Personal development plans – for both parents building aspirations and skills, promoting Care to Learn childcare funding, linked to RPA programme, local workforce development, employment and regeneration plans – and gender neutral!

Small group discussion Strengthening the prevention pathway for young people What’s working well? Are there any gaps? Strengthening the support pathway for young mothers – and young fathers Would your children’s centre/service feel friendly and accessible to young parents – mothers and fathers? Do young parents – mothers and fathers – know about all the support services available? Do practitioners and agencies work well together? Are there any quick wins to improve support for young parents? 28

References: support Ages of Concern: Ofsted Serious Case Reviews http://www.ofsted.gov.uk/resources/ages-of-concern-learning-lessons-serious-case-reviews Are we nearly there yet, dad? http://www.barnardos.org.uk/what_we_do/policy_research_unit/research_and_publications/are-we-nearly-there-yet-dad/publication-view.jsp?pid=PUB-1900 Statutory guidance on the participation of young people in education, employment or training http://www.education.gov.uk/childrenandyoungpeople/youngpeople/participation/g00222993/stat-guide-young-people-edu-employ-train Care to Learn – childcare funding for teenage parents https://www.gov.uk/care-to-learn/overview 29

References: prevention Your local teenage pregnancy statistics www.beds.ac.uk/knowledgeexchange A Framework for Sexual Health in England (DH) (2013) www.gov.uk/government/publications/a-framework-for-sexual-health-improvement-in-england Not yet good enough: Ofsted report on PSHE (2013) http://www.ofsted.gov.uk/resources/not-yet-good-enough-personal-social-health-and-economic-education-schools SRE for the 21st Century: supplementary advice http://www.sexeducationforum.org.uk/resources/sre-advice-for-schools.aspx NICE public health guidance: contraceptive services for young people up to 25 http://publications.nice.org.uk/contraceptive-services-with-a-focus-on-young-people-up-to-the-age-of-25-ph51 Ages of Concern: Ofsted Serious Case Reviews http://www.ofsted.gov.uk/resources/ages-of-concern-learning-lessons-serious-case-reviews Are we nearly there yet, dad? http://www.barnardos.org.uk/what_we_do/policy_research_unit/research_and_publications/are-we-nearly-there-yet-dad/publication-view.jsp?pid=PUB-1900 Statutory guidance on the participation of young people in education, employment or training http://www.education.gov.uk/childrenandyoungpeople/youngpeople/participation/g00222993/stat-guide-young-people-edu-employ-train 30

For more information: Teenage Pregnancy Knowledge Exchange www.beds.ac.uk/knowledgeexchange If you would like to receive free updates from the Teenage Pregnancy Knowledge Exchange, please contact me at: alison.hadley@beds.ac.uk 31