The Teenage Pregnancy Strategy for England: lessons learned but more to do Alison Hadley, Director, Teenage Pregnancy Knowledge Exchange, University of Bedfordshire

The reasons for a Teenage Pregnancy Strategy A key public health issue of health and educational inequalities Disproportionately poor outcomes for young parents and their children Approximately 75% pregnancies were unplanned Historically high rates compared with similar Western European countries and no sustained downward trend

A review of international evidence to inform the Strategy Strongest evidence for reducing teenage pregnancy is provision of high quality sex and relationships education, combined with easy access to youth friendly contraceptive services Universal and targeted. SRE and contraception provision for all young people, with more intensive support for young people at greatest risk of pregnancy Dedicated coordinated support for teenage parents – with more intensive support for the most vulnerable No evidence that alternative approaches – for example abstinence-only education or reducing financial/social benefits are effective in reducing teenage pregnancy

Risk factors for teenage pregnancy Most young people who become pregnant before 18 do not have specific risk factors but some young people are more at risk and need additional support. The strongest associated risk factors for young people are: Family poverty Persistent absence from school Slower than expected academic progress between ages 11-14

Risk factors for teenage pregnancy Other risk factors Young people who have experienced family breakdown, physical and/or sexual abuse Young people with mental health problems Alcohol – a risk factor for pregnancy and STIs, independent of deprivation Teenagers with a previous pregnancy: 20% births conceived to under 18s are to teenage mothers; 11% of abortions to under 19s are repeat abortions

Teenage Pregnancy Strategy A 30-point action plan, with four themes Joined up action: nationally, regionally and locally Better prevention: giving young people choice through improved sex and relationships education and easier access to youth friendly contraceptive services A national communications campaign to reach young people and parents Coordinated support for teenage parents with piloting of the Sure Start Plus programme and specific funding for childcare

The Strategy goals: national and local targets Reduce by 50% England’s under 18 conception rate* from 1998-2010 - to bring the rate in line with comparable Western European countries Local reduction targets for each of the 150 local government areas. Increase proportion of 16-19 year old mothers in education, training or employment to promote choice, financial independence and reduce social exclusion * Conceptions include maternities and abortions and are calculated at the age of the young woman at conception – not at age when she has the abortion or birth

Mid-strategy review Steady decline in national rate but insufficient progress to meet target Wide variation in progress between local areas The national reduction would have doubled if all 150 local areas had the same reductions as the top 25% Government ‘Deep Dive’ in depth review comparing similar areas with contrasting progress Areas with better reductions were implementing all aspects of the strategy, supported by senior leadership

New guidance and Ministerial focus More prescriptive guidance for local areas Self assessment toolkit to help local areas monitor their actions New Ministerial focus on local areas with high and increasing rates: - annual meetings with senior leaders - six monthly progress reports with ministerial feedback to senior leaders Additional support for high rate areas from Regional Teenage Pregnancy Coordinators 9

More prescriptive guidance: the ten key factors for effective local strategies Strategic leadership accountability & Sex and relationships education in schools and colleges Sexual health services contraceptive & Youth friendly y Clear and consistent messages to young people, parents and practitioners on SRE and sexual health Workforce training SRE & access to contraception in youth services Targeted SRE and contraception/SH support for young people at risk Local performance commissioning & management of data for Strong use Dedicated support for teenage parents – including contraception to prevent repeat pregnancies Supporting parents to discuss sex & relationships

2008-11: a strengthened focus on contraception Conceptions leading to births were declining faster than abortions Additional government investment (£33M during 2008-11) to improve young people’s knowledge of and access to full range of contraception, including newer long-acting reversible contraception (LARC) New communications campaign – to normalise discussion about contraception (and chlamydia) – on TV, cinema, print and digital 11

Progress from 1998-2011

New guidance for improved support for teenage mothers and young fathers

Poor child health outcomes 21% higher risk of preterm birth and 93% higher risk for second pregnancies 25% higher risk of low birth weight 60% higher rates of infant mortality 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 11% of all young people not in education, training or employment are teenage mothers or pregnant teenagers 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

Guidance informed by Sure Start Plus and relevant NICE guidance Solution to improved outcomes rests with a range of services working together – health, education, social care, youth support services, housing, the voluntary sector Key ingredients of effective support are: early identification of support needs in the antenatal period, dedicated adviser – coordinating and drawing in specialist services as necessary Family Nurse Partnership: intensive support for young parents from family nurse, from no later than 28 weeks of pregnancy until child reaches two. Expansion to 15,000 places by 2015. Randomised controlled trial reporting in 2014.

A focus on positive involvement of 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

Dedicated and joined up support recommended by serious case reviews 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  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 Both parents need to be supported. The father is as important as the mother and they need support to help them become good parents

Guidance focused on establishing a joined up care pathway  Early pregnancy testing and access to unbiased advice on pregnancy options If continuing the pregnancy is the chosen option - Swift referral to antenatal booking + information to support healthy early pregnancy 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

Guidance focused on establishing a joined up care pathway Clear referral pathway between maternity services and on-going support services 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, linked to local workforce development, employment and regeneration plans – and gender neutral!

Additional government action to support the guidance New commissioning advice on young people friendly maternity services Teenage Pregnancy Midwifery Network – for specialist and non-specialist midwives to share good practice Funding for foundation learning programmes to support young parents who have been out of education Dedicated funding for childcare – 73% of teenage parents reported not being able to return to learning without funding Supported housing pilot to test most effective on-site and floating support for young parents

Progress on prevention:1998-2011 ▪ 34% reduction in under 18 conception rate – from 46.6/1000 15-17s to 30.7 ▪ Lowest under 18 conception rate in England since 1969 ▪ Both maternity and abortion rates now declining ▪ Reductions in 149/150 local government areas 23

Local Progress | 1998-2011 All top-tier local authorities except one (Torbay) have improved performance. Camden has most improved performance, with a rate that is now less than 40% of its rate in 1998. Twenty local authorities have reduced their rates to half (or better) of their 1998 rate.

Progress on outcomes for young parents ▪ Increases in breastfeeding (2005-2010): 51% to 58%, breastfeeding at 4 months almost doubled ▪ Reduction in smoking (2005-2010): smoking before and during pregnancy down 68%-57%; smoking throughout pregnancy down by 25% ▪ Increase in education and training: from 22% to 33% - with some areas reaching >50% But …local data not yet differentiated by age so monitoring of local progress remains difficult and awaiting new indicator on perinatal mental health 25

Some lessons learned Concerted effort makes a difference! High rates are not inevitable if the right actions are put in place and young people given choices Teenage pregnancy needs to be everyone’s business, with evidence translated into clear actions and accountability for each agency - but compulsory SRE was a missing piece of the jigsaw A clear goal and senior leadership are essential – at national and local level To address the causes and consequences of teenage pregnancy, a strategy needs to focus on prevention and supporting young parents 26

Further progress needed Nationally, rates remain higher than similar Western European countries – only two thirds towards original 50% reduction target Progress needs sustaining in the local areas showing good reductions and accelerating in local areas with smaller reductions High quality SRE, easy access to contraception and choice of pregnancy options not yet available to all young people Further improvements needed on coordinated support for young parents with better data collection to monitor outcomes and narrow inequalities 27

Continuing Government Priority Public Health England: under 18 conception rate one of 66 key indicators for national and local improvements in public health Department of Health: a further reduction in the under 18 conception rate is a priority in the Sexual Health Improvement Framework, published in March 2013 ..but less focus, funding cuts, welfare reforms and health and education changes pose significant challenges to making significant progress 28

For more information: Teenage Pregnancy Knowledge Exchange www.beds.ac.uk/knowledgeexchange alison.hadley@beds.ac.uk 29