The Teenage Pregnancy Strategy for England: what we did and what we learned Alison Hadley, Director, Teenage Pregnancy Knowledge Exchange, University of Bedfordshire

The reasons for a Teenage Pregnancy Strategy

The reasons for a Teenage Pregnancy Strategy A key public health issue of health and educational inequalities 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

The disproportionately poor outcomes for young parents and their children 11% of all young people not in education, training or employment are teenage mothers or pregnant teenagers 20% more likely to have no qualifications at age 30 22% more likely to be living in poverty at 30, and much less likely to be employed or living with a partner Children of teenage mothers have a 63% increased risk of experiencing child poverty 3 times the rate of post-natal depression and a higher risk of poor mental health for 3 years after the birth 3 times more likely to smoke during pregnancy, and 50% lower rates of breastfeeding, with negative health consequences for the child Children of teenage mothers have higher rates of accidents and behavioural problems Babies born to teenage mothers have a 60% higher risk of infant mortality

The development of the Strategy

Some key facts 46 per year old women became pregnant in 1998 – 46% ended in abortion 80% of the conceptions to under 18s are to year olds The median age of first sex in England is 16 30% of young people have first sex under the age of 16 96% of births to teenagers are outside marriage, but 76% are jointly registered with the father

A review of international evidence 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

The Strategy goals: National and local targets Reduce by 50% England’s under 18 conception rate* from 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 year old mothers in education, training or employment to improve outcomes for teenage parents and their children. *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

Teenage Pregnancy Strategy A 30-point action plan, with four themes Joined up action: nationally, regionally and locally Better prevention: improving sex and relationships education and access to youth friendly contraceptive services A national communications campaign to reach young people and parents Coordinated support for teenage parents

Teenage Pregnancy Strategy: joined up structures ▪ Central Government Teenage Pregnancy Unit ▪ Cross Government Teenage Pregnancy Board ▪ 9 Regional Teenage Pregnancy Coordinators ▪150 Local Teenage Pregnancy Coordinators in each Local Government area ▪ Local Teenage Pregnancy Partnership Boards - with representation from health, education, housing, social services, youth services and relevant voluntary sector organisations ▪ Teenage Pregnancy Advisory Group of independent experts

Funding Local Implementation Grant for every local area Size of grant: determined by size of population and degree of challenge (150K-600K per year - £25M per year in total) Ring fenced grant with requirement to: - appoint local Teenage Pregnancy Coordinator - establish a local Teenage Pregnancy Partnership Board - provide government with annual report on progress Central government funding to support national campaign and other strategy activity: £7M per year

A strategy for each local government area National guidance from the Teenage Pregnancy Unit Local strategy developed by Teenage Pregnancy Partnership Board Each strategy assessed by Regional Teenage Pregnancy Coordinator and Teenage Pregnancy Unit PCs and TPU

Government actions to support improvements in SRE and access to contraception New statutory guidance on sex and relationships education; SRE professional development for teachers and school nurses; funding for NGO, Sex Education Forum to provide advice for local areas and schools New guidance on: young people friendly contraceptive services; for youth workers and social workers to support young people to use contraceptive services; increasing contraception and condom use by boys and young men; supporting young people from black and minority ethnic communities; establishing school and college contraception and sexual health services

Government support to improve sex and relationships education Government Sex and Relationships Education guidance for schools Sex and relationships education training programme for teachers to improve knowledge, skills and confidence Funding for NGO - Sex Education Forum – to provide evidence based briefings and practical support to schools and local areas

Government guidance to improve access to contraception Guidance on young people friendly contraceptive services Guidance for youth workers and social workers to support young people to use contraceptive services Guidance on increasing contraception and condom use by boys and young men Guidance on supporting young people from black and minority ethnic communities «Guidance on establishing contraception and sexual health services in schools and colleges

Young people friendly services: Department of Health criteria  Easy to use - in the right place, open at the right time  Well publicised in schools, colleges and youth settings  Confidential  Youth friendly environment  Well trained friendly and welcoming staff  Monitored and evaluated by young people - ‘mystery shopping’of services  Someone with a smile would be your best bet!

National communications campaign Sex. Are you thinking about it enough? - universal campaign for under 18s – boys and girls Headline messages: Resisting peer pressure to have early sex Awareness of risk of unprotected sex: pregnancy and STIs The importance of using condoms and contraception to prevent pregnancy and STIs National radio and magazine adverts Local leaflets and posters Supported by website and free national helpline and NGOs – Brook and family planning association

Mid-Strategy review – 2005/6

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

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

The ten key factors for effective local strategies  Strategic: senior leadership and engagement from all partner agencies with accountability for delivery of actions  Data: local data and population knowledge used to inform commissioning of services and to monitor progress  Sex and relationships education (SRE): strong delivery of SRE by all schools & colleges, linked to  Easy access to contraception: young people friendly contraception/sexual health services, in the right place, open at the right time and trusted by teenagers – supported by free condom distribution schemes in community outlets 

The ten key factors for effective local strategies  Targeted prevention for at risk groups: More intensive SRE and sexual health advice for young people more at risk  Workforce training for practitioners in touch with young people: sexual health and relationships training for health and youth practitioners in touch with young people  Partnerships with youth and community services: integrating SRE and sexual health into youth services – contraception and sexual health advice in youth settings or ‘one stop shop services (particularly important for boys)

The ten key factors for effective local strategies  Support for parents : to encourage early discussion on sex and relationships with their children  Communications: clear and consistent messages to young people and parents, practitioners working with young people and the local media - providing accurate information and encouraging young people to seek early advice  Coordinated support for young parents: dedicated coordinated support for teenage mothers – and young fathers – including SRE and contraception to prevent repeat pregnancies

2008: a stronger focus on improving contraceptive use

Improving knowledge, access and use of effective contraception Conceptions leading to births were declining faster than abortions Additional government investment (£33M during ) to improve young people’s access to full range of contraception Particular focus on improving knowledge and access to long acting reversible contraception (LARC) New communications campaign

A new communications campaign Sex. Worth Talking About Contraception. Worth Talking About: there are 15 different contraceptive methods, including new long acting methods which are safe and effective – talk to a nurse or doctor to find the right one for you. Chlamydia. Worth Talking About. chlamydia often has no symptoms but can cause infertility - accept the test. …and remember, you won’t be protected from STIs without a condom

A campaign to reach young people, parents and professionals  Television, cinema, radio and digital adverts – running at prime times to reach widest audience  Leaflets for parents, young people and professionals focused on increasing knowledge and encouraging conversation  Campaign materials for local areas to distribute to services and local communities  Worth Talking About website for more information and details of local services

Contraception worth talking about

Progress so far:

England progress: ▪ 34% reduction in under 18 conception rate – from 46.6/ s to 30.7 ▪ Lowest under 18 conception rate in England since 1969 ▪ Both maternity and abortion rates now declining ▪ >70,000 under 18 conceptions avoided if conception rate had remained the same as 1998

Local Progress | % LAs have reduced rates more than the England average, 53% less. London has the largest reduction (44%). East and North West the lowest (30%)

Some lessons learned

Lessons learned Concerted effort makes a difference! With the right actions rates can be reduced, even in deprived communities Teenage pregnancy needs to be everyone’s business – with all agencies understanding why it matters. Evidence needs to be translated into clear actions for each agency To address the causes and consequences of teenage pregnancy, a strategy needs to focus on prevention and supporting young parents A clear goal and senior leadership are essential – at national and local level

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  The vast majority of pregnancies remain unplanned with at least 50% ending in abortion Outcomes for young parents and their children need further improvement

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 Monitoring of annual and quarterly data will continue at national and local level

For more information: Teenage Pregnancy Knowledge Exchange