Consultation on the Pregnancy and Parenthood in Young People Strategy

Findings and Recommendations

Section 1: Delaying pregnancy in young people

A key aim of this strategy is to work across The Scottish Government policy actions that will enable and empower young people so that they feel a sense of control over their own lives, allowing them to build self-efficacy and providing equality of opportunity for the future.

Evidence shows that education and engagement with learning are key interventions for helping young people to plan for their futures - including pregnancy and parenthood. Supporting aspiration and ambition amongst young people is vital to providing positive destinations, and helping young people to plan their futures. Poor attendance at school, low attainment or achievement, few or no aspirations and free school meals entitlement are key indicators for risk of teenage pregnancy^[20]. This section emphasises the importance of education and support positive aspirations for reducing rates of pregnancy in young people.

In 2014, 75% of young people aged 15 years surveyed in the Health Behaviours of School Aged Children (HBSC) survey reported they had not had sexual intercourse,^[21] compared to 65% in the previous survey in 2010^[22]. This difference is almost entirely due to a change in reported behaviours from young women^[18]. Whilst it is positive to see that young people appear to be delaying sexual intercourse until a later age, it is likely that those who are having sex before 16 are from more disadvantaged groups and therefore are at greater risk of an early, unintended pregnancy. Evidence from the Natsal report also shows the younger the age of first intercourse the lower the level of sexual competence. Ensuring the sexual health and wellbeing of all our young people is essential not only to reduce pregnancy at an early age but also to support mutually respectful and consensual relationships. This section looks at the need for good sexual health and wellbeing, high quality services, positive relationships and high quality sex and relationships education to support young people in their wellbeing, and specifically, a wider group of interventions to support reductions in pregnancy in young people.

Positive Outcomes and Educational Engagement

The Scottish Government's ambition is to raise attainment for all of Scotland's children and young people and to reduce inequalities of outcome. We are clear that good attainment is dependent on certain key foundations of learning, namely literacy, numeracy and health and wellbeing and we want all children and young people to build solid foundations in these three crucial areas, supported by Curriculum for Excellence. However attainment is more than just exam results or test scores and includes wider achievement. Schools can help improve the life chances and outcomes for all children whatever their background or circumstances, to give them the skills, knowledge and attributes they need to succeed whatever they choose to do when they leave school.

Enabling young people to work toward achieving positive outcomes is important for developing self-esteem and self-confidence, building toward a sense of equality of future.

Evidence shows that the flexible provision of learning which is tailored to the needs of the individual is key to preventing, or delaying, pregnancy at an early age. Completion of secondary school provides great benefits for adolescents, improving health and wellbeing, increasing their capacity and motivation to prevent pregnancy empowering them to take responsibility for their own lives and for improving the lives of others.^[23] We also know that parents, carers and families are by far the most important influences in a child's life, and parents who take on a supportive role in their child's learning make a big difference in improving achievement and behaviour.

Maintaining or re-engaging young women in education is a fundamental intervention for reducing the risk of pregnancy. Young women who feel supported by their school and family and who feel confident about their future careers are less likely to view early parenthood as a way of finding meaning and gaining respect from their peers. Equally, supporting young mothers and young fathers back into school or learning is important for preventing a rapid subsequent pregnancy and ensuring better future outcomes for mother and child.

School absenteeism is linked to a number of adverse outcomes, including pregnancy in young people, and it is generally recommended that intervening early to address problematic non-attendance produces the best outcomes for the young person concerned. Deterioration in the academic performance of young women aged between 11 and 14 is a strong risk factor for those young women to become pregnant while still a teenager and once pregnant, to continue with the pregnancy^[25]. Thus, transition from primary to secondary school is an important time for young women in particular, with some evidence showing the benefits of a nurture approach for those who are potentially vulnerable during this time. The development of Scotland's National Improvement Framework^[26] in education will help to improve learners' attainment by providing better understanding of children's progress towards achieving their potential. Support needs may fluctuate with the changing needs of the young people, and therefore appropriate sharing of data and information between services and agencies is important.

Supporting Positive Relationships and Sexual Wellbeing

It is essential that all young people experience healthy, safe, consensual and mutually respectful relationships. This begins in early childhood when positive experiences and learning can enable resilience into adolescence, early adulthood and beyond. Such relationships include peers, boyfriend/girlfriends, parents and carers. Establishing connected relationships with parents/carers have been shown to have an important protective factor for young people. Parents who are aware of their child's activities have adolescents who are less likely to engage in sexual risk behaviours [and] teenage pregnancy^[27] and data show that young people who talk to their mothers/fathers are less likely to have sex before the age of 16^[28].

Whilst partner violence can affect both young men and young women, research has shown that the impact of partner violence is indisputably differentiated by gender; girls report much higher levels of negative impact than do boys^[29] and are also disproportionately perpetrated against.^[30] It is important young people are informed about the different aspects of abuse which can include coercive and controlling behaviours, emotional and mental abuse and not only physical harm.

The Scottish Government is in the process of developing a risk assessment for young people at risk of domestic abuse, which should promote healthy and safe relationships in young people. Such approaches are also important in helping children and young people identify when they are vulnerable to exploitation. Clearly, child sexual exploitation (CSE) and sexualisation of young people is insidious and difficult for children and young people to identify. It is therefore essential that professionals across different agencies actively promote healthy relationships, as well as being able to identify children and young people who may be at increased risk.

Activities to improve social and emotional wellbeing contribute to positive changes in; aspects of psychological wellbeing (self-efficacy, locus of control), confidence (self-concept, self-esteem) emotional wellbeing (anxiety stress and depression, coping skills) and social wellbeing (good relations with others, emotional literacy, antisocial and pro-social behaviour, social skills). These will contribute to young people developing safe, healthy and equal relationships which in turn will contribute to increased positive sexual behaviour. Universal programmes to address social and emotional wellbeing should be delivered effectively and consistently in all settings as part of the Mental, Emotional, Social and Physical Wellbeing organiser of the Health and Wellbeing curriculum area of Curriculum for Excellence. This also links with the National Youth Work Strategy^[31] which has an outcome to ensure young people are well informed and encouraged to make positive choices.

In order to communicate effectively with all young men and young women across Scotland about the importance of healthy, respectful relationships, a communication strategy for young people is required. Covering multiple agencies - including The Scottish Government, Police Scotland, NHS Scotland, Local Authorities and the Third Sector - the strategy would consider approaches for promoting healthy relationships in young people.

Central to the Scottish Governments Looked After Children's Strategy is the importance of relationships. We know that children who are looked after may already have had a number of their most important relationships break down. Strong relationships that last throughout any child's life are crucial and if a key relationship is broken it should be treated as a major concern in relation to that child or young person's wellbeing. It is also important that looked after children are supported to recover from these experiences by being given the opportunity to build, and/or rebuild, strong relationships with those in their lives - their carers, extended family members, social workers, mentors, corporate parents and others, including teachers. This is why the Children and Young people (Scotland) Act 2014 has introduced measures for care leavers and from this year, that allow young people who are aged 16 (born in 1999) to remain in their care placement until they are 21, if they want to, and to continue to receive aftercare support up to the age of 26. The Scottish Government is also developing a national mentoring scheme to provide an opportunity for looked-after children and young people to build long-term relationships with a supportive, reliable and trustworthy adult who is consistently there for them.

Action:

The Scottish Government to work with key partners and young people to carry out research and then develop a communications strategy for promoting understanding of consent and healthy relationships in young people.

Relationships, Sexual Health and Parenthood (RSHP) Education

The provision of Relationships, Sexual Health and Parenthood education (also known as Sex and Relationships Education, or SRE) is acknowledged as a key intervention^[32] to support positive relationships in young people and reducing rates of pregnancy in young people (in conjunction with other evidence-based interventions). RSHP education aims to encourage equality and mutual respect from an early age, as formal education is the only way of ensuring that all young people are provided with the knowledge they need, from reliable sources.^[33] All young people should receive high-quality education on relationships, sexual health and parenthood in order to respect, protect and fulfil their human rights as they grow up.

In December 2014, Guidance on the Conduct of Relationships, Sexual Health and Parenthood Education in Schools^[34] was published. This Guidance will help schools, and other educational settings, to create a positive culture, equipping children and young people with the knowledge, skills and values they need to make informed and positive choices about forming relationships. The Guidance also states that staff teaching RSHP education programmes are provided with appropriate training, and initial and career-long professional learning and support to ensure that they can deliver high-quality RSHP education with confidence to support children and young people's learning.

The young people who participated in the Young Scot engagement exercise told us that they would like to see their RSHP education delivered alongside wider life and relationship education^[35]. This reiterates the results of the Health and Wellbeing Curriculum Impact Report which found that in secondary schools, young people would like to be asked more often about what and how they would like to learn within health and wellbeing^[36]. It is also important that parents and carers take a role in discussing relationships and sexual wellbeing with their children to help the continuous discussion both in school and at home. A review of parental involvement in SRE suggest there is good evidence that school, home and community based programmes involving a parenting component can have a positive impact on young people's knowledge and and/or attitudes and improved parent-child communication.^[37]

Responsibility for RSHP education extends beyond schools and involves all those working with children and young people in Scotland. Strong partnerships between schools and community learning are therefore essential and have shown to be effective. Evidence shows that youth development programmes which include a study or learning component and voluntary service in the community can have positive impact on pregnancy rates of young women and also had a positive impact on academic achievement.^[38]

Peer education can also be an effective way to engage young people in relationships, sexual health and parenthood education. Many young people involved in the development of this strategy expressed a desire for more peer education, so that it was based upon real life experiences from a young person's perspective^[39], particularly in relation to the delivery of RSHP education. Additionally, evidence shows that the provision of peer-led programmes may be effective in reducing teenage pregnancy and delaying sexual initiation^[40]. However, it is important that any peer education programme is implemented effectively, consistently and over a sustained period and is not seen as a substitute for trained educators or a whole school approach. The input of young people into the programme and their training and supervision is key to success.

Young people should be adequately prepared for parenthood, whether that is potentially imminent or sometime in the future - if that is a choice they make. Learning about nurture and attachment can equip young men and women to understand the needs of their children and the impact their interaction and communication has on the development of that child. The Relationships, Sexual Health and Parenthood experiences and outcomes section of Curriculum for Excellence asks that all young people be taught about parenthood. Education on future parenthood is important for empowering young people to make choices about whether and when they would wish to a become parent in the future. Of the young people who participated in the Young Scot national survey for this strategy, only 51% had received education on parenthood, in comparison to relationships and contraception (76%)^[41]. This is a missed opportunity to help young people to consider their role and responsibilities as a potential future parent.

Actions:

Local Authorities to communicate and implement the Relationships, sexual Health and Parenthood education Guidance locally in partnership with key agencies.

Local Authorities to work with young people to deliver information directly on RSHP, the Guidance and their (young people's) rights in relation to it.

Schools, youth work and Local Authorities to engage young people in the development of the Relationships, Sexual Health and Parenthood (RSHP) curriculum in schools, in order to provide RSHP education that is relevant and engaging to young people. Regular review of quality assurance and ensuring content is needs led is essential.

As part of implementing Relationships, Sexual Health and Parenthood education, schools, youth work and other learning establishments to work with young people to support planning for future parenthood and understanding of the impact of the parent on child development.

Sexual and Reproductive Health Services

Evidence shows that interventions such as sex and relationships education should be combined with high-quality sexual health services and the provision of effective contraception in order to inform young people and help reduce numbers of pregnancies in young people.

Sexual health services for young people are provided by all Health Boards in Scotland^[42]. Despite this, some young people have reflected that they feel anxious about accessing some services, notably for contraception^[43]. Of those surveyed, 25% reported that they think there are difficulties for young people in accessing contraceptive services. This included a sense of embarrassment, of being judged and perceptions of [a lack of] confidentiality. It is essential that young men and young women are comfortable and confident in accessing sexual health services and those services are youth friendly and sensitive to their needs, acknowledging the unique circumstances of young people's biological, cognitive and psychosocial transition into adulthood.

All those offering sexual and reproductive health services to young people should ensure a youth-friendly approach which reassures young people about confidentiality and tackles any potential embarrassment. In order to help ensure this approach, The Scottish Government will work with stakeholders to consider the potential for a national 'youth friendly charter' which will help young people to have confidence in services.

Schools and other learning establishments have an important role to play in signposting to such services and in working with colleagues to support young people who may feel anxious about accessing sexual health services. Practitioners in health and other non-educational services are well informed about local SRH services and proactively support young people to access early help. This is particularly important for more vulnerable young people who may have a trusted relationship with a non-health practitioner, e.g. youth worker.

As set out in the Sexual Health and Blood Borne Virus Framework (2011-2015), NHS Boards should work with their Local Authority colleagues to ensure that drop-in clinics are situated in, or close to, schools so that young people can access health, including sexual health, advice and can be signposted to specialist services dependent, on the advice and support they require.

Some young people who access sexual health services may have other concerns or issues that are affecting their lives. Providing a holistic service, with appropriate and relevant integrated care referral pathways to other health and social care services, is vital for ensuring that young people receive the care, advice and support they need.

It is important that young people are aware of the full range of contraceptive options that are available and how to access these locally. Particularly important is the ability to easily access longer acting reversible contraception^[44] (LARC). Recent data has shown an increase in reliance on 'the withdrawal method' to prevent pregnancy and that the use of condoms has reduced^[45]. Such data shows that some young people are not fully informed on how to prevent pregnancy and STIs. It is absolutely essential that both young men and women have a comprehensive understanding of the effective methods of contraception for preventing pregnancy and sexually transmitted infections; that they know how and where to access such contraception; and they are able to access such contraception when needed.

During our engagement with young people, young mothers discussed the impact of contraceptive failure, that they hadn't considered that this could occur and that they didn't have the information about what to do if it does. Some young mothers reported that they had been using contraception when they conceived, and didn't understand why the contraception had failed. The young fathers we engaged with expressed a desire to know more about contraception, as there's "not enough info/advice on female contraception - guys not taking responsibility". Schools, youth services and health services should ensure that young men as well as young women are provided with comprehensive information on the importance of effective methods contraception for avoiding pregnancy.

In Scotland, women can access emergency contraception (EC) from a number of services including community pharmacies, sexual health services and primary care, free of charge. Evidence suggests that amongst some young people, knowledge about emergency contraception is limited, "there is no information told about the morning after pill, only that it exists"^[46]. In additional to longer term methods of contraception, young people should be provided with accurate information on where and when EC can be accessed. EC should be provided in an accessible and consistent way by respectful and non-judgemental staff.

Actions:

NHS Boards to continue to ensure that confidential, high quality sexual and reproductive health services are accessible to all young people at times and in locations that are appropriate to the local population and geography. This includes high quality information on their websites and through public information for young people on contraception and pregnancy.

The Scottish Government to work with stakeholders to develop a 'national youth friendly charter' which will help young people to identify that the services they are accessing are young people friendly.

Drop-in clinics which offer both general and sexual health advice and services to continue to be provided in, or close to, schools and link into other relevant local services and care pathways^[47].

NHS Boards to ensure that appropriate and integrated care pathways exist from sexual and reproductive health services to other parts of the health service so that young people can access additional support rapidly, as required.

Service providers to discuss with young people their full range of contraceptive options, and ensure they explain to the young person how their choice of contraception provides protection from unintended pregnancy and also what options are available when contraception fails or is taken incorrectly. Those not directly providing contraception counselling should ensure that they are aware of on where and when such services are available and provide clear signposting to young people on such services.

Local Authorities to work with partners locally to determine the appropriate provision of contraceptive services out with the health environment, dependent on the needs of the local population. Staff working with young people should be aware of this information and local pathways into services.

Schools, local authorities and NHS Boards to work together to ensure that all young people are provided with accurate and up to date information about the range of contraception methods and local sexual health services, including local provision of emergency contraception.

Section 2: Pregnancy in young people

Young women who have conceived should be provided with objective, and non-judgemental information and support they need to be able to make an informed choice regarding how they proceed with their pregnancy.

Early Identification of pregnancy

Data show that young women who do become pregnant, particularly those aged under 16, access antenatal booking and abortion services later than the general population^[48]. Accessing either maternity or abortion services at an earlier gestation in pregnancy supports better health outcomes for the woman concerned.

For example, in Scotland in 2012/13 only 42% of pregnant young women aged under 16 booked for antenatal care prior to 12 weeks gestation (compared with 81% of all women). For those young women choosing to have an abortion, 55% of young women aged under 16 accessed abortion services early, compared with 69% of women of all ages.

Young women, particularly those in their earlier adolescent years, may not appreciate the typical symptoms of pregnancy. At a time in their lives where their body is still changing, they may not either experience such 'typical' symptoms or recognise them for what they are. Additionally, the likelihood of another pregnancy soon after childbirth may not be recognised by those who have already had a birth. Evidence also shows that young people in Scotland have limited knowledge on abortion, which was also presented by the young people as a barrier to accessing services.^[49]

The provision of information on the signs and symptoms of pregnancy, and the potential for contraception failure can be helpful for enabling young women to recognise pregnancy or risk of pregnancy. However, it is also important to acknowledge that some young women may not access services due to extreme anxiety and desires over their pregnancy, rather than a lack of recognition. Such anxiety and distress can result in non-disclosure of pregnancy until a later stage. It is important that young women are helped to understand who they can confidentially and confidently approach, should they require support and advice about a pregnancy, and that such support should be accessed as early as possible for their own wellbeing.

Young parents engaged in the development of the strategy asked that 'more visible support' be made available for young women disclosing a pregnancy (whatever the preferred outcome)^[50]. It is therefore essential that young women have the information they need to identify that they are pregnant at an early stage (for example, understanding the 'typical' signs of pregnancy, the possibility of contraceptive failure) and be able to disclose the pregnancy to a trusted individual, and access services as early in the pregnancy as possible.

Professionals working with a young woman who have become pregnant must assess whether there are any child protection concerns, both in relation to the young woman herself and her unborn child. Decisions on intervention, supports offered or compulsory measures required to protect children and young people up to the age of 18 are dependent on professional analysis of accurate and relevant information and robust decision- making. The National Risk Framework to Support the Assessment of Children and Young People (2012)^[51] aims to support and assist practitioners at all levels, in every agency, in these tasks. The National Guidance for Child Protection in Scotland, published in 2014^[52], provides a national framework within which agencies and practitioners at local level - individually and jointly - can understand and agree processes for working together to support, promote and safeguard and the wellbeing of all children. It sets out expectations for strategic planning of services to protect children and young people and highlights key responsibilities for services and organisations, both individual and shared. It also serves as a resource for practitioners on specific areas of practice and key issues in child protection. It replaces the previous version of this guidance published in 2010 and Protecting Children - A Shared Responsibility: Guidance on Inter-agency Co-operation, which was published in 1998 and incorporates the Scottish Government guidance, Protecting Children and Young People: Child Protection Committees (2005).

Professionals should be aware that an unplanned pregnancy and or/Sexually Transmitted Infections (STIs) are possible indicators of sexual abuse or sexual exploitation. Anyone who works with a young women who has become pregnant and has concerns that the pregnancy is a result of abuse must make a referral in accordance with child protection procedures set out in Part 3 of the national child protection guidance.

Actions:

Information on pregnancy should be available in venues frequented by young people. Such information should include the importance of telling a trusted person as soon as possible, emphasise the positives of disclosure and access to services offering accurate information and unbiased support that is available locally. Specifically; Schools and Local Authorities: Young people in school to have information (as part of RSHP education) on the support and advice available locally around pregnancy. NHS Boards: Information on access to services related to pregnancy to be readily accessible and should consider the needs and concerns of young people, particularly concerns around confidentiality.

Local sexual health websites aimed at young people to ensure they include accurate and up to date information on pregnancy and local services. This will not only acknowledge the fact that typical symptoms may not manifest, but also that young people may not anticipate contraceptive failure. The resource should include information on the importance of disclosure of pregnancy to a trusted source.

Healthcare Improvement Scotland (HIS) and Information Services Division (ISD) to continue to monitor the standards on early access to services (booking and abortion) ensuring that numbers are broken down by age (both maternal age and pregnancy gestation), where appropriate.

NHS Health Boards to use this information to determine whether young women of various ages who access services are doing so as early as possible. Where delays have occurred, services should liaise with the young person to try and understand what barriers exist and feed into local information provision and referral pathways.

Pathways of care

It is essential that clear, multi-agency referral pathways are in place to provide guidance for professionals and support rapid referral for young people who become pregnant. Such pathways should be accessible to enable confidence when referring young people for additional support and thus enabling young women to access services as early as possible. Both young people and professionals who contact them should be made aware of such pathways. Where appropriate and with the consent of the young person, professionals should be able to refer confidentially into services having discussed the situation with the young person concerned.

Action:

NHS Healthcare Improvement Scotland to develop an Integrated care pathways (ICPs) providing a person-centred, evidence-based framework for delivery of high-quality care for young people under 20 who become pregnant and the professionals guiding them.

Pregnancy options

Abortion

In line with existing sexual health policy, all local areas should have clear referral pathways into abortion services. Information on local gestational time limits should be clear and made easily accessible to all health service providers as well as to women accessing services^[53], as the earlier an abortion is performed, the lower the risk of complication. In line with existing policy and NHS HIS standards, services should offer arrangements that minimise delay in providing a safe abortion of pregnancy, whilst also allowing sufficient time for reflection to consider other options^[54]. Information about the immediate return of fertility after abortion and advice on effective methods of contraception should be made available to all women accessing abortion services. All abortion services should offer effective methods of contraception post-abortion and, wherever medically possible and when acceptable to the women, provide such methods prior to discharge from the service^[55].

The vast majority of women do not require counselling post-abortion. However, it may be helpful for some women. In particular, where there are concerns about the situation in which the young woman found herself to be pregnant (for example if there was coercion, an inability to understand how a pregnancy occurred etc.). This is important for ensuring the safety for these young women and to address any circumstances which may have led to the pregnancy. Lack of such counselling may compromise the safety of the young woman if left unresolved and also may result in another unintended pregnancy.

Continuing with the pregnancy

Young women aged under 20 are more likely to book 'late' for antenatal care (i.e. after the 12^th week of gestation)^[56]. This may be for a variety of reasons, including not realising that they are pregnant, or taking time to come to terms with a pregnancy. For those with more chaotic lifestyles, they may prioritise other issues such as housing/homelessness or income may make attending appointments and maintaining contact with services difficult^[57]. Barriers to accessing antenatal care are not only attitudinal. In some areas, young parents may experience financial or transport issues that make travel to appointments difficult or impossible. In such cases, local services should work with young parents to consider how access to appointments and peer support services can be facilitated. Delayed access to antenatal care risks poorer pregnancy outcomes including higher rates of maternal and infant death and morbidity in women. It is essential that young women who choose to proceed with their pregnancy are enabled to access maternity services as early as possible^[58]. Local pathways of care are vital to this.

For first time mothers aged under 20, accessing midwifery services enables rapid referral to local Family Nurse Partnership (FNP) teams^[59]. This allows the Family Nurse to initiate contact with the young women and discuss how the programme can provide support.

Additionally, it allows NHS services to provide timely referral to local support groups so that links with other young parents can be made, as well as to any other services that the young woman may require, for example housing. As set out in the Refreshed Framework for Maternity Care in Scotland^[60] antenatal care services should be tailored and proportionate to local population need. Research has shown that some young fathers struggle to attend antenatal appointments due to work/college commitments.^[61] Additionally, they can experience negative experiences with maternity/health services and feelings of exclusion or marginalisation are reported.^[62] Supporting father's involvement in their partner's pregnancy and childbirth helps to enable a sense of shared responsibility between parents, when present, and in line with the woman's wishes, should be included in antenatal discussions. Mothers aged under 20 are less likely to attend antenatal classes^[63]. Young parents have reported that they have chosen not to access antenatal classes because of a perception that the classes would not be relevant to them - due to their age - and that they would be 'judged' by older mums and dads^[64], preferring classes targeted at their own age group.^[65]

Evidence also suggests that provision of antenatal classes designed specifically for young women appears to improve contact with antenatal care. Therefore, local areas should consider how best to provide antenatal classes that address the needs and anxieties of young mothers and fathers, helping them also link in with antenatal care.

Given the particular needs of young parents in relation to maternity services^[66], a guide for midwives, doctors, maternity support workers and receptionists will be developed based on the Public Health England guide Getting maternity services right for pregnant teenagers and young fathers. This will help those working in maternity services to better understand the particular needs of pregnant young women and their partners

Actions:

All local areas to have clear referral pathways into abortion services. Such pathways should provide accurate information and unbiased help and support and clearly state local and statutory gestational limits. Delays in accessing services should be regularly monitored and addressed.

All abortion services to offer and, where appropriate, provide effective contraception and counselling post abortion.

In line with the Refreshed Framework for Maternity Care in Scotland, local antenatal care services to consider how best to enable young mothers and fathers to attend antenatal services that are tailored toward their particular needs.

Local services to ensure that young parents are given information on, and are able to access, antenatal classes and support groups locally (both NHS and Third Sector). Such classes should take into account the particular needs and anxieties of young parents.

NHS Health Scotland to adapt the Department of Health England guide "Getting maternity services right for pregnant teenagers and young fathers" for use in Scotland to ensure local areas consider how best to provide antenatal classes that address the needs and anxieties of young mothers and fathers, helping them also link in with antenatal care.

Section 3: Parenthood in young people

Although parenthood is a positive experience for many young people, it is associated with increased risk of a range of poor social, economic and health outcomes for some. Good quality, integrated support for young parents and their families will contribute to better engagement with support services and in the longer term greater engagement in education, training and employment which will contribute to improved health and social outcomes for young parents and their children. Particularly pertinent for inclusion young parents need holistic programmes with the following^[67];

• Tailored information and advice about choices for education, training, employment and careers, childcare, money and benefits and housing
• Individualised plans for return to education and employment which consider the wider costs and benefits of such a return
• Specialised services for young parents
• Advocates to help young parents approach services and/or co-ordinate cross agency support to better match young parents needs
• Childcare provision
• Interventions to reduce domestic abuse and improve relationships

Promoting positive attitudes to young parents

Young parents have expressed that one of the greatest challenges they face is the stigma and judgemental attitudes that they experience because of their age. This is from professionals, friends, peers and even from their own family. All young parents and their babies should be provided with person-centred, safe and effective postnatal care. Such care should ensure that effective communication and liaison processes are in place across agencies (maternity teams, primary care staff, health visitors and local authority services) to ensure the holistic needs of mother and child are taken into account.

Young parents who took part in our engagement exercise reported commonly experiencing stigma, judgement and discrimination.^[68] Age and pregnancy are protected characteristics under the Equality Act (2010) and therefore it is prohibited to discriminate against or treat someone less favourably than their peers. Experiencing negative attitudes is harmful to young parents and can also prevent them feeling that they can ask for help and support. Young parents told us "if I ask for help I am seen as weak and they will use it against me", "they think I'm stupid" and "they don't listen". For many young people the fear of having their child removed from their care if they are seen not to be coping or because of their previous care-history, can act as a significant barrier to seeking early advice and support. As part of the Children and Young People (Scotland) Act 2014, for those under 18, support coordinated through a child's plan ensuring that both the parent and child has a separate plan to ensure both needs are met. If a child is considered to be at risk child protection procedures will be instigated to protect that child and actions integrated into the holistic Child's Plan. For those whose child requires o be accommodated away from home, support should be in place to address the circumstances that led to the child being accommodated and consider what support the mother/father may require in order to cope with the child being accommodated. Careful consideration needs to be given to accommodation needs and how the young person can be positively supported, particularly in the ante-natal period, to understand the stages of pregnancy and how they can begin to prepare emotionally and practically for the arrival of their baby. For some young people who have had a care-history, becoming a parent may raise particular issues about their own upbringing and how they were parented. Professionals should be mindful of this and provide appropriate counselling / emotional support.

During our work with young parents, relationships with professionals were frequently and particularly mentioned. Whilst some relationships were positive and valued, others were identified as problematic and which prevented them accessing services, "[it's] hard to build a trusting relationship with professionals in the community". Professionals working with young parents should be aware of this and consider how to adapt practice to inform and reassure potentially anxious young people. Continuing professional education programmes for frontline staff should address these issues.

Action:

Professionals working with young parents to be aware of issues potentially affecting young people engaging with services and consider how to adapt practice to inform and reassure potentially anxious young people.

Antenatal Support and Maternity Services

For young pregnant women and their partners, maternity services are often their first experience of statutory services as a potential young parent. Young pregnant women are more likely to have complex social needs including socio-economic deprivation, current or recent experience of being looked-after, homelessness, poor engagement with education and involvement in crime. Such factors are also associated with lower levels of access to and use of services.^[69] Young parents are less likely than older parents to access maternity care early on (average gestation at booking is 16 weeks), and are less likely to keep appointments. They can feel discouraged from accessing services due to a range of factors including;

• Being overwhelmed by the involvement of multiple agencies
• Unfamiliarity with care services
• Practical problems making attendance at antenatal services difficult
• Difficulties communicating with healthcare staff
• Anxieties about the attitudes of healthcare staff
• Young fathers specifically may not attend due to:
  • not knowing what maternity services are, or think they are only for mothers
  • fear judged, ignored or not taken seriously by health professionals
  • feel embarrassed about their knowledge
  • feel like they will be blamed for the pregnancy (especially if under 16)

Due to their complex needs, young pregnant woman may need a range of health and social care services, as well as support from partners in the Third Sector. It is essential that agencies communicate effectively to ensure that the needs of the young woman are met. Ideally, the views of young parents should be sought in order to tailor services to the needs of younger mothers and fathers. For those under 18 there are specific duties and provisions in the Child's Plan section of the Children and Young People (Scotland) Act (2014) that place statutory duties on a wide range of public bodies including health boards and local authorities to cooperate to support a Child's Plan. The Act also places duties on the managing authority for the Child's Plan to ascertain and have regard to the views of the child, unless this is not deemed to be practicable.

The Refreshed Framework for Maternity Care in Scotland^[70] is designed to address all care from conception throughout pregnancy and during the postnatal phase. It aims to get maternity care right for every woman and baby in Scotland - including young mothers. A named professional in maternity services who provides continuous care through pregnancy and beyond has been shown to have particular benefits for young mothers.^[71] Some young mothers particularly valued the provision of a 'link midwife'. Such support can ensure that young parents are more likely to access and maintain contact with services and have their needs met. Young mothers reported that they often didn't know what support services were available in their area. Statutory and Third Sector agencies should work together to inform young parents about available services and help young parents to access such services.

NHS services should use local data to understand numbers and characteristics of births in young women in their area and ensure that services provided are relevant and supportive to the particular needs of young mothers and fathers. By working closely with other agencies, including the Third Sector, local areas should be able to provide services that address the needs of young parents, providing them with health, social and peer support. Evidence from practice across Scotland and from young parents themselves has indicated the positive benefits that come from peer support or peer mentorship, for the parents as well as the mentors themselves. Peer mentors can provide support during pregnancy and beyond, supporting new parents to negotiate the challenges of parenthood, providing advice, support and experience.

All parents will be supported further through the implementation of the National Parenting Strategy and Early Years framework and some young parents may also be offered support through Family Nurse Partnership (FNP). FNP is a preventive programme for young first time mothers^[72] in Scotland^[73]. The programme offers intensive and structured home visiting, delivered by specially trained nurses, from early pregnancy until the child is two. FNP has three aims: to improve pregnancy outcomes; child health and development; and parents' economic self-sufficiency. The methods are based on theories of human ecology, self-efficacy and attachment, with much of the work focused on building strong relationships between the client and Family Nurse to facilitate behaviour change and tackle the emotional problems that prevent some mothers and fathers caring well for their child. However there is still a need to provide services to young parents who do not meet the criteria of FNP i.e. not first birth and if contact is made with maternity services before 28 weeks.

Actions:

Agencies working with young parents to ensure that they communicate effectively, across multiple services, putting the young parent(s) and their needs at the centre.

NHS Health Boards to use local data to understand their local population and ensure the provision of local services that are relevant to the needs of young mothers and fathers.

Support in the postnatal period and beyond

The Health Visitor Universal Pathway for the NHS in Scotland promotes progressive universalism but supports communities, parents and families in need of additional support, achieving equity, addressing early identification, intervention and reducing inequalities. Health Visitors have an important role in supporting young parents - either through the universal services or through more intensive support. Again, links to multiple agencies can help young people access the range of services they might need. The Scottish Government has committed to 500 new health visitor posts to support a new health visiting regime in Scotland, by the end of 2018.

Support to control reproductive health and pregnancy spacing

Rapid, repeat pregnancy (i.e. within two years) is associated with an increase in adverse health outcomes, and inter pregnancy interval of less than one year is particularly associated with preterm birth and neonatal death^[74].

Scottish data (2011) show that approximately 25% of mothers aged under 20 will have a subsequent conception within two years (with around 7% conceiving again within one year). Percentages for under 18s are similar (24.9%) however, rapid subsequent pregnancies amongst those aged under 16 are notably lower (5.9%).

Ensuring that young women and their partners understand how quickly fertility returns after giving birth and have access to contraception post-partum will help young mothers to control their reproductive health. Contraception should be discussed with young women and their partner in the antenatal period to enable them to consider their options, and whether contraception post-partum is acceptable to them. Their preference should be recorded in their notes, and where acceptable/feasible, contraception should be provided prior to discharge from hospital^[75]. Whilst vital, provision of post-partum contraception is not the only intervention to help young women and their partners avoid unplanned rapid repeat pregnancy. Enabling young mothers to stay/re-engage in education, attend college and find fulfilling employment are important interventions for helping to address family spacing.

Action:

The Scottish Government to work with young mothers who have taken part in the Growing Up in Scotland (GUS) survey and who experienced a rapid repeat pregnancy (i.e. within two years) to try to understand more comprehensively the factors that may have influenced a subsequent birth.

NHS Boards to ensure that all pregnant women aged under 20 are consulted about their contraception preferences antenatally and that these preferences are provided in the post natal period, preferably prior to discharge from hospital (in line with CEL 1). If this is not feasible then follow up should be made to have their contraception preferences fitted when suitable. Where appropriate young fathers to be informed and involved too.

Education, training and employment

The Scottish Government is committed to ensuring that all young people achieve their potential, and are able to access learning, training or work. For most young people, S4 is the last compulsory year of schooling. Through Opportunities for All,^[76] all young people aged 16 - 19 are entitled to an appropriate offer (or more than one offer if necessary) of learning or training. This applies equally to young parents, as to all young people, and is particularly vital for ensuring that young mothers and fathers are enabled to build a future for themselves and their families. The entitlement to support from a Named Person should help many young people under 18 obtain the advice, support and help that they need to secure appropriate and desirable education, training and employment.

Career and educational interventions are particularly appropriate to the needs of young parents as they improve access to relevant and tailored information about choices, and raise the employment and career aspirations of young people increasing positive long term outcomes for themselves and their families.

Young women who become pregnant and young mothers should be supported to remain in school or college until at least 18 years of age, where they should be able to access education that fits with their skills and aspirations. Flexible and appropriate childcare is central to this and evidence suggests that those programmes with support for childcare (both education and career development) are the most effective.

It is vital that these young people have a positive educational experience as their child will be entering the education system within four years and it is well recorded that experiences and values are passed from generation to generation. A whole family approach to increasing educational aspiration is also important as a mother's low education aspirations for her daughter aged 10, is a risk factor for pregnancy before 18. For those young women (and their partners) who become parents whilst of school-age, a positive school environment is also essential in allowing them to remain in education. In the first instance, both before and after the birth, young people should be encouraged to remain in their own school where they have established relationships with teachers and peers and have a chosen course of study. Local Authorities should develop guidance for schools to ensure that supports and planning processes are in place to allow this to happen. Where a young person cannot or will not re-engage with their current school, alternative learning provision needs to be identified. In some areas there is the option to attend a school that has an integrated young parents' support base on-site. Currently, Scotland has three schools where young mothers can access education with on-site childcare and parenting support;

Smithycroft High School, Glasgow

The Wester Hailes Education Centre, Edinburgh

Menzieshill High School, Dundee

These centres are situated in areas where higher than average rates of young parenthood enable such centres to be established. This Strategy does not recommend one particular model, as it will depend on local circumstances. However, it is strongly recommended that young mothers are actively enabled to stay in school of their choice (some may wish to stay at their local school and not to go to a unit for young mothers or may chose an alternative one to fit their circumstances) and that across Scotland, Local Authorities consider the most appropriate model of childcare for their young people.

Evidence suggests that a focus on employment and provision of jobs and higher earning for young mothers is associated with improved long-term self-sufficiency. There is no published data currently as to how many young mothers remain in education, training and employment. Our ambition is that no young mother has to leave education, training or employment as a direct consequence of a pregnancy.

A focus on young fathers continuing with education/training is important given their high risk of later unemployment. Services report that once they find out they are becoming a father, young men often feel they should bring money into the family and drop out of education into low paid work which then contributes to family and child poverty.

Action:

As part of the evaluation of the Pregnancy and Parenthood in Young People Strategy, the Scottish Government to work to understand the numbers of young mothers in education, training and employment, linking to the National Indicator^[77]on young people in learning, training or work.

Local Authorities should work with local schools to ensure that flexible childcare is available for young mothers staying in school based education. Such childcare should enable them to participate fully in the activities of the schools. Schools should acknowledge the impact of parenting on young mothers and support flexibility in timetabling. Schools and further education settings to also recognise the parenting responsibilities of fathers.

Childcare funding

Where young women have expressed a desire to remain in their current schools, flexible childcare is essential for the young women to finish their education, pursuing qualifications and learning that will enable them to achieve their aspirations and ambitions.

Colleges are allocated childcare funding annually by the Scottish Funding Council (SFC) as part of college student support funds. This funding has two elements; the Lone Parent Childcare Grant (LPCG) and the Discretionary Childcare Funds. Young parents have identified that accessing funding for childcare when in college can be challenging. Work will be undertaken to provide information to young parents on the funding which will help them to complete their time at College. This information should be provided to young parents locally via statutory and Third Sector services.

The Children and Young People (Scotland) Act 2014 has increased, early learning and childcare entitlements. From August 2014, the children are eligible for 600 hours/ year (the equivalent of around 16 hours/ week during term time) early learning and childcare include:

• 3 and 4 year olds, starting from the first term after their third birthday
• 2 year olds from the point that they are looked after, under a kinship care order, or with a parent appointed guardian.
• 2 year olds, starting from the first term after their second birthday, (where their 2nd birthday falls on or after 1 March 2014) with a parent in receipt of qualifying benefits; or, the first term after their parent starts receiving qualifying benefits of:
  • Income support
  • Jobseekers allowance (income based)
  • Employment and Support Allowance (income based)
  • Incapacity or Severe Disablement Allowance
  • State Pension Credit

From August 2015 this will be extended further to include:

• 2 year olds, starting from the first term after their second birthday (where their second birthday falls on or after 1 March 2015) with a parent in receipt of qualifying benefits; or the first term after their parent starts receiving qualifying benefits of^[78]:
  • Child Tax Credit, but not Working Tax Credit and your income is less that £16,105
  • Both maximum Child Tax Credit and maximum Working Tax Credit and your income is under £6,420
  • Support under Part VI of the Immigration and Asylum Act 1999
  • Universal Credit

Once a child becomes entitled to early learning and childcare, they will stay entitled even if their parent becomes employed, or their situation with parent or carers changes.

Housing

Pregnant young women/mothers make up about one in twenty of all applications and homeless assessments in Scotland.^[79] For young people, leaving home is associated with greater autonomy and freedom to act as they choose.^[80] For some young parents, particularly those of a younger age, staying in the family home offers a secure environment for parent and child. However, for many young parents (be they as lone parents or as a couple) independent living enables them to develop self-efficacy and skills they require. They often need help and support to learn independent living skills and how to maintain a tenancy etc. For young parents, secure, permanent housing that is situated in their community is essential in enabling them to build a network of support and provide a positive family environment for themselves and their child/children.

In Scotland, all those assessed as unintentionally homeless by local authorities are legally entitled to settled accommodation. A person should be treated as homeless even if they have accommodation, if it would not be reasonable for the person to continue to occupy it, for example, if it is an unsuitable environment for a family or pregnant woman.

The Scottish Government is working with partners from local government, health and the Third Sector to put in place policies, guidance and legislation to prevent and alleviate homelessness and to ensure that every homeless person is able to receive information, advice and support according to their needs. For Corporate Parents involved in housing and homelessness this follows earlier work on the guidance on Housing Options Protocols for Care Leavers^[81] published in 2013 which we would expect to continue to been seen as a good practice tool and will be refreshing in light of the provisions in the 2014 Act.

Young pregnant women / young parents may not always understand how to access housing "I went down the homeless route but I did not have the right information or support when I went through it" and thus should have the help and support they need to understand their rights in this area.

Action:

Community Planning Partnerships to use their data to understand local circumstances of young parents in regard to housing needs. Ideally, young families should be enabled to stay in their communities where they can access family and peer support. Young pregnant women / young parents should be offered access to secure, permanent housing where they can establish a safe and secure home for themselves and their child/children with additional support to develop independent living skills, tailored to their individual need.

Income Maximisation and Support

Young mothers under 20 are considerably more reliant on state benefits and tax credits than older mothers - a position that remains the case as the child ages.^[82] Through our work with young parents, it is clear that many find accessing the welfare and income to which they are entitled confusing and difficult.

On-going work in the Scottish Government to ensure income maximisation will be essential in providing support for young parents. However, it is clear that the situation that young parents find themselves in is extremely complex, and depends on a variety of personal circumstance. In light of this, the Scottish Government will work with professionals and young parents to build resources to provide the information they need in the language and media they prefer and understand.

Action:

The Scottish Government will work with the Child Poverty Action Group (Scotland) to develop a resource aimed at those professionals who support young parents. The resource will provide up to date information on welfare and other resources available to young parents.

The Scottish Government will work with CPAG (Scotland), Young Scot and One Parent Families Scotland to develop a resource for young parents which provides up to date information and support on accessing welfare and includes help and support to young people to understand their housing rights.