Pregnancy and Parenthood in Young People Strategy

Strand 3: Pregnancy in young people

Young people who have conceived should be provided with objective, and non-judgemental information and support 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^[22]. Accessing either maternity or abortion services at an earlier gestation in pregnancy supports better health outcomes for the woman concerned (action 3.3).

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 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^[16].

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, 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 approach in confidence, should they require support and advice about a pregnancy, and that such support should be accessed as early as possible for their own wellbeing (action 3.1).

Young parents engaged in the development of this Strategy asked that 'more visible support' be made available for young women disclosing a pregnancy (whatever the preferred outcome)^[54]. 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 that they are able to disclose the pregnancy to a trusted individual, and access services as early in the pregnancy as possible (action 3.2).

Professionals working with a young pregnant woman must assess whether there are any child protection concerns, both in relation to the young woman herself and her unborn child. Decisions on intervention, support offered or compulsory measures required to protect children and young people up to the age of 18 are dependent on professional analysis of accurate, as well as relevant information and robust decision making. The National Risk Framework to Support the Assessment of Children and Young People (2012)^[41] 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^[37], 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.

Professionals should be aware that an unintended pregnancy and/or sexually transmitted infections (STIs) are possible indicators of sexual abuse or sexual exploitation. Anyone who works with a young pregnant woman 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.

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 (action 3.4). 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.

Pregnancy options

As with all decisions around pregnancy, young people should be given appropriate information and the opportunity to discuss all available options with a trusted person. There are three options when pregnant; continue the pregnancy and keep the baby, have an abortion or continue with the pregnancy and place the baby for adoption.

Young women aged under 20 are more likely to book 'late' for antenatal care (i.e. after the 12^th week of gestation)^[c]. 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^[11]. 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 (action 3.6). 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^[11]. 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^[48]. 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^[47] 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^[31]. Additionally, they can experience negative experiences with maternity/health services and feelings of exclusion or marginalisation are reported^[31]. Supporting the father's involvement in their partner's pregnancy and childbirth helps to enable a sense of shared responsibility between parents. Mothers aged under 20 are also less likely to attend antenatal classes^[3]. 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^[54], preferring classes targeted at their own age group^[13].

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 (action 3.6). Given the particular needs of young parents in relation to maternity services^[d], a guide for midwives, doctors, maternity support workers and receptionists will be developed in collaboration with the NHS and young parents 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 (action 3.7).

In terms of abortion, all local areas should have clear referral pathways into abortion services in line with existing Sexual Health and Blood Borne Virus Framework update (2015-2020)^[45]. 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^[30], 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, whilst also allowing sufficient time for reflection to consider other options^[17]. 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^[42] (action 3.5).

The vast majority of women do not require counselling post-abortion. However, it may be helpful for some women and fathers. 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. Support may also be required for instances where abortion is required on medical grounds, young parents may require support around mental wellbeing to help them prepare for future pregnancies.

Overview of actions: