Pregnancy and Parenthood in Young People Strategy

Strand 2: Giving young people more control around pregnancy

A key aim of this Strategy is to 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.

Positive Outcomes and Educational Engagement

Evidence shows that education and engagement with learning are key interventions which help young people to plan for their future - including pregnancy and parenthood. Supporting aspiration and ambition amongst young people is vital as 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^[5].

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. 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, it includes wider achievements. 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 opportunity.

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; and empowering them to take responsibility for their own lives and for improving the lives of others^[52]. 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 people in education is therefore a fundamental intervention for reducing the risk of pregnancy (action 2.8). Young people 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^[2]. Equally, supporting young mothers and young fathers back into school or learning environments is important for preventing a rapid subsequent pregnancy and ensuring better future outcomes for mother and child. Appropriate early childhood and educational interventions in all settings, targeted at young people at risk of poor educational outcomes, will contribute to improved educational attainment and connectedness with education. This will support young people to develop their aspirations and skills for the future and ultimately contribute to an increased likelihood of remaining in education or gaining training opportunities or employment as well as a reduction in unintended pregnancy.

School absenteeism is linked to a number of adverse outcomes, including pregnancy in young people. 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 predictor for those young women to become pregnant while still a teenager and once pregnant, to continue with the pregnancy^[5]. 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. 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

In 2014, 75% of young people aged 15 surveyed in the Health Behaviours of School Aged Children (HBSC) survey reported they had not had sexual intercourse^[7], compared to 65% in the previous survey in 2010^[6]. This difference is almost entirely due to a change in reported behaviours from young women^[5],[8-9]. Evidence from the Natsal^[25] report also shows that 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^[8].

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^[29] and data show that young people who talk to their mothers/fathers are less likely to have sex before the age of 16^[7].

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^[27] and are also disproportionately perpetrated against^[1]. It is important that young people are informed about the different aspects of abuse, including coercive and controlling behaviours, emotional and mental abuse and not just physical harm.

The Scottish Government's Equally Safe: Scotland's strategy for preventing and eradicating violence against women and girls^[44] also shares these same outcomes and work is underway to develop 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^[14] 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, consensual and safe relationships, key messaging should will be developed by the Scottish Government to support communications activities and this aspect of this Strategy (action 2.1). These messages will be cross-cutting, will reflect current evidence, and will be relevant and available to multiple agencies - including the Scottish Government, NHS Scotland, Local Authorities, the Third Sector and Police Scotland.

Relationships, Sexual Health and Parenthood (RSHP) Education

The provision of Relationships, Sexual Health and Parenthood education is acknowledged as a key intervention^[25] to support positive relationships in young people and to reduce rates of pregnancy in young people. 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^[29]. For all of these reasons, 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 (action 2.3).

In December 2014, Guidance on the Conduct of Relationships, Sexual Health and Parenthood Education in Schools^[46] 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 Sexual Health and Blood Borne Virus Framework 2015-2020 update^[45] also highlights needs for more comprehensive, consistent and inclusive RSHP education in schools.

The young people, who participated in the Young Scot engagement exercise for this Strategy, told us that they would like to see their RSHP education delivered alongside wider life and relationship education^[54]. 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^[15]. 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 relationship and sexual health education 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^[53].

Responsibility for RSHP education extends beyond schools and involves all those working with children and young people in Scotland. Strong partnerships between schools, youth work and community learning are therefore essential and should be in place. (action 2.2). 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 have a positive impact on academic achievement^[34].

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 is based upon real life experiences from a young person's perspective^[53], 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^[34]. 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 become a parent in the future. Of the young people who participated in the Young Scot engagement exercise for this Strategy, only 51% had received education on parenthood, in comparison to relationships and contraception (76%)^[54]. This is a missed opportunity to help young people to consider their role and responsibilities as a potential future parent. For these reasons, a collaborative approach to preparation for future parenthood, including an understanding of the impact of the parent on child development, should therefore be implemented locally. (action 2.4).

Sexual and Reproductive Health Services

Interventions such as sex and relationships education (RSHP) should be combined with high-quality sexual health services and the provision of effective contraception in order to help reduce numbers of pregnancies in young people^[10].

Sexual and reproductive health services for young people are provided by all Health Boards in Scotland, either directly or in partnership with other partners^[17]. Despite this, some young people have reflected that they feel anxious about accessing some services, notably for contraception^[54]. 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 (SRH) 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 ensure young people know their rights around confidentially in different services (action2.3)

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 should be well informed about local SRH services and proactively support young people to access early help (action 2.6). 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 update (2015-2020)^[45], 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 (action 2.7). The location should reflect the views of young people.

Some young people who access sexual health services may have other health, relationship, social or economic concerns that are affecting their lives. Providing a holistic service, with appropriate and relevant integrated care referral pathways (action 2.5) 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 (LARC)^[b]. Recent data has shown an increase in reliance on 'the withdrawal method' to prevent pregnancy and that the use of condoms has reduced^[7]. This 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. 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 of 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"^[54]. 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.

Overview of actions:

Giving young people more control
Links to short term outcome: Young people have a better understanding of what healthy, safe, consensual and equal relationships are
2.1	Develop key messaging to promote understanding of consent and healthy relationships in young people.	Scottish Government
2.2	Demonstrate partnership working to support the Relationships, Sexual Health and Parenthood (RSHP) education guidance locally.	Local Authorities Third Sector NHS Boards Parents and carers
2.3	Demonstrate how young people are aware of their rights and how they are acting on them.	Local Authorities Third Sector NHS Boards
Links to short term outcome: Young people have increased knowledge of nurture, attachment, preconception and parenthood
2.4	Implement a collaborative approach to preparation for future parenthood including an understanding of the parent's impact on child's development.	Local Authorities Third Sector NHS Boards
Links to short term outcome: Young people have increased knowledge and skills around contraception and sexual negotiation
2.5	Develop appropriate and integrated routes into other health and social agencies to respond to the health and social care needs of young people.	Community Planning Partnerships
2.6	Provide young people with clear signposting to services. Service responses are in line with the user group, reviewed on a regular basis and additional steps are being taken to reach out to non-attenders.	Local Authorities Third Sector NHS Boards
2.7	Determine the appropriate provision of contraceptive services out with the health environment, dependent on the needs of the local population.	Local Authorities Third Sector NHS Boards
Links to short term outcome: Improved attitudes to and experience of education
2.8	Early educational interventions for young people are delivered in all settings and are proportionate to need.	Local Authorities Third Sector NHS Boards