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Teenage pregnancy can be both a cause and a consequence of social exclusion and is more common in areas of deprivation. Evidence clearly shows that having children at a young age can damage young women’s health and emotional well-being, and severely limit their education and career prospects, resulting in increased levels of poverty and social exclusion. The challenge for Nottinghamshire, therefore, is to provide young people with the means to avoid early pregnancy, but also to tackle the underlying circumstances that motivate young people to want to, or lead them passively to become pregnant or young parents at a young age. Girls having sex under-16 are three times more likely to become pregnant than those who first have sex over 16[2]. Around 60% of boys and 47% of girls leaving school at 16 with no qualifications had sex before 16, compared with around 20% for both males and leaving school at 17 or over with qualifications.
Teenage boys and girls who had been in trouble with the police were twice as likely to become a teenage parent, compared to those who had no contact with the police, very much linked to their risk taking behaviours[5]. A significant proportion of teenage mothers have more than one child when still a teenager. Among girls leaving school at 16 with no qualifications, 29% will have a birth under 18, and 12% an abortion under 18, compared with 1% and 4% respectively for girls leaving at 17 or over. Leaving school at 16 is also associated with having sex under 16 and with poor contraceptive use at first sex (see below). Research has shown that by the age of 20 a quarter of children who had been in care were young parents[10]. The prevalence of teenage motherhood among looked after girls under-18 is around three times higher than the prevalence among all girls under-18 in England.
Research findings from the 1970 British Birth Cohort dataset showed being the daughter of a teenage mother was the strongest predictor of teenage motherhood. Research shows that a mother with low educational aspirations for her daughter at age 10 is an important predictor of teenage motherhood.
At age 30, teenage mothers are 22% more likely to be living in poverty than mothers giving birth aged 24 or over, and are much less likely to be employed or living with a partner.
Children of teenage mothers have a 63% increased risk of being born into poverty compared to babies born to mothers in their twenties and are more likely to have accidents and behavioural problems. Teenage mothers are 20% more likely to have no qualifications at age 30 than mothers giving birth at 24 years or over. Children of teenage mothers are at increased risk of lower educational attainment and have lower economic activity in adult life. The infant mortality rate for babies born to teenage mothers is 60% higher than for babies born to older mothers aged 20-39. Teenage mothers, young fathers and their children are more likely to be in poor health and to live in poor housing.
It is however useful to see how the numbers of conceptions rather than just the rate, the graph below shows the reduction in the numbers of conceptions from the 1998 baseline year to 2011, reducing the numbers of teenage conceptions by 163 conceptions. Nationally it is estimated that 20% of all teenage conceptions are repeat conceptions - local data can be a challenge to source.
In 2011 42.6% of all teenage conceptions resulted in a Termination of Pregnancy (ToP) across Nottinghamshire.
Over time the proportion of teenagers who choose to terminate a pregnancy has remained fairly static for Nottinghamshire as a whole.
The proportion of teenage abortions varies across areas, Rushcliffe and Gedling districts having a higher proportion than Mansfield and Bassetlaw.
Data also identifies the proportion of young women under the age of 19 who have repeat abortions.
Teenage conception data varies across Nottinghamshire’s districts as can be seen in the table below. It is important to note, that as teenage conception rates reduce overall across England, a larger number of wards within Nottinghamshire have been identified as hot spots compared to 2008-10. The Slope Index score for 2008-10 was 46.2 which means that there were 46 more teenage conceptions per 1,000 in the most deprived ward compared to the least deprived ward. Figure 12 shows how the SII (without the wards plotted) has changed over different time periods (2001-03, 2004-06 and 2005-07, 2007-09 2008-10).
Under 16 conception data is provided on an aggregated basis over three years as numbers are relatively small and this prevents young women from being identified. Using teenage conception data from the last 20 years we can work to predict the teenage conception rates and numbers for the next seven years until 2020. The table below shows the forecasted conception rate for Nottinghamshire along with forecasts for England and the region.
The forecasted rate shows a steady slow decline in teenage conception rates for Nottinghamshire, however experience from the last ten year teenage pregnancy strategy has shown us that fluctuations exist where there are changes in economic status, educational attainment and aspirations.
The graphs below show the projected teenage conception rate amd numbers for Nottinghamshire to 2020.
Following the national 10 year teenage pregnancy strategy which aimed to reduce teenage conception rates by 50% by 2010, indicators for the reduction of teenage conception remain in the national Public Health Outcomes Framework so Local Authorities will be held to account for performance in reducing teenage conceptions. The Teenage Pregnancy Integrated Commissioning Strategy includes a detailed action plan with a number of milestones and outcomes to achieve that will contribute to the prevention of teenage conceptions as well as improved outcomes for teenage parents and their children.
Effective young people friendly contraception and sexual health service provision which prevents teenage conception and poor sexual health. Ensuring Children and Young People have access to information and education about sexual health and relationships. Contraception and Sexual Health (CaSH) Services offering a range of contraception and advice for young people in a number of localities and settings including West Nottinghamshire College and secondary schools in Bassetlaw. There are 54 different contraceptive clinics available to people of all ages, which provide the full range of contraceptive methods across the county.
The map below shows there are gaps in the current coverage of the C-Card scheme across targeted localities and further work is being progressed to establish more sites in pharmacists, youth centres, and schools. Community Pharmacists offer a range of services free to young people including pregnancy testing, the C-Card condom scheme and Emergency Hormonal Contraception (EHC). Teenage Pregnancy Training is offered for free to practitioners working across Nottinghamshire.

The Family Nurse Partnership (FNP) is a licensed, evidenced based, intensive nurse-led prevention and early intervention programme for vulnerable first time young parents and their children.
The FNP provides structured home visiting from early ante-natal until the child is 2 years of age, by the same Family Nurse to ensure consistency of support. Children‘s Centres bring together childcare, early education, health and family support services for families with children under 12 years old. There are plans to increase the engagement of teenage parents to support their access to education, training or employment in addition to holistic interventions. The Special Educational Needs Team in Nottinghamshire County Council  supports educational packages for pregnant young women of school age as well as teenage mothers with a view that they can maintain or reintegrate with their education. The Teenage Pregnancy midwifery team is offered by Nottingham University Hospital (NUH) and covers Gedling, Broxtowe, Rushcliffe as well as the city. Care to Learn is a national scheme that provides financial support to teenage parents who want to continue their education and need help with the cost of childcare and any associated travel. Healthy Start is a national scheme that aims to improve the health of low-income pregnant women and families on benefits and tax credits. The National Institute of Clinical Effectiveness (NICE) issued guidance[18] in 2005 which promoted the use of Long Acting Reversible Contraception (LARC) for teenagers amongst other groups. The NICE clinical guideline on LARC offers the best-practice advice for particular groups, including women who have HIV, learning disabilities or physical disabilities, or are younger than 16 years. NICE recommends the use of LARC for sexually active young people because the effectiveness of barrier and oral contraceptive pills is dependent on their correct and consistent use.
Currently there is very low uptake of long-acting reversible contraception (around 5% of contraceptive usage nationally). Early intervention can prevent teenage pregnancy and help teenage mothers avoid getting pregnant again too quickly.
Early intervention also helps increase young parents’ take up of work, education or training. Education and career development programmes providing support for childcare can be effective in encouraging young parents back into education or employment. The Family Nurse Partnership is well evidenced as improving outcomes for teenage parents and their children.
Improved employment for mothers, and fewer subsequent pregnancies with bigger gaps between births.
When asked what school nurses should provide the following sample of comments shows the need for young people to have someone accessible that they can go to for information and advice. Teenage Pregnancy disproportionately affects those experiencing poverty and social exclusion. An Equality Impact Assessment was published alongside the Teenage Pregnancy Integrated Commissioning Strategy in January 2012. There is no evidence to suggest that children and young people with physical disabilities are at risk of teenage pregnancy so the strategy does not target this group actively.
Both genders are actively targeted within the strategy when working to prevent teenage conceptions so there should be no adverse impact on different genders.
Children and young people from BME backgrounds are a key target group within the strategy so there should be no adverse impact on people of different races, ethnicity, colour or nationality. There is no evidence to suggest any particular faith group is at risk of teenage pregnancy so no specific groups will be targeted for interventions. The need to address homophobia and support the needs of Lesbian, Gay, Bisexual and Transgender (LGBT) children and young people is important in Sex and Relationships Education and through contraception and sexual health services. The numbers of teenage parents accessing children‘s centres should be higher and it is hoped that the new provider of the centres will proactively engage pregnant teenagers and teenage parents to increase their participation in children centre activities.
Despite there being a specialist teenage pregnancy midwifery team in the South of the County, there is no similar service in central or north Nottinghamshire.
There is no careers service in Nottinghamshire so the need to support pregnant teenagers and teenage parents to access training or employment remains a challenge, this is apparent in the poor take up of the Care to Learn grant which is a key contributor to increasing engagement. Uptake of the Care to Learn childcare grant for teenage parents is low and further work is required to promote the grant to young people and local practiutoners in education and childcare settings. There are a number of gaps in knowledge and further work is required to identify data and knowledge in order to progress a successful strategy.
There is a refreshed Ofsted inspection regime for schools which no longer includes the specific focus on the delivery of Personal Social Health Education (PSHE) or Sex and Relationships Education (SRE), this means there is no way of knowing if and how schools deliver SRE which is critical for the continued improvement of young people’s sexual health. Anecdotal evidence from local services state that many young people seeking support for contraception or a sexual health screen are experiencing sexual exploitation. Teenage mothers are also more likely to need and receive targeted support than older parents. If teenage conceptions increase there will be a greater financial burden on Central and Local Government and the NHS in terms of housing, welfare benefits, and health interventions. A teenage mother who does not work until her child is three can be entitled to benefits of up to £20,000.
Despite the ending of the national teenage pregnancy strategy, there is still a focus on reducing teenage conceptions included in the Public Health Outcomes Framework[3] and Sexual Health Framework[4]. Work to tackle teenage pregnancy is a key element embedded in priority areas of work including Child Poverty and Early Help across Nottinghamshire.
The poorer outcomes associated with teenage motherhood also mean the effects of deprivation and social exclusion are passed from one generation to the next.
Research shows that children born to teenagers are more likely to experience a range of negative outcomes in later life, and are up to three times more likely to become a teenage parent themselves. Among 16-18 year olds surveyed in London, non-use of contraception at first intercourse was most frequently reported among Black African males (32%), Asian females (25%), Black African females (24%) and Black Caribbean males (23%)[3].
Mansfield has the highest conception rate across Nottinghamshire closely followed by Ashfield. Rates are starting to increase in Ashfield, Mansfield and Rushcliffe but rates do fluctuate over time as can be seen below. The relationship between a health issue and deprivation can be quantified using the slope index of inequality (SII) and changes can be monitored over time.

This shows that the conception rate in the most deprived wards has reduced in 2008-10 from that of 2001-03 (top right end of slope) but the conception rate in the least deprived wards has increased. Under 16 aggregated conception rates for Nottinghamshire increased in 2003-05 and have remained static since 1998.
It is also important to remember the high levels of teenage conception in some districts and wards across Nottinghamshire. The map below shows the location of all CaSH services with the exception of school based services. There are higher numbers of specific Children and Young People clinics in the Northern Clinical Commissioning Groups (Mansfield, Ashfield, Newark & Sherwood and Bassetlaw).
There are targets for the scheme to increase the number of access points across settings in hot spot wards. The location of the pharmacists that offer EHC is included in the map below and plans are under way to encourage more pharmacists to offer the service throughout Nottinghamshire in particular in teenage pregnancy hot spot wards. 388 local practitioners participated in training activities from April 2012 to the end of March 2013, all training courses have been evaulated well and plans to target those working with at risk groups are well under way. Families in receipt of FNP support will be supported to access wider service provision, including children’s centre activities.
They aim to tackle child poverty and social exclusion by working with parents-to-be, parents, carers and children to promote physical, intellectual and social development of babies and young children so they have the best start in life.
They are commissioned by Nottinghamshire County Council and delivered by a partnership of County Health Partnerships, North Nottinghamshire College and Family Action.
There is, however, variation across districts, as it is unclear what proportion of the teenage parent population have engaged with children‘s centres across each district.
The service also leads on ensuring that homeless young people are offered appropriate packages of care including supported accomodation when required. Schools are offered funding to support education at school or through a specialist PRU or alternative education provider.
Women qualify during the whole of their pregnancy if they are under 18 when they apply, even if they do not receive welfare benefits.
Evaluation of work in England and in other countries has shown that the three most important aspects are high quality sex and relationships education (SRE), easy access to youth-centred contraceptive services and early intervention to target young women at greatest risk of pregnancy[16]. High quality SRE gives young people the information and skills to make informed choices about relationships, sex, contraception and protection against sexually transmitted infections. In 2008 more than 22,000 young people signed a petition organised by the UK Youth Parliament in favour of improving SRE in schools. By contrast, long-acting reversible methods have high effectiveness that does not depend on daily compliance which is useful for teenagers. A number of studies have shown that many young women wished, in retrospect, that they had waited longer before becoming parents.
For example in Stoke-on-Trent, dedicated teenage pregnancy prevention officers use a screening toolkit to identify young people at risk. For some young people, becoming a parent is a positive choice especially if the young person has low aspirations.
There is however emerging evidence that children and young people with Special Educational Needs (SEN) are often at risk because they face a number of risk factors as stated previously.
Because historically pregnancy and sexual health work focused on young women there has in fact been an increased emphasis on young men.
A better understanding of sexual exploitation locally is required and a new Child Sexual Exploitation pathway is in place[1].
Plans are underway for services and commissioners to enable the assessment of services by seeking user feedback and scrutiny of policies and processes.
Most young parents do not regret having their children but wish they had waited until they were older. The SII takes into account the relative population size and the level of deprivation of each ward in Nottinghamshire. This implies that health inequalities have reduced slightly but not in the way we would want. The team was launched in April 2012 and so far 14 school aged young women have received support to remain or reintegrate into education.
Maternity services are now commissioned to provide an enhanced service for mothers under 20 years of age, who are now classed as intermediate on the maternity pathway.
Childcare payments are made directly to the childcare provider and travel payments are made to the learning provider.
It has a vital role in equipping young people to handle pressure to have sex as well as helping them recognise inappropriate behaviour.
Issues for providers include the initial cost, which may be thought of as too high particularly if the methods may not be used or required for the intended duration, the need for specific clinical skills (including awareness of current best practice, insertion practice and ability to give information or advice on the methods available) and facilities.
There is no additional funding for the work as plans to assess services will be embedded into core provision and commissioning.
The SII shows the difference in conception rates between the most deprived wards and the least deprived wards.
The figures below demonstrate that the Slope Index Value has reduced and is going in the right direction, therefore health inequalities are reducing. Further work is required to enable young people to access LARC methods from a range of accessible sites including GP practices located in hot spot wards who are able to offer one-to-one support. However, this is mainly due to teenage conception rates in the least deprived area increasing slightly or remaining static rather than because they are reducing in the most deprived areas within the County.

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