Why_Teenage_Pregnancy_Matters by Phit Bhwp

1. Introduction - Why Teenage Pregnancy Matters. Teenage pregnancy is a significant public health and social exclusion issue. Having children at a young age places young women and their children at risk of poor outcomes:      

Teenage Parents are less likely to finish their education and are more likely to bring up their children alone and in poverty. The infant mortality rate for babies born to teenage mother is 60% higher than for babies born to older mothers. Teenage mothers are more likely to smoke during pregnancy and less likely to breastfeed, both of which have negative health consequences for the child. Teenage mothers have three times the rate of postnatal depression of older mothers and a higher risk of poor mental health for three years after the birth. Children of teenage mothers are generally at increased risk of poverty, low education attainment, poor housing and poor health and have lower rates of economic activity in adult life. Rates of teenage pregnancy are highest among deprived communities, so the negative consequences of teenage pregnancy are disproportionately concentrated among those who are already disadvantaged.

(Teenage Pregnancy Next Steps: Guidance for Primary Care Trusts and Local Authorities on the Effective Delivery of Local Strategies. DFES 2006) In addition the financial cost of teenage pregnancies is high:    

The cost of teenage pregnancy to the NHS alone is estimated to be £63 million a year. Benefit payments to a teenage mother who does not enter employment in the three years following birth total between £19,000 and £25,000 over three years. Teenage mothers are much more likely than older mothers to require targeted support from a range of local services e.g. to help them re-engage with education, training or employment or to help them access supported housing. Broad estimates suggest that for every £1 spent on the strategy there is a saving of £4 to the public purse when assessed over a period of five years.

(Teenage Pregnancy Next Steps: Guide for Local Authorities and Primary Care Trusts on Effective Delivery of Local Strategies DfES 2006) It has been reported that In Birmingham and Solihull the cost of teenage pregnancies to the NHS alone is estimated to be around £1.5 million a year. (Sex and the City- draft Sexual Health Needs Assessment for Birmingham and Solihull 2007) Birmingham has an additional financial incentive to focus on reducing teenage conceptions. If we achieve our 2008 LPSA stretch target we stand to receive a reward grant of £2.6 million in 2010. 2. 0 Outcome Analysis The Teenage Pregnancy Strategy is subject to a number of national and local performance targets. Progress towards these targets impacts on the Annual Performance Assessment and the Joint Area Review for Children’s Services as well as the Healthcare Commission PCT star ratings. 2.1 Targets The Social Exclusion Unit's Report on Teenage Pregnancy, published in June 1999, set out two national targets: to halve the under 18 conception rate by 2010 (and establish a firm downward trend in the under 16 rate); and to increase the participation of teenage parents in education, training or work, to reduce their risk of long-term social exclusion. The Social Exclusion Unit Report also set a target that all under 18 teenage lone parents who cannot live with family or partner should be placed in suitable supported accommodation by the end of 2003. This target has had a low profile since 2003 and is no longer being used as a key performance indicator. In 2002 a further target was announced to reduce the risk of long-term social exclusion by increasing the participation of teenage mothers aged 16 to 19 in employment, education or training to 60% by 2010. Local Connexions Partnerships share this target, as well as the target to halve the under 18 conception rate by 2010.

There is also a commitment to reduce health inequalities with a target to 'achieve agreed local teenage conception reduction targets while reducing the gap in rates between the worst fifth of wards and the average by at least a quarter in line with national targets'. This target is measured at a national level. Birmingham has two local targets in addition to the main PSA target of a 50% reduction in under 18 conceptions by 2010: LPSA: Achieve an average rate of decline that is 4.8% better than the England rate of decline by 2008 LAA: No more than 7 Birmingham wards to be more than 25% higher than the Birmingham average by 2009. We do not know yet whether the under 18 conception rate will be one of the locally selected targets for the new Local Area Agreement. 2.2 Outcomes for Young People In keeping with the move towards outcome-driven strategic planning, the following outcomes are suggested as the principal outcomes for the Teenage Pregnancy Strategy. These are clear links between these and the Brighter Future Strategy Priority Outcomes.    

Young people are able to make informed choices about their sexual health, sexual behaviour, personal relationships and parenthood. (Physical and Emotional Health) Young people are free from sexually transmitted infections, unplanned pregnancies and avoidable terminations. (Physical Health) Young people have the confidence and skills to ask for information, gain support and to access advice and sexual health services when needed. (Social Literacy) Young people are able to form healthy and fulfilling personal relationships, free from coercion and exploitation. (Emotional Health, Social Literacy, Behaviour)

    

Young people, including young parents, are able to fulfil their educational and economic potential. (Literacy and Numeracy, Job Skills) Young families have a safe place to live. (Physical and Emotional Health) Young parents and their children are healthy. (Physical and Emotional Health) Young people – including young parents -make a positive contribution. (Social Literacy) Young people become successful parents.(Behaviour, Emotional Health)

Work is continuing to identify how we can measure progress towards these outcomes using appropriate performance indicators. 2.3 Conception trends Under 18s Birmingham has seen a decrease in the under 18 conception rate between 1998 and 2005 of 13.4%. The England rate of decline was 11.3% for the same period. Our best performing year was 2002, when our rate of decline was 15.5%, but this was followed by a slight increase in 2003.

2010

1998 baseline

Birmingham MCD England Wes t Midlands LA 2004 target

30 20 10 0 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 p 20 06 20 07 20 08 20 09 20 10

Under 18 conception rate per 1000

70 60 50 40

Year

Fig 1 source ONS. In 2005 the under18 conception rate for Birmingham was 50.5 per 1000 young women aged 15-17, compared with the England average of 41.1. We have the 45th highest rate out of 148 top-tier local authorities. Birmingham has the best rate of decline of our statistical neighbour group as determined by the DfES. Table 1: Under-18 conception trends by DfES Statistical Neighbours Under-18 conception rate LA code 00CN

LA Birmingham MCD

00KA 00CS 00CW

Luton Sandwell Wolverhampton

% difference

Deprivation score 37.6

1998 58.3

2005 50.5

1998-2005 -13.4

23.3 35.4 32.2

43.1 69.1 66.3

41.5 62.1 61.4

-3.7 -10.1 -7.5

00FY

Nottingham City

41.8

74.7

69.3

-7.2

Fig 2 Source: ONS Our rate of decline is better than Manchester, Leeds, Bristol, Sheffield, and Newcastle-Upon-Tyne, but not as good as Liverpool or Leicester. Despite some progress we are not on track to meet our PSA or LPSA target and will have to accelerate considerably to meet them. To achieve the 50% reduction target by 2010 we need to prevent between 100 and 150 conceptions year on year. To achieve the LPSA target we will need to have prevented approximately 40 additional conceptions a year in 2006, 2007 and 2008, assuming that the national rate of decline continues to follow its current trajectory Conceptions Under 16 Figures for the under 16 population show a small but concerning rise in the number and rate of conceptions in the younger age group in Birmingham since 2001, at a time when the England rate is declining Under 16 conceptions

England Birmingham MCD

20012003

20022004

20032005

Number

Rates

Number

Rates

Number

Rates

22,360

7.9

22,132

7.8

22,201

7.7

547

8.5

562

8.7

578

9.0

Fig 3 Source: ONS Under 16 Rate = number of under 16 conceptions per 1000 young women aged 13-15

Terminations As this table and graph illustrate (Fig 4), our under 18 abortion rate has not declined significantly since the late 1990s, it is our maternity rate which has reduced. Repeat terminatons Recent figures on the percentage of repeat abortions for under 19s by PCT show that in 2006 the national average for repeat abortions was 10.7%. Heart of Birmingham PCT was better than the national average at 8.8%, but Birmingham East and North PCT and South Birmingham PCT were worse at 11.4% and 12.3% respectively. Overall in Birmingham in 2006 there were 88 repeat abortions by young women under 19. The rate of second and subsequent pregnancies among teenagers in Birmingham is not known.

Birmingham MCD Under 18 conceptions Abortion rate Maternity rate

Fig 4 Source ONS

1997-99

2003-05 58.1 22.5 35.6

% change 52.1 22.3 29.8

-10.3 -0.6 -16.4

Rate per 1000 girls aged 15-17

Outcome of u18 conception 199799 and 2003-05

Births

Abortions

0 1997-99

2003-05 Years

Ward Data Data at ward level shows us that our under 18 conceptions in Birmingham are more concentrated in particular areas.

WARD NAME

No of u18 conceptions 2001-3

U 18 conception rate 200103

No of u18 conceptions 2002-4

U 18 conception rate 2002-04

change from 2001-3 to 2002-4

Hall Green Sutton Vesey Sutton Four Oaks Moseley Sparkhill Sutton New Hall Small Heath Sandwell Perry Barr Harborne Selly Oak Oscott Edgbaston Handsworth Quinton Nechells Northfield Bournville Brandwood Sparkbrook Washwood Heath Acock's Green Sheldon

37 37 36 37 76 49 108 64 38 42 54 63 36 106 48 118 73 74 62 130 101 81 58

30.68 36.63 35.50 31.44 31.73 36.08 34.02 34.56 34.39 37.91 56.25 64.68 33.27 42.15 56.54 44.05 75.18 66.07 52.41 47.22 36.98 53.82 65.24

42 45 43 36 72 58 94 73 46 38 50 60 41 93 51 98 66 69 69 112 113 85 61

23.45 25.04 25.97 27.21 31.13 31.64 32.95 33.66 34.85 38.50 38.58 41.84 42.84 43.79 44.16 47.69 47.72 48.42 48.42 49.06 50.70 52.76 56.64

7.23 11.59 9.54 4.22 0.60 4.44 1.07 0.90 -0.46 -0.59 17.67 22.84 -9.57 -1.64 12.38 -3.64 27.46 17.65 3.99 -1.84 -13.71 1.06 8.60

decrease decrease decrease decrease decrease decrease decrease decrease increase increase decrease decrease increase increase decrease increase decrease decrease decrease increase increase decrease decrease

Kingstanding Yardley Longbridge Hodge Hill Bartley Green Billesley Soho Weoley Aston Stockland Green King's Norton Kingsbury Fox Hollies Erdington Ladywood Shard End

127 90 108 97 83 112 130 103 151 108 103 69 123 98 89 136

86.87 82.64 64.94 72.01 73.98 92.26 51.77 102.28 53.99 80.12 93.55 78.41 87.92 77.96 44.30 105.10

110 95 122 103 86 129 124 103 145 119 98 82 133 110 104 120

61.32 61.49 61.52 64.29 65.60 65.85 66.24 66.80 70.15 74.00 76.32 77.65 77.91 79.37 81.38 88.30

25.55 21.16 3.42 7.72 8.38 26.41 -14.47 35.49 -16.16 6.11 17.23 0.76 10.01 -1.40 -37.08 16.80

decrease decrease decrease decrease decrease decrease increase decrease increase decrease decrease decrease decrease increase increase decrease

Fig 5 Source: ONS As might be expected there is some correlation between wards with low educational attainment, high deprivation and under 18 conceptions, however two of our most deprived wards, Small Heath and Sparkhill have under 18 conception rates below the national average. (Fig 6 and 7) This could possibly be explained by the ethnic make up of the population in those areas, with a high proportion of young people from South Asian backgrounds. (See 2.4 below)

u 18 concpetion rate vs % of boys with no GCSE passes by ward** 16 Shard End 14 Kingsbury

% boys achieving no GCSEs

Kingstanding Washwood Heath Sparkbrook

Aston

Stockland Green Ladywood

Sparkhill

Nechells Handsworth

Soho

Fox Hollies

Small Heath

0 0.00

10.00

20.00

30.00

**Those named are in most deprived national quintile

40.00

50.00

60.00

70.00

80.00

90.00

100.00

u 18 conception rate

U 18 conception rate vs % of boys achieving 5+ GCSEs at A* to C by ward** 100 90

% boys achieving 5+ A* to C GCSEs

80 70 60 50 Small Heath

Fox Hollies

Sparkhill Soho Nechells Ladywood Sparkbrook Washwood Heath Stockland Green Handsworth Kingsbury Aston Kingstanding Shard End

30 20 10 0 0.00

10.00

20.00

30.00

** Those named are in most deprived national quintile

40.00

50.00

60.00

70.00

80.00

90.00

100.00

u 18 conception rate

2.4 Risk factors for Teenage Pregnancy Although local data about outcomes for risk groups is limited, research gives us an indication of which young people are most at risk of teenage pregnancy. Where young people experience multiple risk factors their likelihood of teenage parenthood increases significantly. Young women experiencing five risk factors (daughter of a teenage mother; father’s social class IV & V; conduct disorder; social housing at 10 and poor reading ability at 10) have a 31% probability of becoming a mother under 20, compared with a 1% probability for someone experiencing none of these risk factorsi. Similarly, young men experiencing the same five risk factors had a 23% probability of becoming a young father (under age 23), compared to 2% for those not experiencing any of these risk factors.

Factors associated with high teenage pregnancy rates Risk factor

Evidence

Risky Behaviours Early onset of  Girls having sex under-16 are three times more likely to become pregnant than those who first have sex over sexual activity 16.ii  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.  Early onset of sexual activity is also associated with some ethnic groups (see below) Poor  Around a quarter of boys and a third of girls who left school at 16 with no qualifications did not use contraceptive contraception at first sex, compared to only 6% of boys and 8% girls who left school at 17 or over, with use qualifications.  Survey data demonstrate variations in contraceptive use by ethnicity. 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%).iii Mental health /  A number of studies have suggested a link between mental health problems and teenage pregnancy. A conduct study of young women with conduct disorders showed that a third became pregnant before the age of 17iv. disorder/  Teenage boys and girls who had been in trouble with the police were twice as likely to become a teenage

involvement in parent, compared to those who had no contact with the police.v crime Alcohol and  Research among south London teenagers found regular smoking, drinking and experimenting with drugs substance increased the risk of starting sex under-16 for both young men and women. A study in Rochdale showed misuse that 20% of white young women report going further sexually than intended because they were drunkvi. Other studies have found teenagers who report having sex under the influence of alcohol are less likely to use contraception and more likely to regret the experience.vii Teenage  A significant proportion of teenage mothers have more than one child when still a teenager. Around 20% of motherhood births conceived under-18 are second or subsequent births Repeat  Around 7.5% of abortions under-18 follow either a previous abortion or pregnancy. Within London this abortions proportion increases to around 12% of under-18 abortions Education-related factors Low  The likelihood of teenage pregnancy is far higher among those with poor educational attainment, even after educational adjusting for the effects of deprivation. On average, deprived wards with poor levels of educational attainment attainment had an under-18 conception rate double that found in similarly deprived wards with better levels of educational attainment. (80 per 1000 girls aged 15-17 compared with 40 per 1000) Dis A survey of teenage mothers showed that disengagement from education often occurred prior to pregnancy, engagement with less than half attending school regularly at the point of conception. Dislike of school was also shown to from school have a strong independent effect on the risk of teenage pregnancy.viii  Poor attendance at school is also associated with higher teenage pregnancy rates. Among the most deprived 20% of local authorities, areas with more than 8% of half days missed had, on average, an under18 conception rate 30% higher than areas where less than 8% of half days were missed. Leaving  Overall, nearly 40% of teenage mothers leave school with no qualifications.ix school at 16  Among girls leaving school at 16 with no qualifications, 29% will have a birth under 18, and 12% an abortion with no under 18, compared with 1% and 4% respectively for girls leaving at 17 or over. qualifications  Leaving school at 16 is also associated with having sex under 16 and with poor contraceptive use at first sex (see below). Family / Background factors Living in Care  Research has shown that by the age of 20 a quarter of children who had been in care were young parents,

Daughter of a teenage mother Ethnicity

and 40% were mothersx.  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.

 Data on mothers giving birth under age 19, identified from the 2001 Census, show rates of teenage motherhood are significantly higher among mothers of ‘Mixed White and Black Caribbean’, ‘Other Black’ and ‘Black Caribbean’ ethnicity. ‘White British’ mothers are also over-represented among teenage mothers, while all Asian ethnic groups are under-represented  A survey of adolescents in East Londonxi showed the proportion having first sex under-16 was far higher among Black Caribbean men (56%), compared with 30% for Black African, 28% for White and 11% for Indian and Pakistani men. For women, 30% of both White and Black Caribbean groups had sex under-16, compared with 12% for Black African, and less than 3% for Indian and Pakistani women  Poor contraceptive use has also been reported for some ethnic groups Parental  Research shows that a mother with low educational aspirations for her daughter at age 10 is an important aspirations predictor of teenage motherhood Teenage Pregnancy: Accelerating the Strategy to 2010. DfES 2006 I

Berrington A, Diamond I, Ingham R, Stevenson J et al (2005) Consequences of teenage parenthood: pathways which minimise the long term negative impacts of teenage childbearing’ University of Southampton ii

Wellings K, et al (2001) Sexual Health in Britain: early heterosexual experience. The Lancet vol.358: p1834-1850 Testa A and Coleman L (2006) Sexual Health Knowledge, Attitudes and Behaviours among Black and Minority Ethnic Youth in London. Trust for the Study of Adolescence and Naz Project London iv Maskey S, (1991) Teenage Pregnancy: doubts, uncertainties and psychiatric disorders Journal of Royal Society of Medicine v Hobcraft J (1998) Intergenerational and life-course transmission of social exclusion: Influences of childhood poverty, family disruption and contact with the police. CASE paper 15, LSE vi Redgrave K, Limmer M (2005) ‘It makes you more up for it’. School aged young people’s perspectives on alcohol and sexual health. Rochdale Teenage Pregnancy Strategy: Rochdale iii

vii

Alcohol Concern (2002) Alcohol & Teenage Pregnancy. London: Alcohol Concern Hosie A, Dawson N (2005) the Education of Pregnant Young Women and Young Mothers in England. Bristol: University of Newcastle and University of Bristol ix National Statistics (2004) Census 2001 table: C0069 Mothers under 19 at birth (Commissioned by Teenage Pregnancy Unit, DfES) x Barn R, Andrew L, Mantovani N (2005) Life after care: the experiences of young people from different ethnic groups Joseph Rowntree Foundation, London xi Viner R, Roberts H (2004) Starting sex in East London: protective and risk factors for early sexual activity and contraception use amongst Black and Minority Ethnicity adolescents in East London University College London, City University and Queen Mary, University of London viii

Ethnicity Data from our local hospitals and abortion service providers shows that young women who are Black or of mixed parentage are over represented amongst young women under 18 who conceive in Birmingham, whereas South Asian groups are under represented. (See Fig 8 Below) However, data from the 2001 census shows that 21.7% of young mothers in Birmingham who had their first child below the age of 19 were of Pakistani origin. This suggests high birth rates for Pakistani young women at 18. Further analysis of local data (see Fig 9 below) shows that among the youngest girls who conceive, Black young women are most likely to continue with their pregnancy. At ages 15, 16 and 17 it is mixed parentage young women who are most likely to continue their pregnancy (i.e. least likely to seek a termination)

The current systems for recording ethnicity do not give us a clear idea of conception patterns within newly arrived populations and anecdotal reports are mixed.

Teenage conceptions by ethnicity April 2003 - October 2006

2% 3% 15%

Black, Black British, African or Caribbean

Asian, British Asian, Pakistani, Indian or Bangladeshi Mixed parentage White Other

15%

not specified

57%

Fig 8

Proportion of live births to teenage mothers by age and ethnicity Apr 2003 -March 2007 100 90 80

percentage (%)

70 60 50 40 30 20 10 0 < 15

age White

Black

Asian

Mixed

All

Fig 9

Looked After Children and Care Leavers

Rates of pregnancy are high among looked after children in Birmingham and exceptionally high among care leavers. These groups are particularly vulnerable to a range of poor outcomes. It is not known to what extent these pregnancies are planned or unplanned. In a sample of 100 16 -18 year old Care Leavers in Birmingham there was evidence that 19 of the 41 young women (46%) had been pregnant at some point, with between 1 and 3 pregnancies each. (This is likely to be an underestimation as young people may not tell professionals about pregnancies that do not result in a birth)There were 20 young parents (15 mothers and 5 fathers) in the sample, with 23 children between them. In a sample of 100 16-17 year old young people in care it appeared that 8 of the 36 females (22%) had been pregnant at some point. (One young woman had been pregnant twice). There were 4 fathers and 8 mothers with 14 children between them. (From the 16+ Care Leavers Needs Analysis January 2006, Birmingham CYPF Directorate) Other Vulnerable Groups Approximately 5% of young parents known to the Connexions Service have a learning disability or difficulty â&#x20AC;&#x201C; the majority of these having emotional or behavioural difficulties. There is currently no system to collect information to monitor the number of young offenders who become young parents in Birmingham. Although there is no local data and limited UK research to compare, a number of large-scale population studies in the United States have highlighted the vulnerability of gay, lesbian and bisexual young people. ď&#x201A;ˇ

Massachusetts 1997 Youth Risk Behavior Survey: LGB youth were 2 times as likely as their peers to have been/or got someone pregnant (24% v. 12%)

  

Seattle 1995 Teen Health Risk Survey: LGB youth were 2 times as likely to be a teen parent (6.7% v. 3.5%) Minnesota 1987 Adolescent Health Survey: lesbian and bisexual young women were twice as likely as their heterosexual peers to report having ever been pregnant. (Only data for girls available (12.3% v. 6.1%) Vermont 1997 Youth Risk Behavior Survey: LGB youth were two or more times likely to have been pregnant or got someone pregnant (15% v. 2%).

(Massachusetts, 1997; Seattle 1995; Minnesota 1987; Vermont 1997: 83.000 -- Sexual Orientation (Safe Schools Coalition of WA) Saewyc et al (1999) suggest the following as possible reasons to explain why lesbian and bisexual teenagers might have had heterosexual experience: 1. Forced sexual contact as sexual abuse, incest and rape are more prevalent among lesbian and bisexual young women than heterosexual young women (Grundlach & Reiss, 1967; Simari & Baskin, 1982). 2. Many may have heterosexual sexual relationships before identifying as lesbian (Henderson, 1984; Sanford, 1989). 3. It may be a strategy employed during identity confusion stage of development. Troiden (1988) notes: "Some adolescents establish heterosexual involvement in hopes of 'curing' themselves of their homosexual interest....In some cases; an adolescent girl may purposely become pregnant to prove that she isn't lesbian. Researchers have also made this proposition based on their clinical experience and investigations (Rotheram-Borus & Fernandez, 1995). 4. Involvement in prostitution as a result of being made homeless due to family rejection on the grounds of their sexual orientation (Bidwell & Deisher, 1991). (Bidwell, R.J. & Deisher, R.W. (1991) Adolescent sexuality: current issues, Pediatric Annals, Vol 20(6), 293-302). (Grundlach, R.H. & Reiss, B.F. (1967) Birth order and sex of siblings in sample of lesbians and nonlesbians, Psychological Reports, Vol 20(1), 61-62) (Rotheram-Borus, M.J. & Fernandez, M.I. (1995) Sexual orientation and developmental challenges experienced by gay and lesbian youths, Suicide and Life-Threatening Behavior, Vol 25(Supplement), 26-34) (Saewyc EM., Bearinger, L.H., Blum, R.Wm., Resnick, M.D. (1999) Sexual Intercourse, Abuse and Pregnancy Among Adolescent Women: Does Sexual Orientation Make a Difference? Family Planning Perspectives, Vol 31 (3), May/June)

(Simari, C.G. & Baskin, D. (1982) Incestuous experiences within homosexual populations: a preliminary study, Archives of Sexual Behavior, Vol 11(4), 329-343) (Troiden, R.R. (1988) Homosexual identity development, Journal of Adolescent Health Care, Vol 9(2), 105-113) 2.5 Relationships Despite the obvious importance to young people of forming romantic, sexual and/or long-term relationships, and the significance of healthy relationships for long-term emotional wellbeing, this is an area where we are not very good at measuring outcomes. Early sexual activity increases the risk of teenage pregnancy. Research carried in 2001 showed that the earlier first intercourse occurred the greater the likelihood that the respondent expressed regret relating to timing and reported being more or less (but not equally) willing compared with their partner. Women were more likely than men to say they wished they had waited longer and to report not having been equally willing. (From Sexual Behaviour in Britain, Early Heterosexual Experience, Wellings, Johnson et al. The Lancet, December 1st 200) . A quarter of girls and nearly a third of boys have sex under 16 but the average age for both sexes is 16. Research tells us that regret is a major issue for young people. 67% of young men and 84% young women who had sex aged 13 and 14 wished they had waited. (2002 National Survey of Sexual Health Attitudes and Lifestyles (NATSAL) Johnson, Wellings et al) Young women who lack emotional resilience are vulnerable not just to teenage pregnancy but also to abuse and exploitation. This is particularly the case for Looked after Children and Care Leavers, for whom entering a sexual relationship or having a child may be an attempt to meet an unmet need for affection and emotional security. Teenage relationships often break down and teenage mothers are more likely to end up bringing up their children alone than older mothers. According to the 2001 Census, 58% of teenage mothers under 19 in Birmingham were lone parents. However 23% of our young mothers under 19 were married, one of the highest percentages in England. This could possibly be explained by the high birth rate to 18 year old mothers from Pakistani families, who are more likely to marry and start a family at a younger age.

Aspirations Current mechanisms for measuring aspirations concentrate on academic achievement and employment, so as yet we do not have a clear idea of the extent to which young people in Birmingham might see parenthood as the best ‘career option’. However the 2001 census shows that 50% of our young mothers under 19 had no qualifications, one of the highest percentages in England (8th worst out of 352 Local Authority districts). Empowerment Young people in Birmingham do not always have the information and the support they need to make informed choices. 40% of young people in Birmingham who took part in the school-based ’Tell Us 2’ Survey would like more or better information and advice on sex and relationships, more than any other topic surveyed. The Tell Us 2 Survey suggests that Q30? of young people in the Birmingham sample worry about girlfriends/boyfriends/sex. Not all young people are knowledgeable about the services that are there to help them. In a Birmingham survey of 175 socially excluded young men, 50% did not have any knowledge of their local sexual health services. (Syconium 2006) ?% Young people simply do not have anyone they feel they can to turn to for advice and support Tell Us 2 Q 31a and 32 2.6 Health of Teenage Mothers and their Babies 2.7 Education and Economic well-being

3.0 Service Gap Analysis

3.1 What works to prevent Teenage Pregnancy? Teenage pregnancy is a complex problem which requires a complex solution. The core business of local teenage pregnancy Strategies has been to focus on ensuring young people have the means to avoid unintended pregnancies by improving knowledge, skills and contraceptive use. It is clear that wider actions to address the underlying causes of teenage pregnancy are also needed to give young people the choice and motivation to aspire to further education and rewarding careers, leaving the decision to have children until later when they are better equipped to deal with the demands of parenthood.

There is a growing body of evidence for effective interventions. What is clear is that in order to improve outcomes, local strategies should have a multi-faceted approach including: -

Sex and relationships education (SRE) in schools and SRE training for professionals working with vulnerable young people Availability of well publicised, young people 窶田entred contraceptive services. Well-resourced youth and career development programmes promoting academic, social skills, self esteem and entry to employment. Intensive structured parenting and family support for vulnerable families. Wider measures to reduce poverty and increase aspiration.

Teenage Pregnancy, an Overview of the Research Evidence. HDA 2004. Teenage Pregnancy and Parenthood: A Review of Reviews. HDA 2003. Teenage Pregnancy Next Steps: Guidance for Local Authorities and Primary Care Trusts on Effective Delivery of Local Strategies.DfES 2006

3.2 Personal, Social and Health education (PSHE) Within Schools, Sex and Relationships Education (SRE) is usually taught under the umbrella of PSHE which covers a wider range of issues such as drugs, alcohol and bullying. School governors have a statutory responsibility for sex and relationships education (SRE) in their school. The 1996 Education Act consolidates all relevant previous legislation. In summary: –

The SRE elements of the National Curriculum Science Order across all key stages are mandatory for all pupils of primary and secondary age.

–

All schools must have an up to date policy that describes the content and organisation of SRE provided outside the National Curriculum Science Order. It is the school governors’ responsibility to ensure that the policy is developed and made available to parents for inspection.

–

Primary schools should either have a policy statement that describes the SRE provided or give a statement of the decision not to provide SRE other than that provided within the National Curriculum Science Order.

–

Secondary schools are required to provide SRE, which includes (as a minimum) information about sexually transmitted infections (STIs) and HIV/AIDS.

Parents have the right to withdraw their children from all or part of sex education, except those areas that are included in the national curriculum programme of study for science. Teachers are within their rights to refuse to teach SRE. Information gathered over the last 18 months from pupils as part of the secondary SRE project has highlighted areas of the curriculum which appear to be weakest. Schools seem to be good at covering the basics around conception, contraception and relationships, however young people want more information and discussion about sex and the law, consent, STIs, where to go for contraception, being a parent and negotiation in relationships.

For the last two years we have focussed our strategy for Birmingham on improving the capacity of schools to deliver high quality SRE by providing help with needs assessment, policy and curriculum planning and training. This in turn contributes to schools achieving National Healthy School Status. Considerable progress has been made in engaging schools with the Healthy Schools programme, with good coverage of schools. Key for all maps primary schools = Secondary schools = Special schools = rate/1000 women aged 15-17 75 and over 50-75 25-50 1-25

Fig 10 Schools with NHSS 2007

Fig 11 Schools working towards NHSS

Fig 12 Schools not engaged in NHSS

SRE is most effective when delivered by people with specialist training. As part of a national programme, the Health Education Service offers a specialist PSHE CPD Course for teachers and community nurses delivering PSHE. There has been a year on year increase in uptake by teachers; however uptake by nurses has been low.

Fig 13 Schools that have or have had a certificated PSHE teacher Only 32% of secondary schools with >20% free school meal entitlement have access to a PSHE certificated nurse.

Fig 14 Schools with a phase 5 teacher working towards certification The Teenage Pregnancy Partnership has commissioned the Health Education Service and Birmingham Brook to work with secondary schools in order to implement a complete review of their SRE provision with consultation with students, staff and parents. Agreement is sought from School Governing Bodies for participation in the programme. Schools were prioritised initially using a range of criteria including location in a high rate ward, educational attainment, attendance and reported pregnancies.

Secondary SRE Programme Schools approached Schools involved Schools expressed an interest Schools not responded to opportunity Schools not wishing to be involved

40 25 3 8 4

(Figures correct as of 31.10.2007)

Steady progress is being made with the schools that are engaged. Barriers to schools getting involved include;   

Schools offended by the offer due to links to Teenage Pregnancy and the fear of upsetting parents. Lack of contactable person in schools due to Teaching and Learning Responsibility points issues. Some schools have abolished their PSHE post and have year heads organising the PSHE programme, this could mean that in one school for example you would have to meet with 5 people to discuss the programme and plan it across the year groups. PSHE provision is so inadequate that they are unable to contemplate the project at this time. Some schools had no recognisable programme and had to acknowledge that they had to firstly look at this issue before looking at provision within the programme.

Factors once recruited have also caused progress to stall in some schools:    

Lack of or out-of-date SRE policy that meant that no teaching or development could go on till Governors had given outline approval. Currently poor practice meant that the starting point was very low with very few teachers having any classroom experience upon which to build or associate to. One school involved in the programme admitted to not having taught any SRE for at least the last 8 years. Lack of motivation of teachers to teach SRE, some schools did have well organised programmes but teachers were not delivering on it and there was a lack of management integrity in the school that would normally be applied to the teaching of core curriculum subjects. Ignorance/ anxiety to ethnic/ cultural issues was a major factor schools cited as a reason not to develop their programme or why staff were hesitant to deliver it.

  

Some schools not willing to address certain topics in SRE such as sexuality and masturbation. Religious reasons are mainly cited for the topics exclusion, but a lot of school are stating Homophobic Bullying is a real problem in schools particularly among the Muslim pupils. Tutor lead programmes means that up to 70 staff could be delivering PSHE in the school and trying to get that many staff to deliver to the same level is a major challenge and a practice that QCA are trying to steer schools away from in favour of a discrete delivery team. Lack of Continued Professional Development (CPD) for teacher’s means many had several years of service but no update or input based around SRE. Newly qualified teachers also felt that preparation for teaching this type of subject in their training was unsatisfactory. Schools who did have a teacher who had completed the DfES CPD PSHE certification were not necessarily better off as the one individual maybe did not have the status to bring about effective change in their school.

Greater availability of data on reported pregnancies over a four-year period has highlighted a further 20 schools where pregnancies have occurred that would need to be targeted in the next phase. Primary Schools Birmingham Children’s Fund has for six years supported the HES to work in partnership with the national charity ‘Positive Parenting’ on a primary SRE project. 70 primary schools have been involved with a further 12 starting this year. The project worker works in a consultative way, speaking to pupils, parents, staff and governors to gain data that is particular to those children in that locality and therefore “tailor-make” an SRE policy and scheme of work that meets the needs of those children. The project is regularly evaluated and is locally and nationally recognised as a great success and a model of good practice. There is now a long waiting list of additional schools that would like to take part in this project.

Input from Outside Agencies There are a number of agencies which offer direct classroom input to complement SRE delivery in schools. These include School Nurses; Youth Workers; Theatre Groups; Voluntary organisations such as Positive Parenting, Brook, and Space. This type of input evaluates well by pupils and schools, however it is difficult to sustain and too dependent on either the willingness of schools to pay,

the availability of short-term funding streams, or the capacity of front-line staff such as school nurses to make a contribution as part of their core role. This means that external input is patchy and not always well-targeted. As a result of feedback from young people’s representatives, a Scrutiny Review of effective SRE is underway in the City, with a final report due in October 2008. Recommendations 1. Aim to provide universal high quality SRE in schools. If SRE is seen as an entitlement for all pupils it should reduce the stigma associated with ‘being targeted’. We should however continue to target efforts at schools where the need is greatest. 2. Further proactive work should be undertaken with governors and parents, particularly at schools were there is a strong religious emphasis. 3. Provide examples of good practice in faith-sensitive SRE 4. Support the Scrutiny process to ensure that good practice is recognised, young people’s views are given full consideration and further improvements are identified.

3.3 Targeted Work Resources and effort have been targeted to reach young people at increased risk on both a geographical and ‘risk group’ basis. Geographical Since 06/07 14 wards have been prioritised for prevention work. The City Council Youth Service along with voluntary sector organisations have been commissioned to deliver Teenage Pregnancy Prevention programmes in these areas. The programmes offer Sex and Relationships Education with an agreed set of learning outcomes, based on work that was being delivered at the Maypole Youth Centre as a National Youth Development Pilot. Within the programmes there is an emphasis on relationships, the realities of parenting and helping young people to think about their future life goals.

Youth Development Programmes Ward

1. Acocks Green 2. Aston 3. Bartley Green 4. Erdington 5. Hodge Hill 6. Kings Norton 7. Kingstanding 8. Ladywood 9. Nechells 10. Shard End 11. Stetchford and Yardley North 12. Stockland Green 13. Tyburn 14. Weoley

No. of actual programmes Delivered from April 05 to Sept 07 1 1 1 2 2 3 2 4 3 2 3 1

Forecast No. of programmes completed by March 08 3 2 3 6 3 4 4 3 2 6 4 4 6 3

An average of 11 young people have taken part in each programme, of which 59% were young women. 91%of participants achieved a Youth service recorded outcome and 79% some sort of accreditation e.g. ASDAN. BME Groups

Monitoring data shows that 90% of the programme participants so far in 07/08 have been white, reflecting less delivery in Aston and Nechells. This is not however the total picture of delivery in those areas as there have been a number of programmes funded directly by Heart of Birmingham PCT, including Sisters with Voices (targeting Black and mixed parentage young women) and City United (working with Black young men). The HYPe (Healthy Young People) project was set up in the SRB 6 area and works mainly with young people from BME communities. Looked After Children and Care Leavers. For at least 5 years there has been a Sexual Health Development Officer post in place to support work with Looked After Children. Until 2005/6 the focus of the work has been on workforce capacity-building i.e. policy development, training and action-planning with staff in residential units, and to a limited extent, training foster carers and social workers. Although there has clearly been a need to support front-line residential staff, it is clear that their role has been mainly reactive, providing information and signposting and dealing with safeguarding issues such as inappropriate sexual behaviour and sexual exploitation. The Development Officer has also coordinated input from external agencies, in particular working with Friction Arts on an annual performance project to raise awareness of Sexual Health, and Positive Parenting who have run parenting awareness sessions in some of the Units. Since 2006/7 the Development Officer has also been required to do some direct delivery to young people and has recently delivered to a group of unaccompanied minors by working in partnership with BUMP (Befriending Unaccompanied Minors Project). More opportunities need to be found to deliver structured prevention programmes. There is a small team of Looked After Children’s Nurses employed by South Birmingham PCT. They have limited capacity for group work……………. For several years the 16+ Care Leavers Service ran an award-winning peer education programme. Care Leavers were recruited and trained to deliver SRE to young people in Care, for which they received a BTEC qualification. This was mainstreamed and integrated into a holistic ‘Preparation for Independence’ programme. This has been on hold now for some time pending the outcome of the current service review. There needs to be more joined up working to promote emotional resilience and to raise aspirations among these most vulnerable young people as this would help to prevent a wide range of poor outcomes

Young Offenders There have been a number of attempts to find the best way to deliver work via the Youth Offending Service, including ‘buying in’ external facilitators, capacity-building of YOS staff and a specialist post within the inappropriate sexual behaviour team. The current arrangement is to have a dedicated person who delivers education and advice on both an individual and small group basis as regular input into each of the YOS area teams. Although this is a recent appointment the early indication is that this approach is working well, with 16 referrals within the first month. Homeless Young People Some project work has been delivered by St Basil’s in the past. This is not something that the Teenage Pregnancy Partnership is funding at the moment but has the potential to be revisited. South Birmingham PCT fund prevention work at the South Birmingham. Young Homeless Project. Youth Inclusion Programmes (YIP) Two of the current YIPs are in high rate Teenage Pregnancy Areas (Kingstanding and Shard End). The young people they work with are identified and assessed as being at high risk of a range of poor outcomes that would also be risk factors for Teenage Pregnancy. Kingstanding YIP has been delivering a specific teenage pregnancy prevention programme. The young people taking part are tracked and so far there have been no pregnancies among what would be a high risk group. This approach to addressing risky behaviour along with other cross-cutting risk factors such as poor educational engagement is very promising. Underdeveloped areas of targeted work The most obvious gaps in the targeted work at the moment are for work with NEET young people, work in the Pupil Referral Units and for work with young people with mental health problems.

Recommendations: 1. Youth Development Programmes to be a resource for Extended Provision Clusters resulting in improved targeting and more joined up delivery. 2. Improve early identification of vulnerability to teenage pregnancy through Pre-CAF and CAF processes. 3. Integrate 1. and 2. above into design for Targeted Youth Support Service. In particular learning from the YIPs. 4. More work to be commissioned with PRUs and NEET young people 5. Link with specialist agencies working with Gay, Lesbian and Bisexual Young People to get a better understanding of what is currently being delivered and where there might be scope for addionality. 6. Review work with Looked After Children and Care Leavers in order to maximise opportunities for delivery with a particular focus on resilience work. 7. Drill-down conception rate analysis to identify hotspots within otherwise affluent wards. 8. Clarify the role of the Sexual Health Promotion Service in supporting this area of work.

3.4 Parenting Support Parentline Plus Speakeasy Local mapping for the parenting strategy 3.5 Contraceptive Services Significance of contraceptive services to achieving targets : Contraceptive services have a significant role to play in reducing teenage conceptions. Research conducted in the United States has shown that approximately one quarter of the decline in US rates between 1988 and 1996 was attributable to abstinence and three quarters to sexually active young people changing their behaviour. They found that there had been little change in the

frequency of sex and only a slight increase in contraceptive use. However a significant proportion of teenagers had changed to long-acting contraceptive methods (by 1998 13% of teenage contraceptive users were using long-acting methods). Alan Guttmacher Institute 1999 In-depth reviews carried out by the Teenage Pregnancy Unit in 2005 identified the key factors for successful strategies to reduce under 18 conceptions. The factor most frequently cited as having the biggest impact on conception rates was the provision of young people-focused, contraceptive/sexual health services, trusted by teenagers and well-known by the professionals working with them. Features of successful services included: easy accessibility in the right location with opening hours convenient to young people; provision of the full range of contraceptive methods, including long-acting methods; a strong focus on sexual health promotion, through for example, outreach work in schools; work with professionals to improve their ability to engage with young people on sexual health issues; and through highly visible publicity. Effective services also had a strong focus on meeting the needs of young men. All high- performing areas also had condom distribution schemes and/or access to EHC in non-clinical settings. Teenage Pregnancy Next Steps: Guidance for Local Authorities and Primary Care Trusts on Effective Delivery of Local Strategies. DfES 2006

A detailed contraceptive service needs assessment has recently been carried out on behalf of the Birmingham and Solihull Sexual Health Joint Commissioning Board. The main findings are summarised below: Level and Distribution of Services in Birmingham Only twelve of the 23 Birmingham Family Planning clinics are in areas with the highest rates of teenage pregnancy. The service hosted by HOB tPCT has a large well- qualified team of 16 doctors [1 consultant, one associate specialist and 13 medical officers] and 19 nurses. 9 of the 16 medical staff are trained to insert and remove implants; 10 to insert and remove IUDs; 10 are DFFP trainers. 8 out of 19 nurses have a family planning certificate.

Rate/1000 women aged 15-17 75 and over 50-74 25-49 1-24

Teenage Conception rate 2002-2004 by ward and location of family planning clinics (Source: ONS & Local Data)

The national contract for GP practices requires them to provide basic contraceptive services. Most provide this as part of a general consultation, rather than through dedicated clinics.

Almost all GP practices offer advice and prescription of the oral contraceptive pill; some offer contraceptive injection and IUD fitting; few if any offer contraceptive implant fitting. Practices refer patients to FP clinics to supply services they do not deliver themselves. There are major variations between PCTs in the amount and costs of contraception which GPs prescribe, which appears to be unrelated to population size or need. For example, GPs in HOBtPCT prescribing spend is only one third that spent by other 2 PCTs. Attempts to improve primary care based sexual health services through the Sexual Health In Practice [SHIP] scheme have had limited success. For instance there is great variation in the amount of basic contraception prescribed by different practices ( Appendix Figures D,E,F,G) Many practices trained under this scheme do not actively provide sexual health services and deliver the objectives of this scheme. There is little capacity within the SHIP team [1.2 wte] to follow up practices and ensure proper implementation. Provision of enhanced sexual health services in GP practices is Table 1 â&#x20AC;&#x201C; SHIP provision Name of PCT No of practices No who actively provide with SHIP additional sexual health training services e.g. free condoms, Chlamydia testing HOBtPCT 27 3 BEN 57 5 SBCT 45 9 Solihull 29

particularly poor in areas with the highest need, HOBtPCT and parts of BEN. % of SHIP trained practices in PCT

31% 89% 66% 93%

Birmingham Brook is the major provider of contraceptive services to young people under 25 years. This service sees around 12000 new clients per year in their City-Centre base, of who the majority are between the ages of 16 â&#x20AC;&#x201C; 19 years of age. New Clients at Brook 2005/6 (Source: KT31) 1800 1600 1400 Number

1200 1000 800 600 400 200 0 <15

20-21

22-23

25-29

Age Group

Information, Advice and Basic Services

In Birmingham these services are provided in a range of young people’s settings delivered by different agencies and funded through various funding streams. Services are limited where there is no input from qualified contraceptive and sexual health nurses. Young people have to be signposted to Brook, a GP or Family Planning Clinic to access more reliable forms of contraception. This may involve an unacceptable distance to travel, a fear of recognition or approaching a venue perceived as unwelcoming. Service

Ward/Area

Ward Conception Rate

Funding

Comments

Here 4 You (BEN) Provides weekly sessions offering advice and info, condoms, pregnancy testing and Chlamydia Screening. Working towards EHC provision.

Erdington Hodge Hill Kingsbury (Castle Vale) Shard End Sutton New Hall (Falcon Lodge) Yardley

Very High High Very High

BEN and Youth Service provide staffing – supplies funded through TP Grant.

751 contacts April 06Feb 07

Very High Low

Main age range 14-16 year olds 57% of clients are young men

High Falcon Lodge is a pocket of deprivation in an otherwise affluent ward. HYPe (HOB) Provides holistic health advice, condoms, pregnancy testing, Chlamydia screening, EHC,

Aston (x2) Handsworth Sandwell (X2). Small Heath Soho (X2)

High Low Low Low High

Originally SRB 6. HOB funding roll out £248,000

Family Planning qualified nurse is available. Service is relatively new

hormonal contraception. Youth Information Shops Provide advice, information, condoms, pregnancy testing, Chlamydia Screening. Nurse available at Base KS and Northfield for one session per week.

C-Card Condom Distribution Scheme Condoms and advice provided by trained staff in young people’s settings.

Northfield

Low

Kings Norton

High

Kingstanding/Oscott

High

Brandwood (Druids Heath) Erdington Fox Hollies Perry Barr

Low

Very High Very High Low

Youth Worker staffing costs funded by the Youth Service, Condoms and pregnancy tests by TP Grant. Northfield Nurse funded by NRF.

Northfield Youth Shop is on a main bus route and attracts young people from a wide geographical area.

Funded through Now coordinated by the TP Grant Brook with scope for £27,000 (includes expansion 07/08 supplies for Youth information Shops)

(In addition to Youth Information Shops) Brook Satellite Sessions City College: Advice condoms, pregnancy testing, Chlamydia screening. Nurse-led session at Handsworth

Handsworth, Newtown and Tysley

Students travel in from a wide area.

Funded through TP Grant £15,400 per annum

Uptake is low at some sessions and very high at others.

offering hormonal contraception.

The following wards have high or very high under 18 conception rates and do not have any local advice services in young people’s settings: Acocks Green –SBPCT Billesley -SBPCT Bartley Green - SBPCT Ladywood - HOBtPCT Longbridge - SBPCT Stockland Green - BENPCT Sheldon- BENPCT Washwood Heath- BENPCT Weoley-SBPCT In all Birmingham PCTs the School Nursing Service offers generic drop-in advice sessions to secondary Schools but this offer isn’t always taken up. South PCT have targeted their service to secondary schools in high rate areas (Bartley Green, Billesley, Acocks Green and Quinton) BEN and HOB PCTs have negotiated drop-in sessions on a school by school basis. The extent to which services are ‘open’ access rather than available via teacher referral varies. The school nursing service in these PCTS is stretched. Sessions are cancelled when there is no sickness cover or additional demands such as immunisation.

Service Access

Up to date information is currently being collected about young people’s perceptions of access to sexual health services. Birmingham Brook is open 6 days a week I [10 –6 pm] including all day Saturdays and offers advice over the phone. Postcode analysis to be added. An analysis of service attendees indicate that In Birmingham the Family Planning Service is predominantly used by older women (25 – 35 + ), the majority of whom are Pakistani , white British or Irish Female First Contacts 2005/6 & 2006/7 (Source: KT31) * No data available for the 3 Birmingham PCTs for 2006/7 8000 7000 6000

Number

5000 2005/6 2006/7

4000 3000 2000 1000 0 <16

16-19

20-24

25-34

35+

<16

Birmingham PCTs

16-19

20-24

25-34

35+

Solihull Age

Brook has sees a much higher % of Black African Caribbean young people than GPs or FP clinics. HOBtPCT manages FP clinics for the three Birmingham PCTs. Since July, because of high DNA (did not attend) rates, these clinics are now provided on a walk-in basis. The mean number of patients seen per session is 10.8 [range 0.2 â&#x20AC;&#x201C; 27]. 6 clinics see less than six patients per session, namely Good Hope, Broadmeadow, Hillmeads, Sanctuary, Weoley Castle and Yardley Wood. Of the 51 FP clinic sessions held per week in Birmingham, 18 are specifically for young people, 6 are held in the evening and 4 on a Saturday morning. In most wards there are no evening FP services. The BRASH service for young people and hosted by HOBtPCT provides an advice line weekdays only [9am to 4.30 pm.] The FP services also offer specialised clinics as follows - pregnancy counselling - psychosexual clinics - complex family planning or medical needs - drugs or alcohol misuse - vasectomies Both FP services undertake very few or no domiciliary (home) visits [n= 0 â&#x20AC;&#x201C; 3 per year]. There is no targeted provision of contraceptive services for Looked After Children or Care leavers Hawthorn House and the Drake Unit also offer contraception as part of their wider sexual health services but the volume of activity is not known. Long Acting Reversable Contraception (LARC)

NICE guidance indicates that Long Acting Reversible Contraceptives i.e. IUDs and implants] are much more cost effective than Combined Oral Contraceptive pill even 1 year after use - and that women should be given information and choice about such methods. In Birmingham and Solihull GP prescribing of Oral Contraception is nearly twice the “ideal” level. To achieve the “ideal “level of LARCs will require EITHER a major investment in developing GP competency and financial incentives to provide these services OR using the capacity of our FP services to improve access to LARC services The way to target the “at risk” population for LARCs is to provide an enhanced contraceptive advisory service after termination or requests for EHC.

Comparison between current profiles and ideal profile of contraception provision (adapted from Armstrong N, Donaldson C. The Economics of Sexual Health. Family Planning Association 2005)

Percent of Prescribable Contraceptives

70 60 National GP B&S GP Mean Ideal GP National FP B&S FP Mean Ideal FP

50 40 30 20 10

ap /C D

ia ph ra gm

D IU

Im pl an t

je ct io n

PO P

C P

Pregnancy Testing and Advice

Younger women are more likely to need additional support in the case of an unplanned pregnancy. Research carried out by Southampton University in Birmingham showed that young women under 18 took a longer time on average to suspect a pregnancy and to make a decision about whether or not to have an abortion. 48% of under 18s reported delaying a termination due to ‘fears about how my parents would react’. Abortions at ten and more weeks in Birmingham, Roger Ingham and Steve Clements, Centre for Sexual Health Research, University of Southampton.2007 Preventing Second Pregnancies Around 20% of births to under 18s are to young women who are already teenage mothers. Teenage Pregnancy:Accelerating the Strategy to 2010. DfES 2006 Teenage Pregnancy Midwives in each of the four Maternity Units in Birmingham are undertaking training which will qualify them as reproductive and sexual health nurses and enable them to work under PGDs to provide contraception as part of the care pathway for young parents. Some health visitors have been trained to provide post natal contraceptive advice and supply condoms, however this is not currently monitored.

3.6 Service information and signposting Information about the main local services is available in leaflets and posters produced by the City’s Sexual Health Promotion Service and the Teenage Pregnancy Partnership. The Sexual Health Promotion Service has a large database of agencies who are

encouraged to order materials for distribution. Distribution therefore has a tendency to be a bit patchy as it is dependent upon all agencies taking a level of responsibility for getting information out to their clients. Schools are encouraged to provide service information to young people as part of PSHE. However there is no capacity to audit the extent to which this is actually happening. Services are also promoted through other media as radio as part of occasional advertising campaigns or new service launches. A number of NHS providers in Birmingham have recently developed separately branded services and websites aimed at young people, namely e.g .HYPe, Here4you, BRASH, BStreetwise and Ship-Shape. The impact and costs of this brand proliferation is not yet known, but has the potential to create confusion and not deliver value for money in terms of impact . Commissioners have not contracted a single agency responsible for maintaining a comprehensive local service database, helpline or leading a city wide marketing strategy There is limited capacity within any of the clinical services for staff to get out into young people’s settings to promote their service. Brook is able to do this as part of their education and training work, but this has had to be separately funded from other sources such as the Teenage Pregnancy Grant. Front-line practitioners are encouraged through training to actively support and signpost sexually active young people to help them access services. In some service areas more work needs to be done to clarify workers’ roles and responsibilities in this area. Recommendations The city wide commissioning board should:1. Ensure that all SLAs /contracts with providers of sexual health and reproductive services, [including independent contractors contracted through a LES ] include the DH ‘You’re Welcome’ Quality Standards for young people 2. Monitor that these standards are being delivered in practice 3. Commission a single agency to coordinate the marketing strategy for Birmingham and Solihull, develop a local service directory/ helpline and database of sexual health services.

4. Ask each PCT to develop, with input from their PBC groups, an SLA specifying the location , type and volume of contraceptive services they wish to commission for young people n particular to specify a) which neighbourhoods will be served by practices already actively providing sexual health services for young people and how these practices will be commissioned to enhance their current provision to drop in /open access to that neighbourhood as a whole. b) which neighbourhoods will be served by sexual health /contraceptive services commissioned to operate in young peopleâ&#x20AC;&#x2122;s settings 5. A separate SLA on behalf of all PCTs should be developed for City centre based young peopleâ&#x20AC;&#x2122;s contraceptive services. 6. Develop separate service specifications for the FP service , Brook and Hawthorn House which clearly identify the particular contribution expected [ or not ] from each service in providing contraceptive services to young people [ under 25s ] 7. Agree 3 year trajectory for changing the ratio of LARS to CORC prescribing 8. Include post-natal contraceptive provision into maternity and health visiting care pathways and service specifications. 9. Review and, if appropriate, improve the capacity and targeting of the SHIP scheme to deliver more effective and equitable distributed young people contraceptive services within primary care. 10. Highlight to the Children and Young Peoples Board those schools and neighbourhoods whose young people are least well served by contraceptive and sexual advice services. 11. Commission jointly with the TP Partnership, basic training to enable all front line workers working with young people and other groups at risk to signpost them to sexual health services. 12. Ensure that the service specification for specialist FP services requires that all the Doctors and nurses working in such services are appropriately trained to deliver specialist FP services, fit and remove LARCs. Service provision Organisations commissioned by their PCTs to provide contraceptive services for young people should:13. Actively promote their services in young peoples settings and include this promotion as part of their business plans 14. Develop the competence of the nursing workforce to offer contraceptive advice as part of their day to day role

15. Increase the number of qualified reproductive and sexual health nurses able to work flexibly in young peopleâ&#x20AC;&#x2122;s settings. 16. Rationalise, merge or cluster Family Planning /primary care services which are inefficient or lack resilience and consolidate provision in areas of highest need. 17. Ensure that all staff working in Specialist FP clinics are trained to deliver specialist FP care

3.8 Workforce training, policies and guidance Delay

5. Acknowledgements Prepared by Sarah Farmer and Christiane Moron With contributions from: Angela Collard Akhtar Chowdry Richard Wilson Dr Jacky Chambers Dr Michael Caley Niall Crawford Andrew Cooper Nicky Martin Becky Crampton Jan Norton Mandy Tyler Helen Davis Suzanne King West Midlands Perinatal Institute Birmingham and Solihull Connexions