Consultation on the Pregnancy and Parenthood in Young People Strategy

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Contents

Supporting documents

Policy Mapping is available online in word format
Outcomes Framework is available online in word format
Feedback Report is available online in word format

Ministerial forward [to be inserted]

Introduction

Background and rationale

Why young people need extra support
Who is at risk of early pregnancy?
Why young parents need extra support
Aim of the Strategy

Making the policy links

Developing the Strategy

Strategy Steering Group
Involving young people
Outcomes Framework

Findings and Recommendations

Section 1: Delaying pregnancy in young people

Positive outcomes and educational engagement
Supporting positive relationships and sexual wellbeing
Relationships, sexual health and Parenthood education
Sexual and Reproductive health services

Section 2: Pregnancy in young people

Early identification of pregnancy
Pathways of care
Pregnancy options

Section 3: Parenthood in young people

Promoting positive attitudes
Antenatal support and maternity services
Support in the postnatal period and beyond
Support to control reproductive health and pregnancy spacing
Education, training and employment
Housing
Income maximisation and support

Leadership and accountability

Governance

Summary of actions for the Strategy

References

Appendices

Appendix 1: Birth rates for 15-19 year olds in the European Union and further afield

Appendix 2: Membership of Steering Group

Appendix 3: Logic Model

Appendix 4: Summary of review level evidence

Appendix 5: Consultation Questions

Introduction

This is the first Scottish Strategy focused on pregnancy and parenthood amongst young people. It aims to increase the choices and opportunities available to young people which will support their wellbeing and prosperity across the life course. The Strategy addresses the fundamental causes of pregnancy in young people and its consequences, with actions focused on how we can impact on the wider environmental and social influences and individual experiences which effect inequalities. Reducing levels of pregnancy in young people helps to reduce the likelihood of poverty and a recurring cycle from one generation to the next.

The rate of pregnancy (this is defined as all conceptions i.e. live births and abortions) in the under 20s age group is decreasing in Scotland although it is still high compared to other countries, including comparable western states (appendix 1). Between 2007 and 2012, Scotland saw a 28%, 33% and 28% decrease in pregnancy rates in the under 20, 18 and 16 age groups respectively. This shows that high rates can be influenced with effective interagency joint working and evidence informed approaches. However, these rates are still high compared to other countries in the European Union and further afield (appendix 1) and some of this can be explained by the challenge posted by the gap in inequalities (figure 1). Females aged under 20 years old and living in a deprived area are 4.6 times more likely to experience a pregnancy and nearly 12 times more likely to continue the pregnancy as someone living in the least deprived areas of Scotland. Reducing levels of pregnancy in young people helps to reduce the likelihood of poverty and a recurring cycle from one generation to the next[1].

Figure 1: Rates of teenage pregnancy under 20 years old in Scotland by deprivation quintile (SIMD)[2] 2007-2012[3]

Background and rationale

Pregnancy in young people is often a cause and a consequence of social exclusion[4] and therefore should be seen as wider than a sexual health issue or even a health issue. This strategy looks at the fundamental causes of pregnancy in young people with actions focused on how we can impact on the wider environmental and social influences and individual experiences which effect inequalities. Young people face a wide range of challenges and opportunities in their lives and therefore require support that is responsive and holistic to match their life circumstances. By using an integrated interagency approach and looking at an individual holistically, outcomes can be improved for young people, i.e. for those under 18 or still at school a Getting It Right For Every Child (GIRFEC) approach.

Universal services, across all agencies, have an important role to play in identifying and supporting the needs of young people and these responsibilities will be strengthened through the commencement of the provisions and duties in relation to the Named Person Service in the Children and Young People (Scotland) Act 2014. The Institute of Fiscal Studies report[5] concluded that to significantly reduce levels of teenage pregnancies you cannot concentrate on high risk groups alone. Whilst this is important, we also need a particular focus on those who are most vulnerable. This 'proportionate universalism' approach is described by the Marmot Review[6] as being actions that must be "universal but with a scale and intensity that is proportionate to the level of disadvantage". This is the focus of actions in this Strategy.

Why young people need extra support

After the early years, the adolescence years are the next most influential period for improving an individual's outcome[7]:

- Youth is a unique and critical period of life, a major developmental transition from childhood to adulthood.

- Young people experience key biological, cognitive, emotional and social changes which bring challenges and opportunities for both the individual and society.

- Young people who are looked-after are particularly vulnerable, it is common for them to leave their care placement at a significantly younger age than their non-looked after peers for whom the average age of leaving home is 25, and they therefore lack the family support experienced by their peers.

- Young people are prone to risk-taking and experimentation as they learn to manage new capabilities and greater freedom.

- Common patterns of risk taking behaviour start during youth.

- Young people are influenced by social, economic and cultural factors which are different to those experienced during the early years.

- Young people are tomorrow's workforce, parents and leaders. Any limitations on the potential of young people in Scotland will impact on their ability to contribute productively as citizens, family members and employees/employers.

Who is at risk of early pregnancy?

The majority of young people who become pregnant do not have specific risk factors, but these are the risk factors for those who are most vulnerable. The most vulnerable groups include, but are not exclusive to:

Young people…

- living in poverty and/or areas of deprivation

- who are looked after and accommodated and or Care Leavers

- who are, or at risk of, homelessness

- who have poor attendance at school

- who have low educational attainment

- who are disabled

- who have learning disability

- who have experienced abuse and violence

- who are in contact with the justice system

- whose parents had children under 20

Most young people have multiple risk factors which increases their chances of having children in their teenage years. It is essential that all young people are supported to be healthy, achieving, nurtured, active, respected, responsible, included and above all, safe.[8]

Why young parents need extra support

Parenthood can be daunting at any age and is often seen as a expected life event rather than a choice. Providing young people with the ability to consider their aspirations and ambitions for the future can increase their opportunities and choices; and help achieve their potential as an individual. Parents under 20 tend to have poorer perinatal health outcomes (later engagement with services, lower birth weights, higher infant mortality and higher rates of postnatal depression[9]). The circumstances and experiences of mothers aged under 20 compared with older mothers, show that younger mothers face significant socio-economic disadvantage in terms of lower educational qualifications, lower employment levels and lower income.[10] Young fathers have double the risk of being unemployed aged 30, even after taking account of deprivation.

Young mothers also experience poorer mental health in the first three years after giving birth than do older mothers, are less likely to breastfeed, and the children themselves are more likely to become teenage parents. Young mothers are at a higher risk of mental health issues, and postpartum depression than average, which is associated with feelings of isolation and low self-esteem. Postpartum depression, if unchecked, can have long-term consequences for both the mother and her child. In addition, a lack of support with mental health difficulties can have negative effects on parenting practices and can affect the mother's ability to bond with her child. A lack of support with daily stress, family difficulties and emotional issues can impede adjustment and the development of good coping abilities. Young mothers often experienced problems in their relationship with the father of their child; these problems sometimes led to the involvement of police, legal advisors and social services.[11]

These disadvantages underlie many of the additional issues that young parents face. Taking action on these issues will have particular impact in addressing the inequality that exists between older and young parents.[12] Younger mothers who exhibit child nurturing behaviours, such as reading to their child/children, promoting a healthy lifestyle and who provide a secure and stable environment have similar chances of raising children with positive outcomes as older mothers who do the same. Whilst mothers aged 20-24 are relatively advantaged when compared with their younger counterparts, they are still at a significant disadvantage when compared with older parents (25+). This is why this Strategy looks to support young parents aged up to 26, with a focus on those who are most disadvantaged.

Research with young fathers has shown that those who are co-parenting their children highly value the experience; however young fathers tend not to engage with health and social services as well as young mothers. This can be for a variety of reasons however; key to the progression of support to young parents will be to highlight the role of fathers both as a partner and as a father, helping them to feel welcome to engage with services[13].

Whilst the needs of each young parent will vary and such needs should be considered on an individual basis, there are some groups that professionals should be aware of as requiring additional and likely on-going comprehensive interagency support. This may particularly include young parents who are:

- Living in social/economic deprivation

- Homeless

- Looked after

- A Care Leaver

- Involved in the criminal justice system

- Not engaged with education/employment/training

These risk factors are virtually the same as those who are at risk of early pregnancy. As ever, putting the young person at the centre of any decision about their needs will enable the provision of support that is necessary and appropriate together with the young person concerned.

Aim of the Strategy

This strategy aims to drive actions that will decrease the cycle of deprivation as associated with pregnancy in many young people under 18 and provide extra support for young parents, particularly those who were looked-after up to age of 26 in line with the Children and Young Peoples (Scotland) Act 2014. For some, this may be with little or no additional support, for others this might be intense, targeted support. For all, it is essential we continue to put the young person at the centre to help them achieve their potential both as individuals and where appropriate, as parents.

Making the policy links

This Strategy links to the Government's National Outcomes[14] for young people, namely:

- Our young people are successful learners, confident individuals, effective contributors and responsible citizens.

- Our children have the best start in life and are ready to succeed.

- We have improved the life chances for children, young people and families at risk

The Pregnancy and Parenthood in Young People Strategy covers many complex areas that are influenced by a large number of policies, legislation and guidance across the Scottish Government. It is, therefore, important that the Strategy compliments existing policy and practice. The supporting document Pregnancy and Parenthood in Young People Policy Mapping[15] sets out the policies, legislation and guidance that impact directly in this area. The Sexual Health and Blood Borne Virus Framework (2015) currently includes actions for pregnancy in young people therefore this strategy aims to build on these commitments. An update is planned in 2015 for the Sexual Health and Blood Borne Virus Framework and will still include actions for unintended pregnancy – i.e. in older women.

The Getting It Right For Every Child (GIRFEC)[16] approach and the introduction of the Children and Young People (Scotland) Act 2014[17] are key foundations that are core to young people achieving positive wellbeing, now and in the future. Enabling young people to have equality of opportunity and the ability to achieve their aspirations and ambitions is central to this. In terms of this particular Strategy, this means providing young men and women with the knowledge, tools and skills they require to consider where parenthood lies in their future plans.

Furthermore, the Scottish Government's Looked After Children's Strategy[18] reaffirms our commitment to improving outcomes for looked after children and lays out our vision for achieving this. At the heart of the strategy is the importance of relationships for our looked after children and young people. For children and young people the quality of relationships with carers, their birth families, social workers, other trusted adults and corporate parents is fundamental to their ability to develop and thrive. We have identified three priority areas of work that are necessary if we are to achieve our aims. These are early engagement, early permanence and improving the quality of care. Taken together, and underpinned by the conditions for success outlined in the document, they provide a coherent approach to improving outcomes for looked after children.

The Children and Young People (Scotland) Act 2014 introduced a new framework of corporate parenting duties and responsibilities for public bodies listed in Schedule 4 This includes local authorities, Health Boards, Healthcare Improvement Scotland, Scottish Police Authorities, the Mental Welfare Commission for Scotland, Education Scotland and Scottish Prison Service (as Executive Agencies under Scottish Ministers). These new duties commenced on 1 April and place a duty on Corporate Parents to assess the needs, promote the interests, and provide opportunities to promote the wellbeing of looked after children and care leavers currently up to age 26. All Corporate Parents, must collaborate with each other consider how best they will work in partnership, within organisations and with other Corporate Parents, to ensure children and young people overcome barriers and live a life they feel in control over. All Corporate Parents will be required to develop and publish a plan of how they are going to meet their corporate parenting duties and the Act also introduces a new reporting and accountability structure, with national progress on improving outcomes reported by Scottish Ministers to the Parliament every three years beginning in 2018.

The Public Bodies (Joint Working) (Scotland) Act 2014 puts in place arrangements for integrating health and social care, in order to improve outcomes for patients, service users, carers and their families. The Act requires Health Boards and Local Authorities to work together effectively to deliver quality, sustainable care services. Key features of the Act are national outcomes for health and wellbeing, which will apply jointly and equally to the NHS and Local Authorities and Integrated Joint Boards. The Integration Joint Board is responsible for the strategic planning of the functions delegated to it and for ensuring the delivery of those functions through the directions issued by it under section 25 of the Act. The Integration Joint Board will also have an operational role as described in the locally agreed operational arrangements set out within the integration scheme in Section 4 of the Act.

Developing the Strategy

In 2013, the Health and Sport Committee held an inquiry into teenage pregnancy in Scotland. One of the recommendations from the inquiry was for a stand-alone strategy for Scotland to further progress teenage pregnancy, moving the focus away from a solely health-based agenda, and to continue to act on the wider determinants. In order to address this complex area, the strategy was developed using a collaborative approach as described below.

Strategy Steering Group

The Pregnancy and Parenthood in Young People Strategy Steering Group was an advisory group to the Scottish Government, providing recommendations on the content and development of the Strategy based on their expert knowledge, experience and evidence. The Strategy Steering Group supported the development; approved content of the draft strategy, provided strategic leadership and guidance to develop a multi-disciplinary strategy with full partnership engagement. Membership of the Steering Group can be found at appendix 2.

Involving Young People

The Pregnancy and Parenthood in Young People Strategy has been developed both with and for young people. Young Scot carried out a 'co-design' process which sought the views of young people and young parents through an online survey and through four focus groups (supporting document). To supplement this, the Scottish Government also linked with other local parenting groups, including young fathers in Her Majesty's Young Offenders Institution Polmont, in order to obtain the views and attitudes of wide range of young people and young parents (supporting document). The results of these engagement exercises, along with the views of professionals and high level evidence, have been central in informing the content of the strategy.

Outcomes Framework

A logic model was developed (appendix 3) to help determine the short, medium and long term outcomes of the Strategy. This is designed to support and inform policy makers, planners, evaluators and researchers. It may also help community planning partners (and others) develop an outcomes-focussed approach to planning and performance in supporting young people in their own area. The Strategy was developed using review level evidence[19] to inform an outcome framework. A summary of review level evidence can be found in appendix 4. It should be noted that for a variety of reasons we do not always have 'good' review level evidence for all the links in the logic model. This lack of evidence, however, does not necessarily mean there is no link between two components in the logic model nor that evidence of effectiveness does not exist, it may be that it has not been reported or evaluated. Similarly, lack of evidence should not always prevent us from acting. In some instances plausible theory has been drawn on to explain the links in the model. An outcomes triangle and results chains have not been fully developed but are still being considered.

Findings and Recommendations

Section 1: Delaying pregnancy in young people

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

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

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

Positive Outcomes and Educational Engagement

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

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

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

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

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

Supporting Positive Relationships and Sexual Wellbeing

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

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

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

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

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

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

Action:

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

Relationships, Sexual Health and Parenthood (RSHP) Education

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

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

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

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

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

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

Actions:

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

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

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

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

Sexual and Reproductive Health Services

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

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

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

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

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

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

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

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

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

Actions:

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

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

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

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

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

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

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

Section 2: Pregnancy in young people

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

Early Identification of pregnancy

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

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

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

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

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

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

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

Actions:

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

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

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

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

Pathways of care

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

Action:

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

Pregnancy options

Abortion

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

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

Continuing with the pregnancy

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

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

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

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

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

Actions:

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

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

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

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

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

Section 3: Parenthood in young people

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

- Tailored information and advice about choices for education, training, employment and careers, childcare, money and benefits and housing

- Individualised plans for return to education and employment which consider the wider costs and benefits of such a return

- Specialised services for young parents

- Advocates to help young parents approach services and/or co-ordinate cross agency support to better match young parents needs

- Childcare provision

- Interventions to reduce domestic abuse and improve relationships

Promoting positive attitudes to young parents

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

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

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

Action:

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

Antenatal Support and Maternity Services

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

- Being overwhelmed by the involvement of multiple agencies

- Unfamiliarity with care services

- Practical problems making attendance at antenatal services difficult

- Difficulties communicating with healthcare staff

- Anxieties about the attitudes of healthcare staff

- Young fathers specifically may not attend due to:

- not knowing what maternity services are, or think they are only for mothers

- fear judged, ignored or not taken seriously by health professionals

- feel embarrassed about their knowledge

- feel like they will be blamed for the pregnancy (especially if under 16)

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

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

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

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

Actions:

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

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

Support in the postnatal period and beyond

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

Support to control reproductive health and pregnancy spacing

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

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

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

Action:

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

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

Education, training and employment

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

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

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

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

Smithycroft High School, Glasgow

The Wester Hailes Education Centre, Edinburgh

Menzieshill High School, Dundee

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

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

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

Action:

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

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

Childcare funding

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

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

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

- 3 and 4 year olds, starting from the first term after their third birthday

- 2 year olds from the point that they are looked after, under a kinship care order, or with a parent appointed guardian.

- 2 year olds, starting from the first term after their second birthday, (where their 2nd birthday falls on or after 1 March 2014) with a parent in receipt of qualifying benefits; or, the first term after their parent starts receiving qualifying benefits of:

- Income support

- Jobseekers Allowance (income based)

- Employment and Support Allowance (income based)

- Incapacity or Severe Disablement Allowance

- State Pension Credit

From August 2015 this will be extended further to include:

- 2 year olds, starting from the first term after their second birthday (where their second birthday falls on or after 1 March 2015) with a parent in receipt of qualifying benefits; or the first term after their parent starts receiving qualifying benefits of:[78]

- Child Tax Credit, but not Working Tax Credit and your income is less that £16,105

- Both maximum Child Tax Credit and maximum Working Tax Credit and your income is under £6,420

- Support under Part VI of the Immigration and Asylum Act 1999

- Universal Credit

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

Housing

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

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

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

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

Action:

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

Income Maximisation and Support

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

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

Action:

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

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

Leadership and accountability

Improved service organisation, informed by local data, the needs of young people and greater partnership working across agencies will contribute to local services being developed in a more comprehensive and integrated way. Evidence from the evaluation of the Teenage Pregnancy Strategy in England[83] showed that high level, leadership at the local and national level is essential for enabling progress in this area. It is vital that there is an accountable person who can support and enable local multi-agency partners in delivery as well as monitoring and reacting to performance management. Strong leadership both locally and nationally will be essential for the effective implementation of the Strategy. Each Community Planning Partnership (CPP) will therefore identify such an individual at a senior level to take on this vital, executive role both locally and nationally. The Scottish Government will also appoint a National Lead for implementation of the Strategy to provide national leadership. The National Lead will be responsible for the strategic delivery of the strategy, engaging with local and national organisations, ensuring the consideration of up to date evidence and policy, monitoring and reacting to progress and enabling cross Scotland sharing of experience and best practice.

Part 3 of the Children and Young People (Scotland) Act 2014 places a duty on each local authority and the relevant health board to jointly prepare a Children's Services Plan for the area of the local authority, covering a 3 year period. Children's services plans should be prepared with a view to achieving the aims of providing children's services and related services in the area, in a way which: best safeguards, supports or promotes the wellbeing of children; ensures that any action to meet needs is taken at the earliest appropriate time and that, where appropriate, action is taken to prevent needs arising; is most integrated from the point of view of the recipients; and constitutes the best use of available resources.

In order to ensure that the Children Service Plans are meeting the need of the young people they should be informed by "live", local data. The use of local data is essential for understanding local circumstance in relation to pregnancy and parenthood in young people. Where appropriate, agencies should share data and risk assess as part of a joined up strategy to understand the needs of the local population – i.e. those potentially at risk of a pregnancy at a young age, and young parents. The data sharing through the Children and Young People (Scotland) Act 2014 will aid strategic planning and will also help the provision of integrated services that meet the needs of those who use them.

As part of the implementation of the Strategy, the Scottish Government will work with agencies across Scotland to collate examples of best practice and real life case studies in relation to pregnancy and parenthood in young people. Such examples will be shared as a way of promoting and sharing good practice in Scotland.

Workforce development activities across the range of different services working with young people will enable staff across all sectors to have the appropriate knowledge, attitudes and skills to understand the needs of young people and work effectively with them to meet their needs and aspirations. Multi-agency training and education of the workforce in this area will be vital in order to enable professionals to respond to all aspects of pregnancy and parenthood in young people. Such training should include evidence around pregnancy in young people (not just the sexual health aspect), relate to local data and circumstance, should acknowledge the local needs and views of young people and acknowledge local data sharing and safeguarding procedures.

Actions:

A young people's strategic needs assessment is carried out by Community Planning Partnerships to include pregnancy in young people. As a result, data collecting protocols and data sharing polices including proper protection of privacy/confidentiality are in place for young people who are at risk of a pregnancy.

The Scottish Government to develop a national generic e-module for statutory and non-statutory professionals providing training on the evidence around young people at risk of pregnancy links with wider issues and practical actions for supporting young people.

Local Authorities to bring all partners together to consider the evidence and local data and to agree local pathways.

The Scottish Government to develop and maintain a digital resource for professionals which shares best practice, training opportunities and case studies in relation to pregnancy in young people and young parents across Scotland.

Each Community Planning Partnership to assign a senior accountable person for coordinating leadership/implementation/championing the Strategy.

Governance

The Strategy will be overseen jointly by the Children and Young People and Public Health Minister and Public Health Minister [tbc].

Independent Advisory Group for the Pregnancy and Parenthood in Young People Strategy

The Independent Advisory Group will consists of key individuals from across organisations and sectors who may have a role in delivering the strategy, academic interest and/or have an interest in decreasing inequality in young people. This will champion the Strategy and encourage work in this area. The Group will submit an annual report to the Minister (and be available to the public) on their views on the implementation progress of the Strategy, highlighting issues that require particular Ministerial attention. The English Teenage Pregnancy Strategy had a similar group which was reported as a particular strength of the English Strategy.

National Lead for Pregnancy and Parenthood in Young People

The Scottish Government's National Lead for the Pregnancy and Parenthood in Young People Strategy will provide national strategic leadership in the implementation of the Strategy. The Lead will have policy experience; will be experienced academically and engaged with the evidence; able to provide the national link across Scotland as well as providing advice and updates to Ministers on progress, both locally and nationally. The National Lead will be responsible for the delivery of the strategy, engaging with local and national organisations, ensuring the consideration of up to date evidence and policy, monitoring and reacting to progress and enabling sharing of experience and best practice across Scotland.

As committed in its response to the Scottish Parliament's Health and Sport Committee, following publication of the Strategy the National Lead will provide an annual update to the Scottish Parliament on progress against the strategy. This update will also be an opportunity to consider any new or updated evidence (academic or practice based), ensuring a Strategy that is continually up to date and relevant.

Summary of actions for the Strategy

Section

Action

Responsibility

Section 1: Delaying pregnancy in young people

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

The Scottish Government

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

Local Authorities
NHS Boards
Third Sector organisations

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

Local Authorities

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

Schools and Local Authorities

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

Schools and other learning establishments

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

NHS Boards

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

The Scottish Government

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

NHS Boards
Youth Work
Local Authorities
Third Sector organisations

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

NHS Boards

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

NHS Boards
Youth Work
Third Sector organisations

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

Local Authorities

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

Schools
Local Authorities
NHS Boards

Section 2: Pregnancy in young people

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

Schools
Local Authorities
NHS Boards
Youth Work
Third Sector organisations

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

NHS Boards
Third Sector Organisations

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

NHS Healthcare Improvement Scotland (HIS)
NHS Information Services Division (ISD)

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

NHS Boards

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

NHS Healthcare Improvement Scotland

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

Local Authorities
NHS Boards

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

NHS Boards

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

NHS Boards

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

NHS Boards
Local Authorities
Third Sector organisations

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

NHS Health Scotland

Section 3: Parenthood in young people

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

Third Sector organisations
Local Authorities
NHS Boards
Youth Work

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

Agencies working with young parents

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

NHS Health Boards

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

The Scottish Government

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

NHS Boards

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

The Scottish Government

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

Local Authorities

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

Community Planning Partnerships
Integrated Joint Boards

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

The Scottish Government
Child Poverty Action Group (Scotland)

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

The Scottish Government
Child Poverty Action Group (Scotland)

Section 4: Strong leadership and accountability

A young people's strategic needs assessment is carried out by Community Planning Partnerships to include pregnancy in young people. As a result, data collecting protocols and data sharing polices including proper protection of privacy/confidentiality are in place for young people who are at risk of a pregnancy.

Community Planning Partnerships
Integrated Joint Boards

The Scottish Government to develop a national generic e-module for statutory and non-statutory professionals providing training on the evidence around young people at risk of pregnancy links with wider issues and practical actions for supporting young people.

The Scottish Government

Local Authorities to bring all partners together to consider the evidence and local data and to agree local pathways.

Local Authorities

The Scottish Government to develop and maintain a digital resource for professionals which shares best practice, training opportunities and case studies in relation to pregnancy in young people and young parents across Scotland.

The Scottish Government

Each Community Planning Partnership to assign a senior accountable person for coordinating leadership/implementation/championing the Strategy.

Community Planning Partnership

References

Barter, C.,McCarry, M., Berridge, D. and Evans, K. (2009) Partner exploitation and violence in teenage intimate relationships. NSPCC. Available from http://www.nspcc.org.uk/globalassets/documents/research-reports/partner-exploitation-violence-teenage-intimate-relationships-report.pdf

Bonnell, C., Fletcher, A., and McCambridge, J. (2007) Improving school ethos may reduce substance misuse and teenage pregnancy. British Medical Journal 334(7594): 614-616

Bradshaw, P; Schofield, L & Maynard, L (2014) The experiences of mothers aged under 20: Analysis of data from the Growing Up in Scotland study. Edinburgh: The Scottish Government

Cameron ST, Lakha F, Milne D , Sim J. Pilot of enhanced contraceptive service to postpartum mothers in South East Edinburgh. Edinburgh and Lothians Health Foundation [tbc when published]

Currie C, Levin K, Kirby J, Currie D, van der Sluijs W and Inchley J (2011) Health Behaviour in School-aged Children: World Health Organization Collaborative Cross-National Study ( HBSC): findings from the 2010 HBSC survey in Scotland. Child and Adolescent Health Research Unit, The University of Edinburgh. Available from: https://research-repository.st-andrews.ac.uk/bitstream/10023/2076/1/HBSC_National_Report_2010_LowRes.pdf

Currie, C., Gabhainn, S.N., Godeau, E., Roberts, C., Smith, R., Currie, D., Picket, W., Richter, M., Morgan, A. and Barnekow, V. (2008) Inequalities in young people's health: international report from the HBSC 2006/06 survey, (Health Policy for Children and Adolescents, No.5). WHO Regional Office for Europe, Copenhagen. Available from: http://www.euro.who.int/en/health-topics/Life-stages/child-and-adolescent-health/publications/2008/inequalities-in-young-peoples-health.-hbsc-international-report-from-the-20052006-survey

Crawford, Cribb & Kelly (2013) Teenage Pregnancy in England. Centre for Analysis of Youth Transitions (CAYT) Impact Study: Institute of Fiscal Studies: Report No. 6

Department of Health (2008) Teenage Parents: Who Cares? A guide to commissioning and delivering maternity services for young parents – Second edition. Available from: http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/standard/Childrenandfamilies/Page11/DCSF-00414-2008

Department of Health (2009) Getting Maternity Services right for pregnant teenagers and young fathers – 2nd edition. Available from: http://webarchive.nationalarchives.gov.uk/20100203100908/http://publications.everychildmatters.gov.uk/default.aspx?PageFunction=productdetails&PageMode=publications&ProductId=DCSF-00673-2009&

Department of Health (2010) Teenage Pregnancy Strategy: Beyond 2010. Available from: https://www.education.gov.uk/consultations/downloadableDocs/4287_Teenage%20pregnancy%20strategy_aw8.pdf

Education Scotland (2013) Health and wellbeing 3-18 curriculum impact report. Available from: http://www.educationscotland.gov.uk/resources/0to9/318impactreporthwb/report.asp

Education Scotland (2014) National Youth Work Strategy: our ambitions for improving the life chances of young people in Scotland. Available from:

http://www.educationscotland.gov.uk/communitylearninganddevelopment/about/policy/youthworkstrategy.asp

Franz,M., McEachran, J., Whitehead, R., van der Sluijs, W., Currie, C. (2015) Sexual health of 15 year olds in Scotland 3: Protection at last intercourse. HBSC [to be added once published]

Harden, J., Purcell, C., Rowa-Dewer, N. (2015) Young People's knowledge, beliefs and attitudes to abortion: an exploratory focus group study. [tbc when published]

Healthcare Improvement Scotland (2011) Improving Sexual Health Services in Scotland. Integration and Innovation: National Overview. Available from: http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal_child/sexual_health/national_overview.aspx

Henderson, M. Smith, D. Elliot, L. Nixon, C. Wright, D. Vulnerable young people in alternative education settings: their sexual health needs, experience and use of sex education and sexual health services. Medical Research Council. Occasional paper 21. June 2011. Available from: http://www.sphsu.mrc.ac.uk/op021.pdf

Institute of Health Equality (2010) The Marmot Review: strategic review of health inequalities post 2010. Fair Society Health Live. Available from: http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review

ISD (2015) Teenage Pregnancy – Year ending 31st December 2012 [online] (Accessed May 2015) Available from: http://www.isdscotland.org/Health-Topics/Maternity-and-Births/Teenage-Pregnancy/

ISD (2015) Abortion Statistics – Year ending 31 December 2012 [online] (Accessed May 2015) Available from: http://www.isdscotland.org/Health-Topics/Sexual-Health/Abortions/

Joseph Rowntree Foundation (2002) The youth divide: Diverging paths into adulthood. Available from: http://www.jrf.org.uk/publications/youth-divide-diverging-paths-adulthood

London School of Hygiene and Tropical Medicine (2005) TPSE Teenage Pregnancy Strategy Evaluation Final Report Synthesis. Available from: http://webarchive.nationalarchives.gov.uk/20130401151715/http://www.education.gov.uk/publications/eOrderingDownload/RW38.pdf

National Society for the Prevention of Cruelty to Children (2010) Children and families experiencing domestic violence. Police and children's social services' responses. Available from: http://www.nspcc.org.uk/preventing-abuse/research-and-resources/children-families-experiencing-domestic-violence/

NHS Health Scotland (2013) The importance of young people's health within the life course. Available from: http://www.healthscotland.com/documents/21401.aspx

NHS Health Scotland (2015) Pregnancy and parenthood in young people: an evidence review [tbc when published]

Parker, I. (2014) Young people, sex and relationships. The new norms. Institute for Public Policy Research.

Purcell, C., Cameron, S., Caird, L., Flett, G., Laird, G., Melville, C. and McDaid, M. (2014) Access to and Experience of Later Abortion: Accounts from Women in Scotland. Perspectives on Sexual and Reproductive Health, Vol 46, Issue 2.

Ross, J.N, Church, S., Hill, M., Seaman, P and Roberts, T. (2010) The fathers of children born to teenage mothers: a study of processes within changing family formation practices. CHILDREN 1st

Available from: http://www.children1st.org.uk/media/69930/spr-pub-031.pdf

The Scottish Government (2014) Well-being: A guide to measuring meaningful outcomes. Available from: http://www.gov.scot/Topics/People/Young-People/gettingitright/background/wellbeing

The Scottish Government (2014) Children and Young People (Scotland) Act. Available from: http://www.gov.scot/Topics/People/Young-People/legislation/proposed-bill

The Scottish Government (2007) Scotland Performs Available from: http://www.gov.scot/About/Performance/scotPerforms

The Scottish Government (2010) A Refreshed Framework for Maternity Care in Scotland. Available from: www.scotland.gov.uk/Resource/Doc/315880/0100454.pdf

The Scottish Government (2010) Getting it right for every child. Available from: http://www.gov.scot/Topics/People/Young-People/gettingitright/background

The Scottish Government (2010) Guidance on the Conduct of Relationships,

Sexual Health and Parenthood Education in Scottish Schools. Available from: http://www.gov.scot/Publications/2014/12/8526

The Scottish Government (2011) The Sexual Health and Blood Borne Virus Framework 2011-2015. Available from: http://www.gov.scot/Publications/2011/08/24085708/0

The Scottish Government (2010) Family Nurse Partnership Programme. Available from: http://www.gov.scot/Topics/People/Young-People/early-years/parenting-early-learning/family-nurse-partnership

The Scottish Government (2011) Opportunities for All Supporting all young people to participate in post-16 learning, training or work. Available from: http://www.gov.scot/Publications/2012/11/7618

The Scottish Government (2011) Health Promoting Health Service: Action in Hospital Settings. Available from: http://www.sehd.scot.nhs.uk/mels/CEL2012_01.pdf

The Scottish Government (2012) National Risk Framework to Support the Assessment of Children and Young People. Available at: http://www.gov.scot/Resource/0040/00408604.pdf

The Scottish Government (2014) National Guidance for Child Protection in Scotland. Available at: http://www.gov.scot/Resource/0045/00450733.pdf

Social Exclusion Unit (1999) Teenage Pregnancy, presented to the Parliament by the Prime Minister by command of her Majesty. Available from: http://dera.ioe.ac.uk/15086/1/teenage-pregnancy.pdf

Survivor Scotland (2005) A Survivor-centred strategic approach for survivors of childhood sexual abuse. Scottish Executive. September 2005. Available from: http://www.survivorscotland.org.uk/research-library/item/national-strategy-document-1/

UNICEF (2001) A league table of teenage births in rich nations,

Innocenti Report Card No.3. UNICEF Innocenti Research Centre, Florence. Available from: http://www.unicef-irc.org/publications/pdf/repcard3e.pdf

Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A, Currie C. (2012) Adolescence and the social determinants of health Lancet 2012; 379: 1641-52

Wight D and Fullerton D. A review of interventions with parents to promote the sexual health of their children Journal of Adolescent Health 2013: 52 4-27Young Scot (2015) Co-designing the teenage pregnancy and young parents strategy. Available from: (tbc)

Appendix 1: Birth rates for 15-19 year olds in the European Union and further afield

Birth rates for 15-19 year olds in the Europe union and further afield[84]

Although rates in both the UK and Europe have been decreasing, the UK still has high numbers of births in 15-19 year olds. Please note that we can only compare births due to the variation in recording data in the various countries.

Note: EU28 is the 28 European Union countries average.

Appendix 2: Membership of Steering Group

Pregnancy and Parenthood in Young People Steering Group Membership

Chair:

Professor John Frank (The Scottish Collaboration for Public Health Research & Policy)

Members:

Alison Hadley OBE (Director of the Teenage Pregnancy Knowledge Exchange, University of Bedfordshire)

Alison Hardie (Young Scot)

Andrea Priestley (Centre for Excellence for Looked After Children in Scotland)

Anita Morrison (Scottish Government)

Ann Milovic (Scottish Government)

Ann Eriksen (NHS Tayside)

Anne Mullin (Deep End GPs)

Carolyn Wilson (Scottish Government)

Carrie Lindsay (Fife Council)

Catherine Calderwood (Scottish Government)

Chloe Swift (Scotland's Commissioner for Children and Young People)

Christine Boyle (Scottish Government)

Clare Burns (Centre for Excellence for Looked After Children in Scotland)

Clare Simpson (Parenting Across Scotland)

Christine Greig (Scottish Government)

Dona Milne (NHS Lothian)

Felicity Sung (Scottish Government)

Gareth Brown (Scottish Government)

Heather Sloan (NHS Greater Glasgow and Clyde)

John Higgins (Education Scotland)

Kathryn Dawson (Rape Crisis Scotland)

Kerri Todd (Strategic Youth Health Improvement Leads)

Liz Fergus (Scottish Government)

Pauline McGough (Sexual Health Lead Clinicians)

Marian Flynn (Glasgow City Council)

Moira Niven (Association of Directors of Education in Scotland)

Nicky Coia (NHS Greater Glasgow and Clyde)

Rebecca Wade (NHS Borders)

Ruth Johnston (Scottish Government)

Shirley Windsor (NHS Health Scotland)

Thomas Lynch (Father's Advisory Panel)

Appendix 3: Logic Model

Appendix 4: Summary of review level evidence

Executive Summary of Review Level Evidence

Evidence and/or evidence-informed recommendations and suggested have been drawn primarily from four key health related sources:

1. National Institute for Health and Care Excellence (NICE) public health guidance (and relevant NHS Health Scotland Commentaries/Scottish Perspectives)

2. National Institute for Health and Care Excellence (NICE) clinical guidance

3. NICE and Health Development Agency (HDA) public health briefings.

4. Publications from the World Health Organization (WHO).

We have called this information 'highly-processed evidence'. Additional sources of evidence and theory have been drawn from relevant key systematic reviews identified largely through the Cochrane Collaboration, the Evidence for Policy and Practice and Co-coordinating Centre (EPPI) and the Campbell Collaboration, reviews and reports commissioned by the The Scottish Government, the UK Government and national organisations and collaborators. Highly processed evidence, including systematic reviews, is used as it provides a summary of high quality evidence that has been quality assured and therefore less subject to bias.

Much of the evidence is drawn from evaluations of studies in North America and other countries where the health, social care and education systems are different to those in Scotland, Where the evidence is largely from outside Scotland the applicability of the evidence to the Scottish context should be considered carefully as results may not replicate in a different context.

For a variety of reasons, we do not always have 'good evidence'. This lack of evidence, however, does not necessarily mean there is no link between two components in a logic model nor that evidence of effectiveness does not exist, it just has not been reported or evaluated. Similarly, lack of evidence should not always prevent us from acting or testing new approaches.

Strand 1: Strong leadership and workforce

- Young people face both personal and service related barriers that influence their access to services. These include embarrassment about discussing sex and using services, perceptions of trust and legitimacy of services; accessibility of services in terms of location/opening hours and the attitudes of staff, in particular the importance of respectful and non-judgemental staff.

- Staff training is associated with improved access to services by young people.

- More co-ordinated services to access appropriate information and advice helps young people to make choices appropriate to their needs and circumstances.

Strand 2: Supportive and youth friendly services

- Young people experience a range of personal and service barriers to accessing service. Youth friendly services increase access to services and may contribute to reduced sexual risk behaviour. The evidence is based on relatively poor quality research.

- Targeted intensive community based interventions which include sexual health services are effective in improving sexual behaviour and reducing pregnancy however transferability to the UK is questionable. Targeted outreach programmes, some specifically targeting socially disadvantaged young people, can increase access to services. No high level evidence was identified about the effectiveness of tailored and targeted services for young people who are in looked after accommodation, are homeless or from Black and Ethnic Minority communities.

- Young people have gaps in their knowledge about sexual activity, contraception, including emergency contraception (EC), and where to access contraception. They may also have negative views about EC and the trustworthiness of services. Advanced provision of emergency contraception increases use and speed of use of EC and does not generally impact on other contraceptive use or increase sexual risk behaviour.

- Long Acting Reversible Contraception (LARC) is the most effective and cost-effective form of contraception. NICE guidance outlines a range of recommendations for the provision of LARC.

- Outreach services may increase access and maintained contact with generic service though the extent to which this impacts on sexual health behaviour and pregnancy is unclear. A small number of studies have evaluated comprehensive multicomponent programmes and these are effective in reducing pregnancy however the provision of LARC is particularly important.

- Interventions that include discussion and demonstration of condoms is effective in engaging young people in services and increasing use of condoms. There is evidence that some interventions that use additional services to increase contraceptive use may be effective.

- School Based and School Linked Health Centres are not associated with increased sexual activity and may contribute to reduced levels of sexual activity and delay sexual initiation. On-site dispensing of condoms is associated with greater provision/uptake of condoms though impact on use has not been fully evaluated.

- A range of personal and service based factors influence access and use of services by young people. Based on the available evidence key characteristics have been proposed to inform service development and evaluations.

- Carrera, an intensive community based youth development programme may be effective in reducing pregnancy and improving sexual behaviour. A UK adaptation of this model reported negative impacts though these may be explained by the study design and poor implementation fidelity.

- Pregnant young women are less likely to access services early in pregnancy. Late engagement with services is associated poorer health outcomes for mothers and their offspring and in relation to termination services can result in reduced choices for young women.

- No highly processed evidence was identified about effective ways of supporting young people to make early informed choices following conception.

- Young women experience a large number of personal and service barriers to accessing antenatal care. There is promising evidence that specialist service which emphasise early initiation of care and multifaceted community based service, including home visits by trained lay advocates increased early booking.

Strand 3: Education and Positive Destinations

- Comprehensive sex and relationship (SRE) programmes are effective in contributing to positive sexual behaviour and no evidence that they increase risky sexual behaviour. Few studies have examined the impact of pregnancy and a small number of studies have found a positive impact. Comprehensive programmes are more likely to be successful if they include a theoretical basis, are delivered by trained professionals and provide specific content focusing on sexual risk reduction. The available evidence points to a number of common characteristics that are associated with the effectiveness of interventions in terms of the development, content and delivery of SRE programmes.

- Programmes that are multimodal and incorporate education, skills building and condom promotion may reduce pregnancy and sexual activity.

- The effectiveness of abstinence based programmes is inconclusive and is based on a smaller number of high quality evidence. Better quality studies suggest these programmes are not effective in reducing sexual activity or pregnancy.

- A small number of studies indicate that general health education programmes which involve a community components are effective in reducing sexual risk behaviour. Weak evidence from one study suggests that whole school approach may have impact on sexual behaviour in the long term.

- There is limited evidence about the effectiveness programmes including a parenting component in reducing risky sexual behaviour. Programmes that are intensive and focus on parental monitoring or regulation are the most promising. There is reasonable evidence to suggest that intensive programmes have a positive impact on child-parent interactions.

- A range of interventions to address the social and emotional wellbeing of children and young people in schools can be found in the mental health improvement outcomes framework (MHIOF)

- No highly processed evidence was identified for the effectiveness of parenthood programmes on improving knowledge around parenting, delaying pregnancy and improving health and social outcomes for parents and children in the long term.

- Limited highly processed evidence was identified for the effectiveness of programmes to address gender based inequalities and violence. Whilst some primary prevention approaches are promising, there is not currently sufficient evidence to recommend any particular adolescent dating violence prevention programme over another

- Early childhood intervention and social development projects in primary school targeted at those who experience social disadvantage can have a positive impact on pregnancy and/or birth rates, reduced sexual activity or increase safe sexual behaviour and contribute to reducing unintended teenage pregnancy.

- Youth development programmes addressing non-sexual risk factors for unintended teenage pregnancy as well as those incorporating services to address sexual risk factors can have a positive impact on unintended teenage pregnancy.

- A range of school, community and afterschool interventions in primary and secondary schools are effective in reducing school dropout and increasing school attendance and that targeted school-, court- and community-based intervention have a modest impact on school attendance.

Strand 4: Supporting young parents

- Young women experience a large number of personal and service barriers to accessing antenatal care. Specialist services which emphasise early initiation of care and multifaceted community based service, including home visits by trained lay advocates increase early booking.

- Antenatal classes designed for young people, home visiting and assistance with transport costs, specialist antenatal services and continuity of care for young women help young people maintain contact with services. There is conflicting evidence about the most appropriate additional services and limited evidence about what additional information is need to support young women.

- Enhanced home visiting beginning pre-natally and extending upto 18 months by professionals (such as the Family-Nurse-Partnership) can reduce repeat pregnancy and increase the spacing of pregnancy. It can positively impact upon the social and emotional development of young mothers and their children (see below).

- Young people experience a range of problems with housing, childcare, financies, educaton, training and employment. Common themese include diverse needs and lack of choice; stereotypes of teenage mothers; reliance on family; consideration of the cost and benefits of education and employment; continuation of social problems prior to pregnancy. Actions to meet these needs may contribute to improved life courses for teenage pareents

- Education/career development programmes and welfare sanctions and bonus programmes are effective in improving in education and training though the former are more effective and may be more appropriate to the needs of young people. Neither type of programme had a long term impacts on employment rates. Education alone is unlikely to improve employment prospects. A focus on employment and provision of jobs and higher earning for teenage mothers is associated with improved long-term self-sufficiency. Holistic programmes address many of the needs identified by young people however, the effectiveness of these programmes in terms of improving participation in education, training or employment has not yet been established.

- Education/career development interventions and holistic programmes had a positive but non-significant effect on emotional wellbeing and had a non-significant impact on reducing further pregnancy.

- A number of recommendations for social inclusion have been proposed on the basis of the available qualitative and quantitative evidence

- Enhanced home visiting is effective in increasing maternal employment as well as reducing use of welfare, arrest/convictions and domestic violence

- Day care for young children is associated with improved prospects of education, training and employment for mothers, including teenage mothers. The Abecedarian project, an early childhood intervention targetted at teenage parents was assocated with improvements in high school completion, participation in training and employment as well as a reduction in repeat pregancy.

- There is limited highly processed evidence about the experiences of young fathers and how to effectively and appropriately engage them in services to improve outcomes for themselves, their partners and their children. There is promising evidence from evaluations of FNP and Sure Start Plus which begin to address this area.

Appendix 5: Consultation Questions

The respondent information form and consultation questionnaire are available online in Word format

Footnotes

1. International comparisons of teenage births (2014) Office of National Statisitcs, available at http://www.ons.gov.uk/ons/rel/vsob1/births-by-area-of-usual-residence-of-mother–england-and-wales/2012/sty-international-comparisons-of-teenage-pregnancy.html

2. The Scottish Index of Multiple Deprivation (SIMD) is the Scottish Government's official tool for identifying those places in Scotland suffering from deprivation. In this context, deprivation is defined more widely as the range of problems that arise due to lack of resources or opportunities, covering health, safety, education, employment, housing and access to services, as well as financial aspects.

3. ISD (2015) Teenage Pregnancy – Year ending 31st December 2012 [online] (Accessed May 2015) Available from: http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/data-tables.asp?id=1256#1256

4. Social Exclusion Unit (1999) Teenage Pregnancy, presented to the Parliament by the Prime Minister by command of her Majesty. Available from: http://dera.ioe.ac.uk/15086/1/teenage-pregnancy.pdf

5. Crawford, Cribb & Kelly (2013) Teenage Pregnancy in England. Centre for Analysis of Youth Transitions (CAYT) Impact Study: Institute of Fiscal Studies: Report No. 6

6. Institute of Health Equality (2010) The Marmot Review: strategic review of health inequalities post 2010. Fair Society Health Live. Available from: http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review

7. NHS Health Scotland (2013) The importance of young people's health within the life course. Available from: http://www.healthscotland.com/documents/21401.aspx

8. The Scottish Government (2014) Well-being: A guide to measuring meaningful outcomes. Available from: http://www.gov.scot/Topics/People/Young-People/gettingitright/background/wellbeing

9. NHS Information Service Division (2015) [reference to be confirmed when published]

10. Bradshaw, P; Schofield, L & Maynard, L (2014) The experiences of mothers aged under 20: Analysis of data from the Growing Up in Scotland study. Edinburgh: The Scottish Government

11. Young mums together: promoting young mothers' wellbeing (2013) Mental Health Foundation: http://www.mentalhealth.org.uk/content/assets/PDF/publications/young-mums-together-report.pdf?view=Standard

12. Bradshaw, P; Schofield, L & Maynard, L (2014) The experiences of mothers aged under 20: Analysis of data from the Growing Up in Scotland study. Edinburgh: The Scottish Government

13. Ross, J.N, Church, S., Hill, M., Seaman, P and Roberts, T. (2010) The fathers of children born to teenage mothers: a study of processes within changing family formation practices. CHILDREN 1st

Available from: http://www.children1st.org.uk/media/69930/spr-pub-031.pdf

14. The Scottish Government (2007) Scotland Performs Available from: http://www.gov.scot/About/Performance/scotPerforms

15. The Scottish Government (2015) Pregnancy and Parenthood in under 20s policy mapping [tbc]

16. The Scottish Government (2010) Getting it right for every child. Available from: http://www.gov.scot/Topics/People/Young-People/gettingitright/background

17. The Scottish Government (2014) Children and Young People (Scotland) Act. Available from: http://www.gov.scot/Topics/People/Young-People/legislation/proposed-bill

18. Reference to be confirmed: Publication of Strategy due Summer 2015

19. NHS Health Scotland (2015) Pregnancy and parenthood in young people: an evidence review [tbc when published]

20. Crawford, Cribb & Kelly (2013) Teenage Pregnancy in England. Centre for Analysis of Youth Transitions (CAYT) Impact Study: Report No. 6

21. HBSC 2015 report [tbc when published]

22. Currie C, Levin K, Kirby J, Currie D, van der Sluijs W and Inchley J (2011) Health Behaviour in School-aged Children: World Health Organization Collaborative Cross-National Study ( HBSC): findings from the 2010 HBSC survey in Scotland. Child and Adolescent Health Research Unit, The University of Edinburgh. Available from: https://research-repository.st-andrews.ac.uk/bitstream/10023/2076/1/HBSC_National_Report_2010_LowRes.pdf

23. Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A, Currie C. (2012) Adolescence and the social determinants of health Lancet 2012; 379: 1641-52

24. Bonnell, C., Fletcher, A., and McCambridge, J. (2007) Improving school ethos may reduce substance misuse and teenage pregnancy. British Medical Journal 334(7594): 614-616

25. Crawford, Cribb & Kelly (2013) Teenage Pregnancy in England. Centre for Analysis of Youth Transitions (CAYT) Impact Study: Report No. 6

26. Reference to be confirmed once published: http://news.scotland.gov.uk/News/Action-to-improve-literacy-188b.aspx

27. Parker, I. (2014) Young people, sex and relationships. The new norms. Institute for Public Policy Research

28. Currie et al (2015) HSBC case study [tbc when published]

29. National Society for the Prevention of Cruelty to Children (2010) Children and families experiencing domestic violence. Police and children's social services' responses. Available from: http://www.nspcc.org.uk/preventing-abuse/research-and-resources/children-families-experiencing-domestic-violence/

30. Barter, C.,McCarry, M., Berridge, D. and Evans, K. (2009) Partner exploitation and violence in teenage intimate relationships. NSPCC. Available from http://www.nspcc.org.uk/globalassets/documents/research-reports/partner-exploitation-violence-teenage-intimate-relationships-report.pdf

31. Education Scotland (2014) National Youth Work Strategy: our ambitions for improving the life chances of young people in Scotland. Available from:

http://www.educationscotland.gov.uk/communitylearninganddevelopment/about/policy/youthworkstrategy.asp

32. Macdowall, W et al (2015) Associations between source of information about sex and sexual health outcomes in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), BMJ Open; 5:e007837 doi:10.1136/bmjopen-2015-007837

33. Parker, I. (2014) Young people, sex and relationships. The new norms. Institute for Public Policy Research.

34. The Scottish Government (2010) Guidance on the Conduct of Relationships,

Sexual Health and Parenthood Education in Scottish Schools. Available from: http://www.gov.scot/Publications/2014/12/8526

35. Young Scot (2015) Co-designing the teenage pregnancy and young parents strategy. Available from: (tbc)

36. Education Scotland (2013)Health and wellbeing 3-18 curriculum impact report. Available from: http://www.educationscotland.gov.uk/resources/0to9/318impactreporthwb/report.asp

37. Wight D and Fullerton D. A review of interventions with parents to promote the sexual health of their children Journal of Adolescent Health 2013: 52 4-27

38. NHS Health Scotland (2015) Pregnancy and parenthood in young people: an evidence review [tbc when published]

39. Young Scot (2015) Co-designing the teenage pregnancy and young parents strategy. Available from: (tbc)

40. NHS Health Scotland (2015) Pregnancy and parenthood in young people: an evidence review [tbc when published]

41. Young Scot (2015) Co-designing the teenage pregnancy and young parents strategy. Available from: (tbc)

42. Healthcare Improvement Scotland (2011) Improving Sexual Health Services in Scotland. Integration and Innovation: National Overview. Available from: http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal_child/sexual_health/national_overview.aspx

43. Young Scot (2015) Co-designing the teenage pregnancy and young parents strategy. Available from: (tbc)

44. The intrauterine device (IUD) and intrauterine system (IUS) and the implant

45. Curry et al (2015) HBSC evidence briefing [to be added when published]

46. Young Scot (2015) Co-designing the teenage pregnancy and young parents strategy. Available from: (tbc)

47. The Scottish Government (2011) The Sexual Health and Blood Borne Virus Framework 2011-2015. Available from: http://www.gov.scot/Publications/2011/08/24085708/0

48. Information Services Division (2014) http://www.isdscotland.org/Health-Topics/Maternity-and-Births/Publications/2014-08-26/mat_bb_table9.xls

49. Harden, J., Purcell, C., Rowa-Dewer, N. (2015) Young People's knowledge, beliefs and attitudes to abortion: an exploratory focus group study. [tbc when published]

50. Young Scot (2015) Co-designing the teenage pregnancy and young parents strategy. Available from: (tbc)

51. The Scottish Government (2012) National Risk Framework to Support the Assessment of Children and Young People. Available at: http://www.gov.scot/Resource/0040/00408604.pdf

52. The Scottish Government (2014) National Guidance for Child Protection in Scotland. Available at: http://www.gov.scot/Resource/0045/00450733.pdf

53. Purcell, C., Cameron, S., Caird, L., Flett, G., Laird, G., Melville, C. and McDaid, M. (2014) Access to and Experience of Later Abortion: Accounts from Women in Scotland. Perspectives on Sexual and Reproductive Health, Vol 46, Issue 2.

https://isdscotland.scot.nhs.uk/Health-Topics/Sexual-Health/Publications/2015-05-26/mat_aas_table11.xls?

54. Healthcare Improvement Scotland (2011) Improving Sexual Health Services in Scotland. Integration and Innovation: National Overview. Available from: http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal_child/sexual_health/national_overview.aspx

55. The Scottish Government (2011) Health Promoting Health Service: Action in Hospital Settings. Available from: http://www.sehd.scot.nhs.uk/mels/CEL2012_01.pdf

56. Data from 2012/13 show that 80.7% of all women achieved the target, whereas none of the young women in the 'teenage' age groups (<20, <18, <16) achieved the target. This was strikingly notable for the under 16 age group, of whom only 41.9% were booked for antenatal care by 12 weeks. http://www.isdscotland.org/Health-Topics/Maternity-and-Births/Publications/2014-08-26/mat_bb_table9.xls

57. Department of Health (2008) Teenage Parents: Who Cares? A guide to commissioning and delivering maternity services for young parents – Second edition. Available from: http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/standard/Childrenandfamilies/Page11/DCSF-00414-2008

58. Department of Health (2008) Teenage Parents: Who Cares? A guide to commissioning and delivering maternity services for young parents – Second edition. Available from: http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/standard/Childrenandfamilies/Page11/DCSF-00414-2008

59. The Family Nurse Partnership programme (FNP) is available in most parts of Scotland. http://www.gov.scot/Topics/People/Young-People/early-years/parenting-early-learning/family-nurse-partnership/background

60. The Scottish Government (2010) A Refreshed Framework for Maternity Care in Scotland. Available from: www.scotland.gov.uk/Resource/Doc/315880/0100454.pdf

61. Ross, J.N, Church, S., Hill, M., Seaman, P and Roberts, T. (2010) The fathers of children born to teenage mothers: a study of processes within changing family formation practices. CHILDREN 1st

Available from: http://www.children1st.org.uk/media/69930/spr-pub-031.pdf

62. Ross, J.N, Church, S., Hill, M., Seaman, P and Roberts, T. (2010) The fathers of children born to teenage mothers: a study of processes within changing family formation practices. CHILDREN 1st

Available from: http://www.children1st.org.uk/media/69930/spr-pub-031.pdf

63. Bradshaw, P; Schofield, L & Maynard, L (2014) The experiences of mothers aged under 20: Analysis of data from the Growing Up in Scotland study. Edinburgh: The Scottish Government

64. Young Scot (2015) Co-designing the teenage pregnancy and young parents strategy. Available from: (tbc)

65. Department of Health (2009) Getting Maternity Services right for pregnant teenagers and young fathers – 2nd edition. Available from: https://www.rcm.org.uk/news-views-and-analysis/news/getting-maternity-services-right-for-pregnant-teenagers-and-young

66. maternity services refers to the specialist care provided by midwives, obstetricians, anaesthetists, neonatologists, paediatricians

67. NHS Health Scotland (2015) Pregnancy and parenthood in young people: an evidence review [tbc when published]

68. Young Scot (2015) Co-designing the teenage pregnancy and young parents strategy. Available from: (tbc)

69. NHS Health Scotland (2015) Pregnancy and parenthood in young people: an evidence review [tbc when published]

70. The Scottish Government (2010) A Refreshed Framework for Maternity Care in Scotland. Available from: www.scotland.gov.uk/Resource/Doc/315880/0100454.pdf

71. NHS Health Scotland (2015) Pregnancy and parenthood in young people: an evidence review [tbc when published]

72. The Scottish Government (2010) Family Nurse Partnership Programme. Available from: http://www.gov.scot/Topics/People/Young-People/early-years/parenting-early-learning/family-nurse-partnership

73. The Scottish Government (2010) Family Nurse Partnership Programme. Available from: http://www.gov.scot/Topics/People/Young-People/early-years/parenting-early-learning/family-nurse-partnership

74. Cameron ST, Lakha F, Milne D , Sim J. Pilot of enhanced contraceptive service to postpartum mothers in South East Edinburgh. Edinburgh and Lothians Health Foundation [tbc when published]

75. The Scottish Government (2011) Health Promoting Health Service: Action in Hospital Settings. Available from: http://www.sehd.scot.nhs.uk/mels/CEL2012_01.pdf

76. The Scottish Government (2011) Opportunities for All Supporting all young people to participate in post-16 learning, training or work. Available from: www.gov.scot/Publications/2014/08/4869

77. The Scottish Government National Indicator: "increase the proportion of young people in learning, training or work" (previously School leavers, from Scottish publicly funded schools, in positive and sustained destinations: Further Education (FE), Higher Education (HE), employment or training).

78. The income thresholds for Child Tax Credit and Working Tax Credit are determined for the purposes of section 7(1)(a) of the Tax Credits Act 2002 and can vary annually.

79. http://www.gov.scot/Topics/Statistics/Browse/Housing-Regeneration/RefTables

80. Joseph Rowntree Foundation (2002) The youth divide: Diverging paths into adulthood. Available from: http://www.jrf.org.uk/publications/youth-divide-diverging-paths-adulthood

81. Housing Options Protocol for Care Leavers, Guidance for Corporate Parents: Improving housing and accommodation outcomes for Scotland's care leavers (2013) The Scottish Government, available from: http://www.gov.scot/Publications/2013/10/6147

82. Bradshaw, P; Schofield, L & Maynard, L (2014) The experiences of mothers aged under 20: Analysis of data from the Growing Up in Scotland study. Edinburgh: The Scottish Government

83. London School of Hygiene and Tropical Medicine (2005) TPSE Teenage Pregnancy Strategy Evaluation Final Report Synthesis. Available from: http://webarchive.nationalarchives.gov.uk/20130401151715/http://www.education.gov.uk/publications/eOrderingDownload/RW38.pdf

84. Source: Eurostat data, compiled by the Office for National Statistics http://www.ons.gov.uk/ons/rel/vsob1/births-by-area-of-usual-residence-of-mother–england-and-wales/2012/sty-international-comparisons-of-teenage-pregnancy.html