A more measured approach to teen pregnancy
The early, headlong rush into parenthood by many young Scots is an issue that tends to stir up misinformation. The country has long had a stubbornly high rate of teenage pregnancy, and the debate around it has often been marred by dogma and ineffectual hand-wringing.
An inquiry into teenage pregnancy by the Scottish Parliament's health and sport committee may prove to be a watershed, however. It has been defined by cool-headed discussion and a determination to be guided by evidence.
A picture has emerged of a country finally getting to grips with this issue, of a coherent national approach starting to form and pregnancy rates falling for four years in a row. But there is a long way to go. Scotland still has one of the highest teenage pregnancy rates in western Europe, and attempts to address it are, at times, hopelessly inadequate.
The committee's work - leading to a report in May - has underlined shifting approaches to teenage pregnancy. Renfrewshire education director Robert Naylor spoke for many when he said it was "probably far more of a social demographic issue than a health issue". Cath King, health improvement policy manager for Highland Council, stated bluntly: "Our view is that any measures to tackle deprivation will tackle teenage pregnancy - it is as simple as that."
There is more onus now on schools and local authorities to take some of the strain from health services. A national sexual health and blood-borne virus framework recommends that authorities seek to reduce teenage pregnancies in their single-outcome agreements, although public health minister Michael Matheson told the inquiry that only some have done so thus far.
But even if education bosses accept that they have a central role, the funding has yet to follow from health to other services. "No resources have been transferred, as far as I have seen," said Mr Naylor, a view backed up by Marian Flynn, Glasgow City Council's strategic manager for young people's sexual health.
The strong link between deprivation and teenage pregnancy was repeatedly stated during the inquiry. The government itself, through Mr Matheson, made much of its commitment to the bold and pricey "family nurse partnership" programme, which involves home visits to vulnerable first- time mothers. This has worked successfully in the US over 30 years.
But a related danger was also exposed: fatalism can creep into the approaches of those meant to be helping the vulnerable young women most likely to become pregnant.
"The attitude of `It's just like that round here' was quite a challenge," said Alison Hadley, director of the Teenage Pregnancy Knowledge Exchange at the University of Bedfordshire, and previous head of the UK government's teenage pregnancy unit.
"Some of them had focused more on improving support for young parents than on prevention, because they thought that they could not do much on prevention," she said. "Only when we reflected back to them that similarly deprived areas had made big progress on prevention did they start to think that there was something that they could do."
Simple data in Scotland show that sky-high rates of teenage pregnancy in deprived areas are far from inevitable. Committee convener Duncan McNeill compared the pregnancy rate in his patch, Greenock and Inverclyde, of 6.9 per 1,000 girls under 16, against Dundee, with 14.4 per 1,000 - despite similar levels of deprivation.
There is a complex range of reasons why young people become pregnant. Alcohol and drugs cause unintended pregnancies, but at times the causes are harder to pin down - a confusing vortex of low self-esteem and purposelessness, perhaps heightened by abusive relationships.
"Sometimes, they just hope that a baby will love them and that they can love it and that that will fill a bit of a gap," said Anne Houston, chief executive of the charity Children 1st. These girls demand "very different responses" from those who may simply have made a mistake after over- imbibing.
Schools struggle with sex education, or, as some prefer to call it, relationships, sexual health and parenthood education. At times it is done "in fairly large groups and the young people and the teacher are embarrassed, and the whole thing is a bit of a disaster", said Ms Houston.
But the blame ultimately lies at a higher policy level, experts believe. "There is no monitoring and accountability, nor sanctions in place for non-compliant schools, and schools are free to determine content," said Ruth Holman, chair of the Scottish Sexual Health Lead Clinicians Group.
At the same time, there are increasingly pervasive, malign sources of knowledge about sex: Kathryn Dawson, sexual violence prevention coordinator at Rape Crisis Scotland, said men were "increasingly exposed to sexualising influences through media and peer group which encourage early sexual activity and prescribe narrow, gendered roles, which place expectations on young men to be highly sexually active".
Too often, the standard of sex education hinges on one person, as Ms Houston explained: "It depends to some extent on how forward-looking and open the headteacher is. In our experience, that has to do with, I guess, a certain belief base.
"I do not want to characterise it totally as being to do with non- denominational or denominational schools, but there have been occasions when we have had more difficulties in some of the denominational schools."
Faith-based approaches are not inherently problematic, explained Lucy Emmerson, coordinator at the Sex Education Forum: "A range of views on sex and relationships can be discussed, including faith perspectives, but teachers must be clear when they are presenting facts and when they are presenting opinions or beliefs."
Jane Hughes, deputy chief executive of Brook, which describes itself as the UK's leading provider of sexual health services and advice for under- 25s, advised the inquiry: "Young people consistently tell us that the sex and relationships education that they receive is too little, too late and too biological. What they ask for is education support that equips them with the language and skills to manage their relationships effectively, understand appropriate and inappropriate behaviour, and enable them to resist peer pressure."
That was a view backed up by four young parents from different backgrounds who addressed the committee: they learned plenty about the biological side of sex in school, but not much about relationships. In the same session, public health minister Michael Matheson revealed his intention to carry out an audit of young people's views.
According to Lucy Emmerson, international research shows that people who have experienced good-quality sex education are more likely to use contraception, delay their first sexual experience and have fewer sexual partners.
But Ruth Holman points out that some local authority managers will not allow condom distribution - a decision "often fuelled by the misconception that talking about sex and provision of sexual health interventions encourage young people to have sex", as well as a fear of bad publicity.
Sex education often finds itself on a fragile footing. As Alison Hadley puts it: "If a school is starting to deliver some really good sex education programmes or is setting up a school-based clinic, one bad headline like `Condoms for 11-year-olds' makes everyone very nervous, and it stops delivery of good practice."
But some Scottish schools are showing the courage of their convictions. Derek Allan, headteacher at the 1,100-pupil Kirkcaldy High in Fife, argues: "Evidence points out that discussing sexuality and sexual health does not encourage promiscuity or early adoption of sexual behaviour - quite the opposite".
Although the evidence to date is anecdotal, he believes that a bold pilot project at his school, involving the dispensing of condoms and pregnancy testing, is proving a success. Between August and October 2012, 45 girls and 33 boys used a drop-in service, with 373 condoms given to girls and 252 to boys.
"There has certainly been a culture change," Mr Allan said. "We are bringing these matters to the fore, talking about them more openly and taking a more proactive and pragmatic approach, and that is helping us to tackle the issue."
As public health minister, Mr Matheson has highlighted work by NHS Fife to extract data around teenage pregnancy specific to small local areas. Joint efforts between local authorities and health boards to tackle teenage pregnancy, leading to more tailored responses, is a model he would like to see replicated across Scotland.
There is a danger of seeing solutions to teenage pregnancy as a simple choice: either espouse abstinence from sex, or accept that teenagers will have sex and try your damnedest to ensure they do it safely. A number of witnesses told MSPs that this was badly off the mark.
"Abstinence-based approaches to sex education have received bad press and immediately invoke negative responses from many people who are emphasising the importance of contraception," said Lisa Milner-Smith, a midwife with a secondary teaching background.
"However, if this message is used as one part of the overall message encouraging teenagers to delay their first sexual encounter until long- term committed relationships, such as marriage, the message is accepted by young people as being common sense. Instead of saying `Don't have sex' or `Use condoms', I suggest that there should be a third voice that says: `It's OK to wait'." This, she stressed, mirrored Unicef's "ABC" message: abstinence, being faithful and condom use.
Jonathan Sher, Scotland director for the WAVE (Worldwide Alternatives to ViolencE) Trust, said there was "not much evidence in history" that teenagers could be prevented from having sex, but he also thought the amount of sexual behaviour at that age was being exaggerated. "Part of informed choice for a particular teenager is understanding that he or she is not the last person in town who is not having sex," he said.
Some, such as the Christian Medical Fellowship, argued that history made clear the need for a fundamental change of approach. It cited economist Professor David Paton who, in the Education and Health Journal, stated that "unwanted pregnancy has proved remarkably resilient to policy initiatives implemented by different governments over the past 40 years". The fellowship also referred to research suggesting that an abstinence- only approach resulted in "significantly later sexual initiation".
Few witnesses advocated a strict abstinence-based approach, but there are signs emerging of consensus around a fundamental shift in approach of another kind - that work to prevent teenage pregnancies should start when children are barely out of nappies.
Napier University's Professor Lawrie Elliott, of the school of nursing, midwifery and social care, is less sanguine about sex education, based on his own research and analysis of a number of reviews. Sex education improves sexual health knowledge but has little impact on behaviours such as condom use, it appears, although there may be benefits from augmenting sex education with sexual health services.
When he and his colleagues looked at a sophisticated programme that combined sex education with drop-in services and an "overarching communications strategy", the impact was still limited; there was even evidence that pupils became more tolerant of sexual coercion.
"Poor outcomes in teen years, including sexual risk-taking, are best tackled in the early years (pre-birth to age eight) of a child's life," he said.
Committee deputy convener Bob Doris concurred: "Dynamics around why young girls are sexually active relate to a lack of empowerment, self-esteem and self-worth issues, and low aspirations. They do not manifest themselves only when young people become sexually active. I suggest that they manifest themselves in primary school, and possibly even pre-school."
There is a danger of ignoring boys when dealing with teenage pregnancy - an issue flagged up by Ruth Colman among others - and writing them off as feckless ne'er-do-wells who will want nothing to do with their child.
Young fathers often feel "marginalised and ignored" by maternity services, and that there is a lack of support specifically for them. Children 1st can point to its research that shows that a "surprisingly high" number of fathers want to stay involved with their children; many young fathers see a pregnancy as a turning point in their life that can steer them away from alcohol and criminal activity. Teenage pregnancy is so often framed as a social malaise that positive stories can be obscured.
"The starting point should not be that it is always a bad thing and should always be prevented," said Dr Sher. Or as Sarah Vernon, policy and information officer for Children 1st, put it: "While we acknowledge the need to reduce teenage pregnancies in Scotland, it should also be acknowledged that young mums can be good mums."
EASING THE BURDEN FOR YOUNG MUMS
Most women can expect to be showered with goodwill when they announce they are pregnant. But for the expectant mum in her teens, it can be a very different story - of bullying, ostracisation and doom merchants insisting that her chances of getting on in life are over.
Nothing could be further from the truth at Threads, a Barnardo's project in Paisley, and a haven for young mums and mums-to-be. It is an informal, homely place, where young women sink into settees with a mug of tea and swap stories about their pregnancies.
Away from Threads - which receives part of its funding from Renfrewshire Council, LloydsTSB Foundation and the Energy Saving Trust - the experience is often very different.
"As well as the pressure of being pregnant, a lot of the young people are being judged by their peers, and sometimes other adults, even if they are trying to be helpful," explains children's service manager Lynne O'Brien.
They want to be good mums, but people often tell them they got pregnant to get a house, and assume that they will never go back to work or education; those at school are often bullied as a direct result of becoming pregnant.
Threads works with under-21s, and 250 families per year. Some 140 young parents attend support groups. At any one time, the 10 staff can be working with 80 families, ranging from minimal support to intensive work.
But sometimes it is the opportunity to share time with others in their situation that counts: "Peer support is so important - quite often that's what makes the difference."
The young people receive practical advice about the physical, emotional and practical impact of bringing a child into the world, but staff also help them to think about personal development - what they want to do with their lives, not just what they will do for their child.
"That's so significant for a young person of 16 or 17," says Ms O'Brien. "They need to believe they are going somewhere."
And many do flourish after passing through Threads; some have gone on to university.
"I see young mums every day who, despite the challenges, are determined to be good parents," says Ms O'Brien. "Our job at Threads is to help them on that journey."
EXPERIENCES OF THREADS
"I felt a lot calmer because I know other mums are going through the same things as me and they worry too."
"By attending the group I feel more patient and more relaxed when he cries, knowing that I'm not alone . the group gives me the chance to meet other mums."
"Before coming to the group I felt I lost all my friends."
"I am a more confident parent, and knowing that I'm not the only young mum has made me stronger."
"Coming to the group gets us out and about and building a social circle. When I'm here, it picks my mood up."
Original headline: A more measured approach to teenage pregnancy