Health and Sport Committee

Meeting date: Tuesday, January 22, 2013

Official Report 519KB pdf

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Teenage Pregnancy Inquiry

Agenda item 2 is our first evidence-taking session in our inquiry into teenage pregnancy. It might be useful if we begin by introducing ourselves.

I am the MSP for Greenock and Inverclyde, and the convener of the Health and Sport Committee.

I am the principal health improvement officer for sexual health with NHS Greater Glasgow and Clyde.

I am an MSP for Glasgow, and the deputy convener of the committee.

I am the executive lead for sexual health and blood-borne virus with NHS Tayside.

I am the MSP for Clydebank and Milngavie.

I lead the blood, organ donation and sexual health team in the Scottish Government.

I am an MSP for Mid Scotland and Fife.

I am the sexual health and HIV national co-ordinator at the Scottish Government.

I am an MSP for Glasgow.

I am an MSP for North East Scotland.

I am a consultant in public health medicine with NHS Ayrshire and Arran, for which I am the sexual health lead.

I am an MSP for South Scotland.

I am a consultant in public health medicine with NHS Fife, and I lead on sexual health strategy.

I am an MSP for North East Scotland.

I am the MSP for the Kirkcaldy constituency.

Before we move to our first question, I note that I will give priority to our guests when it comes to speaking today. I think that the MSPs understand that; we are trying to encourage witnesses to engage in a discussion. If someone says something that you feel that you need to add to or with which you disagree, you may say so. If you do not say so, we will assume that you agree with the comments.

David Torrance will ask the first question.

I represent Kirkcaldy constituency, which has the highest teenage pregnancy rate in Europe, even though we have education in schools, partnership working between Fife Council and NHS Fife, drop-in centres, community pharmacies, an active third sector—with organisations such as Kirkcaldy teens, the YWCA and the YMCA—and community halls.

What evidence is there of planned teenage pregnancy, and what factors play a part?

11:45

I cover the Fife area, so I will start. We are particularly concerned that the recent statistics for Scotland show that the rates in Fife are higher than those in other health board areas.

Teenage pregnancy covers a spectrum of circumstances. We are aware that some young people decide that they want a pregnancy at a young age. Some of the issues behind that are to do with self-esteem and the degree of respect that is afforded in their relationships and community. It might reflect a lack of aspiration or of job opportunities.

That illustrates that teenage pregnancy is a complex issue to unpick. Many young people did not think that it would happen to them and the pregnancy is in no way intended or planned, but we certainly come across young people who say that it is what they want. When we are aware of that, we work with the young people and with the local services on the ground to consider their needs and to understand their situation. We perhaps try to explain to young people that there are a lot of wider factors to consider before planning a pregnancy, such as the circumstances into which the child will be born, whether their relationship is stable, whether they can build a stable home for a family and whether they are mature enough to cope.

That answer brings out a number of the complexities. I am sure that my colleagues will be able to expand on it.

I agree with the point about the complexity of the issues. NHS Tayside covers Dundee, which has historically had some of the highest rates of teenage pregnancy. That prompted us to carry out local research to get a better understanding of young women’s circumstances and to find out whether pregnancies are planned or unplanned, the extent to which they are unplanned and how ambivalent young women are about being pregnant.

The research—which was carried out fairly recently, in 2011—showed that, for the young women who said that they wanted to be pregnant and wanted a baby, it was very much about looking for love and affection and looking for someone whom they could love unconditionally and who would love them in return. Another reason was to do with gaining recognition and status in their family and the community. Some young women might not see educational attainment or employment as providing that status, so it almost seems that having a baby means being recognised as moving into adulthood.

Another factor that came up in our research, and which comes through in the wider evidence as one of the strongest predictors of whether someone will be a young mum, is whether their mum had them when she was young. There are issues to do with the patterns in communities and families.

A final theme that emerged was that some young women hope that they will be able to get their own accommodation and so be able to move out of the family home. That was interesting, because the point had been raised for a number of years but the professionals had not felt that it was a factor. However, the young women raised the issue and clearly had that perception.

Mr Torrance’s question was about the extent to which teenage pregnancies are unplanned. The core issues in planned teenage pregnancies have been well articulated, but our sense from the research evidence base, and particularly from the abortion rate in teenagers, is that most teenage pregnancies are unplanned. We have heard about the issues and caveats to do with planned pregnancies, but our sense is that most teenage pregnancies in Scotland are unplanned.

I very much echo what Nicky Coia says. That the vast majority of teenage pregnancies are unplanned was certainly borne out in the local research in Dundee. However, the factors that influenced decision making were quite different in the group of young women who expressed a desire to have a baby.

That is sometimes why we use terminology such as “unintended”. The word “unplanned” indicates a real sense of what a person wants to do and the reasons why. A baby or a pregnancy may not be intended, but it might not be unintended. That links to some of the complexities around fatalism and to issues around aspiration, education and giving young people, including young women, a reason to delay parenthood. It is sometimes helpful to think about the word “unintended” rather than the words “planned” or “unplanned”.

I do not get a sense that that research told you much that you did not already know, perhaps other than about the driver of setting up accommodation. When the strategy was outlined and targets were set, there would have been a similar understanding. What has happened or not happened in the time since then that has resulted in the targets not being met and the lack of progress on the matter? That is what has brought about the committee’s attention to it and the inquiry.

From the Government’s perspective, it is true that we did not meet the target that we set, but we missed it by 0.3 per cent, I think. The area is still challenging, but it is important to recognise that there have been signs of progress. The official ISD Scotland statistics that are produced annually show that teenage pregnancy rates in under-18s and under-20s have gone down consistently over the past four or five years; indeed, I think that they are now at their lowest levels since 1994. That is not a reason for complacency—we still need to do work—but there are signs of progress.

I think that that situation reflects the fact that we launched the first Scottish full strategy on sexual health and teenage pregnancy back in 2005 and we have kept up the momentum. We have maintained funding and messages to our local partners about the importance of education in schools and access to sexual health clinics. There has been consistent investment in resources and activity, and we are starting to see a downward trend. That is not to say that we have solved the problem, but I would hate to leave people with the impression that there has been no progress, because there has certainly been some progress.

We commissioned the local research essentially because, at that stage, the data from ISD Scotland suggested that teenage pregnancy rates in Dundee were double the national rate. It was important for us to understand whether the factors that we know about from the international and national evidence were at play in Dundee or whether there was something more significant than that. The local research confirmed that Dundee was not particularly different, although there are probably stronger factors relating to social and community norms around early parenthood.

A significant amount of work has been carried out locally on the basis of the national strategy, and I can certainly say from local data in Tayside, and Dundee in particular, that there was a 50 per cent reduction in all teenage conceptions in Dundee in the past five years to the end of 2012. It is absolutely right to say that we should not be complacent, but it would be wrong to arrive at the conclusion that no progress has been made. The same may well be the case in other parts of Scotland where there are more up-to-date data.

It may have been how I asked it, but I do not think that there was any implication in my question that no progress has been made. I think that the committee understands that progress has been made in the under-18 and under-20 age groups, but we would like to have a practical understanding of how that has been delivered on the ground.

We also want to know why, according to the figures that we have, there has been little or no progress in the younger age group. I am sure that when we get further into the discussion we will talk about the variation across Scotland and how we can tackle it. Do we need to shift our priorities?

I will make a couple of observations in response to your question about the under-16s; other witnesses are more knowledgeable than I am and might say more.

The pregnancy rate in under-16s has been consistent and has been fluctuating around the same figure. In a Scottish context, we are talking about a very small number—we might be talking about 600 cases a year—and, given that cases are widely dispersed around the country, there are very small numbers in local areas. That is not to say that we cannot do anything about the issue. People who conceive at such a young age will have particular needs and be in particular circumstances.

I am not aware that anyone internationally has cracked the issue of pregnancy in the very young. The issue is difficult to get into. In some ways it relates to what you heard in the previous evidence session about intergenerational issues, deprivation and complex needs. You are right to say that the rate has not significantly improved, but we must bear in mind the context of the numbers being very small and the complexity of tackling the issue.

The figure equates to about 3,000 babies over a parliamentary session. Harry Burns talked about the challenge that is presented by very young mothers.

Something that is often missed is that the ISD figures on teenage pregnancy include conceptions that result in termination, so they do not necessarily reflect the number of births.

On the challenge of making progress, we know that the areas in which the rate is particularly high are often the ones with the socioeconomic inequalities that the committee has been discussing.

There are also cultural factors. We find that in some areas it is quite the accepted norm that someone will have a baby when they are young. The perception in the environment is, “Well, I did it, so it’s okay.” We need to realise that, if that is the attitude, things will not change. Therefore, we have to challenge some of the cultural norms and acceptance around the issue. It is very much about working with parents and carers to support them to have the right kind of conversations with young people, when they are at the right age. Not everybody feels competent to do that.

It is important to support people in the environment—parents, carers, school staff and youth workers—so that young people can engage in positive activities, have positive aspirations and feel empowered to make choices in their lives, rather than feel that having a baby is the norm and the accepted way to behave in their community. There are issues to do with activities and perceived boundaries in the areas where young people are growing up. It is about more than sex and sexual health services. What do we do before the young people get to that stage?

We need to look at the context of the relationships that young people make. Are they respectful relationships? We hear worrying stories about a lack of respect between girls and boys in some communities. We also hear about access to pornography and about a worrying use of social media and electronic devices. People might think that some boundaries are old-fashioned, but there is an issue to do with the values that we are transmitting to young people. We might be talking about a small minority of young people, but we need to think carefully about how we got into this situation and how we can tackle cultural issues.

12:00

I agree with Lorna Watson. There is really good evidence on the importance of talking, not just about sex and sexual relationships but generally, as part of the relationship between a parent or carer and a child from a very young age. Evidence from the healthy respect demonstration project shows that, if there is such connectedness between a parent or carer and a young person, those conversations help to set up the boundaries that were mentioned. That can help to support the young person to delay forming a sexual relationship, to be strong and to have relationships that are based on mutual respect and so on. It can really help them in terms of delaying parenthood.

On the attitudes that we heard about in some communities where there is a more positive or more enabling attitude towards childbirth in the teenage years, there is a job to do to skill up a range of workers, including youth workers and other practitioners on the ground, to be able to frame a different set of options for young people in a way that does not come across as judgmental. Sometimes, the risk that they will come across as judgmental is a barrier for staff. Communication should be framed in the context of wanting better for the young person, with people saying “I want more for you, and I want you to want more for yourself.” That ties into the point about aspirations.

The respect issue was understood when we developed the strategy but, a number of years on, the outcome for the group that we are discussing has not been successful. The committee is looking for some ideas and for your experiences, which might influence our recommendations. What have you learned?

I am going to bring in Mark McDonald, but others will get an opportunity to respond.

There is a double-edged sword. Obviously, we want to reduce instances of underage pregnancy. There are instances in which people are over the age of sexual consent—they may be in a stable relationship—and a pregnancy occurs, and there are instances in that age group in which unplanned pregnancies occur.

My focus is more on those who are under 16, who are at much more risk due to social issues as a result of a pregnancy, be it planned or unplanned. The difficulty is that, if there is a stigma around that, such individuals will be more likely to disengage from services or from social groups. If we accept that, no matter how much success we have with the message, there will still be people out there having sex, how do we ensure that that does not translate into unplanned teenage pregnancies?

When a teenage pregnancy occurs, whether it is planned or unplanned, how do we ensure that the appropriate support is in place for the individual? I was 28 when we had our first child and it was a terrifying experience. I cannot begin to imagine what it would have been like if we had been half that age. How do we ensure that people get appropriate access to antenatal support, for example? They might find themselves alone in a room with couples in their 30s who are having children.

How do we ensure that the stigma that is attached to teenage pregnancy does not lead to people disengaging while, at the same time, doing all that we can to prevent teenage pregnancy from occurring? That is a difficult balancing act, but I would be interested to hear the witnesses’ views on it.

I will respond to a couple of your points. There are a few things that we have promoted and pushed since “Respect and Responsibility: Strategy and Action Plan for Improving Sexual Health” was produced. If young people are having sex, how do we ensure that that does not turn into a pregnancy? We ensure that good-quality sexual health services are available to all young people at or near schools. We provide good access to condoms and contraceptives, which means that people in that situation can use contraception if they need to.

You are absolutely right to say that it is important that people get support when they end up pregnant, particularly if they are younger. A relatively recent development that might bring a lot to that is the family nurse partnership, which works with particularly vulnerable young people. There is evidence that the partnership might be able to increase the time between pregnancies, which can allow those who are working with young people to have an impact on their lives. Others might know more about that than I do, but it is clear that it gives tailored and intensive support to the young people who need it most.

As Gareth Brown has said, we have done good work through high-quality services and the provision of longer-acting, reversible contraception, which, for young women in particular, can mean implants. That kind of contraception lasts for about three years and, although it does not protect young women against sexually transmitted infections, it protects them against unintended pregnancy. That is something else that we have been working on to help young people prevent such things from happening.

On the question of gaining a practical understanding of what we need to deliver and how we deliver it on the ground, we began by explaining some of the complex factors that influence teenage pregnancy. We must acknowledge that there is no one thing that we should be doing and that we need a range of interventions of the scale that is required to influence change.

I absolutely support people’s comments about the importance of young people making informed decisions, of consistent and high-quality sex and relationships education that builds young people’s skills, communication and confidence and of young people being able to access sexual health services, particularly contraception. Undoubtedly, more effective contraception has had an impact on reducing teenage pregnancy, but we need to couple such things with interventions in the earliest years of childhood, such as the early years collaborative, which Harry Burns mentioned in the previous evidence session, and the really important intensive support that is provided through programmes such as the family nurse partnership, which right from the beginning builds young people’s resilience and aspirations.

I should also highlight our work with adolescent and preadolescent young people on building their aspirations, expectations for themselves and self-efficacy. The encouraging evidence in that respect concerns the experiences that young people are having—instead of being told things, they are getting opportunities to volunteer, to buddy, to be peer educators and to get involved in their own communities. That offers some protection not just against teenage pregnancy but with regard to many of the outcomes that we are trying to improve for children and young people.

All that needs to be coupled with the competent workforce that Nicky Coia mentioned of youth workers and teachers who are really confident in delivering meaningful and relevant education in our schoolrooms and way beyond that in the school context. There also needs to be a strong partnership with local authorities, the health service and the third sector and a commitment to working together to tackle the issues with evidence-based approaches.

The most important issue is how we work with communities. Instead of doing things to people, we should take the kind of asset-based approaches that Harry Burns talked about and work alongside communities and particularly young people to identify approaches, share the evidence that we have as professionals, help communities share their experiences and then look to develop shared solutions that are more meaningful to people’s lives and communities. We have done that for the past two or three years in communities in Tayside with the highest teenage pregnancy rates, and the tremendously innovative response that we have had from young people and the community in general has been very heartening and certainly much better than we could have expected.

That is resulting in changes in how we deliver sex and relationships education in the classroom. We have peer educators who want to go out and work in communities. The issue is how we work with communities. The focus is very much on improving outcomes for children and young people.

Before the meeting, we were discussing things in the coffee room—as you do—and most of us felt that it was important to get it across that, although the focus has very much been on sex and sexual health services, the focus and responsibility for teenage pregnancy should be much broader. That is about the leverage to change young people’s life circumstances. That is why we welcome the shift in the framework to give leadership on teenage pregnancy to local authorities, because they have more influence.

I will pick up on the different contributions to addressing teenage pregnancy that various partners can make. Ann Eriksen talked about sexual health. I guess that Scotland has been on a journey in the past 10 years. We have had the respect and responsibility strategy, which focused on ensuring that we had good-quality sexual health and relationships education in schools throughout Scotland, which we hope was reinforced by parents and sexual health services. Scotland needed to address that because we were not in that position 10 years ago. The strategy very much enabled that work to happen.

It is interesting that, simultaneously, an additional financial allocation was given to local authorities through Learning and Teaching Scotland to enable teacher training. A range of things happened in 2005 and 2006, after which the downward trend in teenage pregnancy rates in Scotland started to kick in. I do not think that that was an accident.

As for where we are now, we need to keep the solid foundation that we have built in sexual health, as Ann Eriksen said. We cannot let that go. However, we now need to do wider work. At the risk of repeating what everybody else has said, I refer to the early years work and the work on teenage transitions. That relates to what shows up in research evidence as youth development approaches and is very much about taking young people’s talents and natural interests and getting them to apply those in a voluntary capacity and so on.

The next challenge for us is the issue of smaller neighbourhoods. We have looked at things on an NHS board basis and a local authority basis. We now need to get underneath the figures and look at smaller neighbourhoods where the rates are particularly high. We need to do some very focused work. I guarantee that there are workers in every area who, if they were told, “These are the indicators that tell you which young people are at risk of teenage pregnancy,” could tell us who those young people were. We need to skill those workers up to put in place the right interventions.

I will go back to what Mark McDonald said about stigma and the concern that young people might be put off accessing services such as antenatal services. We are quite aware of that. When young people give birth and become parents, that should be seen as a positive event and they should be supported to parent their child and have that child grow up with a positive future. We are very aware of the need to support young people who come through in that situation.

With respect to antenatal services, as we have heard, the family nurse partnership has been introduced for teenage parents. That is great but, before that, vulnerable young people in the under-16 group are identified by midwifery staff and generally have some form of enhanced antenatal care in which there is more one-to-one support that looks more broadly at the aspects of vulnerability in the young people’s lives.

If young people are offered antenatal classes, they might be with other young people who are in similar circumstances. As Mark McDonald said, it may well not work for them to be in with a bunch of people in their 30s. There must also be a targeted approach through antenatal services and the antenatal inequalities framework.

12:15

We are very conscious that people who are pregnant have different needs, and the under-16s are definitely part of that. Some of the coexistent issues may be domestic abuse, substance or alcohol misuse, learning disability or borderline learning disability. The issue is not always age alone; we have to consider the circumstances of young people—or, indeed, people of any age—who require maternity care.

We need to consider carefully the level of support. That ties into inquiries such as the confidential inquiry into maternal deaths. We know that vulnerable young people or those who are in complex social circumstances are more likely to experience adverse outcomes.

Our antenatal services and the antenatal and postnatal support services will be very much enhanced by the family nurse partnership. However, enhanced support for vulnerable people in such circumstances predates that.

I will make one point on prevention. Accessible drop-in services for young people are important. They are not usually just about sexual health. Young people can go to such services for advice on smoking, mental health issues or other concerns. In most cases, the advice that a drop-in service or a school nurse offers is not solely about sexual health.

Great efforts are made so that such services are accessible and confidential and so that, as far as possible, young people can go to them without feeling that a stigma is attached. Young people must be engaged in those services to ensure that they meet their needs and perceptions.

I will pick up on what Lorna Watson said about the next steps beyond pregnancy. We have a difficulty with what to do with a young person under 16 who has a baby. The child’s parents do not quite know what to do or how to normalise the situation. The school certainly does not know what to do, how to normalise it or how to get such children back into education. We know that their outcomes will be much better if they can return to education and consider a more positive prospect.

Sexual health must be viewed not in isolation but alongside other risk-taking behaviours, such as using alcohol, experimenting with drugs and pushing the boundaries. We know that one important element in that is how parents respond to such behaviour, how they manage their children and how the rest of society manages those children.

We need to ensure that the links are made with other agencies that address alcohol and drugs issues, for example. In our area, we have a strong link between sexual health services and the alcohol and drug partnerships to try to move things forward.

I am conscious that, in Ayrshire and Arran, we have quite high levels of under-16 pregnancy. We have a strong deprivation gradient, which is another element that we are trying hard to consider. Our concern is that socioeconomic circumstances are such that the situation may get worse before it gets better.

Teenage pregnancy is not an issue for sexual health services or the health service alone. There is a strong need to try to engage and work with partners who, for a variety of reasons, do not want to be engaged. In Ayrshire, we certainly still have issues to overcome in that.

I point out to Dr Watts that I did not set her up for my next question, which links in well to what she said. That was unintended.

Ann Eriksen mentioned the link between teenage pregnancy and whether the girl’s mother had a child at a young age. I imagine that the support that the witnesses give very young mums who are having their first child will determine how their children will be 13 or 14 years down the line, so we must always look at the medium to long term.

Yesterday, the committee visited Smithycroft secondary school in Glasgow, where young mums from across the city, who can choose to be supported in their own secondary schools, have the option of continuing their education with much wider societal support that is linked with a variety of age groups. Having spoken to individuals involved in the project, I understand that the initial evidence suggests that the likelihood of multiple pregnancies among those young mothers—of them going on to have a second or third child—is reduced, which should be a positive outcome for them.

The hope is that, within a few years, those young mothers will have formed a positive relationship with their children. When we met them yesterday, they were fantastic. They are obviously forming wonderful relationships with their children, so the likelihood that their children will flourish and that the young mothers will not have further unplanned teenage pregnancies should be higher.

I see from the nodding heads that the witnesses are likely to say that that is the kind of project that we need. Rather than just have an affirmation that such support is a good thing, it would be more useful to the committee to know about the prevalence of such quality support across the country. How do we ensure that we reach all parts of the country where that is clearly needed?

Such support is not that common, although city areas find it easier to provide than rural areas do. We need to ensure that the support is not simply a project but that it is sustained. Whatever we do has to be something that can continue and is not just a one-off. We cannot just say, “We will try this; it might work and, if it does, we will think about whether we should put money into that or into something else.”

We need a service that we can continue to provide. I imagine that people are trying to build that kind of sustainable service into education. We would encourage that, so that we have control through secondary preventions to ensure that there is good family spacing and sufficient support—with sufficient support from the community as well—for each individual child.

In Fife, we have a young mothers initiative with a specific worker who supports those who are still in education so that they can remain in education and stay engaged. That brings in quite a wide range of supportive elements.

There might be more concern when people have left school or are disengaged from school, because it is then a little bit harder to provide the setting in which all the supports can be put in place. If the conception happens just before the young person turns 16, quite often she will leave school and the school may not be aware that the pregnancy has occurred. When the people in the school see the statistics, they may come back to us to say that they were aware of only one or two pregnancies, whereas in fact the numbers were greater. When people are still in education, the support can be easier to co-ordinate.

From the Government’s perspective, we are always interested in the evidence and in anything that works, so the sort of project that Bob Doris mentioned sounds really good.

Under “The Sexual Health and Blood Borne Virus Framework 2011-15”, which we published in 2011, we are trying to move away from telling local authorities and NHS boards exactly what to do and, instead, to guide them on what we want to achieve. Rather than say that something will necessarily work all the time, we should try to avoid taking something that works in one area and just plugging it into another area. As has been mentioned, local authorities, NHS boards and communities need to decide what works locally and investigate that.

We have tried very much to make the funding that supports the sexual health and BBV framework flexible and to make its outcomes high level so that people locally can innovate—it is almost a case of liberate to innovate—and so that they are given the opportunity to find out what works. If projects that work are now percolating through, we want to learn from them and see whether they can work elsewhere. It is not automatic that, for example, something that works in an urban area will work in a rural area, but I am sure that we can always learn things from such projects.

I would like to say something about the funding of a resource such as that in Glasgow, which was a very hard-won service to deliver. It is not funded directly through sexual health moneys. It is quite difficult politically to achieve funding for such a service because teenage pregnancy is seen, particularly at a local authority level, as sexual health business. Trying to contextualise such a service beyond sexual health to attract funding can be really challenging.

That illustrates my belief that local authorities have a central role in addressing teenage pregnancy. Going forward, it would be useful to have much clearer guidance and direction for local authorities about what that means for them in their community planning structures and children’s services structures, with regard to the stuff that is not necessarily about sexual health but about wider sets of issues. Although it is clear in the framework that local authorities are the lead for the issue of teenage pregnancy, my experience of working with colleagues in local authorities is that, when faced with such a requirement, their next question is, “Okay, what next?”

The committee has heard what a complex issue teenage pregnancy is, so making sense of it and turning that into practical, tangible action is challenging. I therefore think that there is a place for clearer guidance for local authorities and particularly for community planning partnerships on their respective contributions to the agenda.

It is interesting following the earlier evidence session with this one, in which we are hearing about things being the council’s job.

The interaction of services is a point that we have picked up in the past couple of days, having had the benefit of visiting Smithycroft secondary school as well as hearing the evidence in the earlier session. It would be interesting to develop that point with regard to shared information—you mentioned earlier that not all services will be aware of teenage pregnancies. We picked up the point about midwifery services and how they connect, as well as, obviously, education services.

It was suggested earlier that we need a strong and wide range of quality interventions. However, there is the question of access. I suggest that that is perhaps a job for the Scottish Government and that perhaps it should at least identify where best practice is. Local autonomy in this area is a virtue, given what we have heard. Is there evidence in the witnesses’ networks that there is good access right across the board to, for example, the people involved in midwifery services, education and the health service? Are they working together effectively to create the interventions that we want? What are the barriers to your doing a better job and delivering in this area? We have Scottish Government officials present, so let them take some messages back.

It depends on whether we start out at the level of primary prevention or the level of identifying a young person who has fallen pregnant. We can split it into those levels. If it is about the primary prevention work, then it is quite difficult to demonstrate that we have an issue that needs to be addressed collaboratively. That is because of the small numbers and high variability involved in the case of under-16s who become pregnant.

The actions that we have taken around, for example, family nurse partnerships and moving into some of the asset-based approaches are starting to develop a momentum and to build success. However, we are also aware that young people, particularly the under-16s, are much more likely to conceal a pregnancy and present late. They might not even realise that they are pregnant until they go into labour.

We would love to encourage early access and early antenatal care, but that is not practicable for a number of these children, who do not identify that they have an issue that they need to deal with or who have other issues in terms of family disruption, their relationship with their boyfriend or the lack of one, or substances that they use. Those elements also come into play.

It is really complex.

If it were simple, we would have solved it.

Yes. We are getting the message today that all these problems are really difficult. I think that that is why we are having an inquiry.

12:30

Although we welcome the local authorities’ transition and leadership role, it is extremely important that this has always been a partnership. It is a partnership of local authorities, health, the voluntary sector and the communities, and that will always remain the case. Health has a fundamental role in not just delivering services, but ensuring that we share the evidence on what works and the epidemiological data that we hold.

In Tayside we have worked very hard. I believe that the committee is coming to Dundee next week to gather evidence. We have good, strong partnerships with community planning in all three council areas and that is no different for sexual health and teenage pregnancy. We invested quite a lot of time in setting out why teenage pregnancy matters and is relevant. In doing that, it was quite important not just to concentrate on under-16s. As a number of people have said, the number of under-16s who get pregnant is quite small and it can seem quite a marginal issue to council colleagues who deal with issues that affect much larger populations. We invested a lot of time in setting out why the issue matters, why it is relevant and what we can all do together to make a difference. Embedding that in the work around getting it right for every child and the early years framework has been very important.

Getting the buy-in and strategic leadership at the right level is pretty crucial. Having the ear of the chief executive, the director of education and the director of social work is vital, because they are the people who can make some of this happen locally.

You asked about the extent to which those sorts of partnerships are working across the country. We go out under the sexual health and BBV framework and visit each NHS board at least once a year—we finished a series of those visits at the tail end of last year. We invite local authorities and other parties along, as well, so it is not just an NHS board visit. We use those visits to probe just these sorts of issues across the framework and find out how well things are working. It is true that things are working in some areas better than they are in others.

We have to bring back what we find out and facilitate learning between different parts of the country. For example, if the relationship between the health board and the local authority in Tayside is working very well, we can try to export that to other parts of the country. We have very good networks with all the executive leads, who meet regularly and who can share that sort of experience.

However, it is a challenge, because local authorities think that teenage pregnancy is a health issue. From my perspective, a lot of things that could contribute to a reduction in teenage pregnancy are things that local authorities do or should be doing anyway, but if you put a teenage pregnancy badge on it, local authorities get a bit nervous. The issue is about deprivation and aspiration—all the things that local authorities do, and do well. We just need to have that sort of conversation with them at the right level, which can be difficult.

It would seem that the variance might come down to some of the political skills. You have described the process that you have to go through to get buy-in from a local authority: you have to have a good relationship with the chief executive and win the argument with them. That process is hardly free flowing and it is down to the skills of individuals.

Partnership is obviously very important. The multi-agency resource service and the child protection network have merged into WithScotland, which is an academic unit that draws together research and best practice on child protection, and helps to channel that back out. If you like, it is an organised, centralised unit that supports progress in that field. Do we have the same thing in the sexual health field? Sexual health is not dissimilar to child protection, except that, as you said, sexual health is seen as more of a health issue than a social work issue whereas MARS and child protection were very much a social work thing. There was quite a lot of work involved in getting health engaged with child protection.

Do we have good analysis and promotion of research evidence? Do we do toolkits in the same way as WithScotland does? How do we reward success? If a project works in an area and achieves despite funding difficulties and all the rest of it, as Nicky Coia said, how do we reward that? Is that a central function or do we leave it to local authorities to continue to battle away? Do we say, “That’s great—we’ll now put 20 or 30 per cent of the funding into that, because it’s working,” and send a signal to everybody else that they need to follow that project?

There was a lot in what you said. I am not aware that we have a formal hub, such as the one that you described, but good research activity is going on in Scotland and across the UK. We have good links with good, respected academics who we can draw from and share. We have regular meetings with people in networks across Scotland and we can share information well.

There are toolkits, such as the reducing teenage pregnancy toolkit, but I sense that you are asking whether there is a concentrated hub where all the activity can take place and be considered and where what has worked in areas can be considered. Perhaps we need to formalise that a bit more; we have relied on networks and having conversations.

We are still developing the sexual health and BBV framework, which was launched in 2011. We have only just finished the first series of visits, and perhaps we need to learn how we take the evidence more formally into a mechanism that will evangelise about what works. If the Parliament recommends that, we will be happy to look at that.

No one else wants to respond to Richard Simpson—we were satisfied by the response—and no other committee members want to ask a question.

We had a pre-meeting and the witnesses had a coffee meeting. The subject is important and we appreciate you coming along. You might have wanted to put on the record issues that have not been covered; if so, I give you the opportunity to do that now. We are also happy to have further representations through emails or letters. We encourage you to follow our inquiry and, given your specialist interest, we would appreciate your observations on other evidence that is given.

I give you the opportunity to put on the record any issues that you feel that we have not covered.

The committee has covered pretty much everything that I wanted to say. In summary, teenage pregnancy is not just a sexual health issue; it is about deprivation. There is no magic bullet and to deal with the issue we need complex, multifaceted interventions, which must happen in partnership. If the inquiry’s outcome was clear guidance on that to sets of stakeholders in various sectors, I would welcome that.

I very much support what Nicky Coia said. I will return to the issue that we just left. It would help to think about research in the Scottish context on what works and not just about capturing what appears to be working locally and disseminating that better than before—lead executives have recently looked at that in relation to the framework more broadly. Understanding our population’s needs is crucial. That concerns research and supporting nationally the quality evaluation that would be needed for that.

The witnesses should not feel pressure to speak if they do not have issues to raise.

I do not think that we have mentioned looked-after children, who are one of the groups that are at risk. We have been keen to engage with social work colleagues and carers in relation to them. There are barriers. For example, we set up a training session for foster carers at a time and in a place that they said would suit them, but I think that one person turned up, and they were already quite clued into the subject. The level of engagement is an issue, as is understanding which groups are at risk and who the key people to give consistent messages are in relation to the young people.

Another aspect is involvement in training social workers, who are in contact with a lot of the vulnerable young people who might be at higher risk. We have managed to train social workers, but we might go back another year and find that they are too short staffed or that there are too many pressures for them to take that work on. Those are the kind of issues that we come across.

A few years ago, I remember discussing with a headteacher the delivery of education and the importance of work to prevent teenage pregnancy. It was an extremely interesting discussion. The headteacher explained that the young people in the area had no job prospects in the community and that there was a lack of good male role models and a lack of positive alternatives. From his point of view, there were other issues to deal with. He did not think as strongly as we did that good-quality sex and relationships education had a place in that area precisely because of those circumstances and because there were vulnerable young people there.

I might challenge that, to some extent. If we consider teenage pregnancy as a symptom and not as a condition, that enables us to put it in the wider socioeconomic context and to consider it alongside the behaviours of young people in relation to alcohol and drugs. Is the fact that they behave as they do an intergenerational thing? Is there an epigenetic element, which Harry Burns talked about?

I will put on a different hat and mention foetal alcohol harm. We know that children who are exposed to alcohol in pregnancy are more likely to consume alcohol and to be at greater risk when it comes to teenage pregnancy. That is a different strand. For me, the symptomatology is important.

I want to make one final comment that I am sure everyone in the room understands and agrees with, but which it is nonetheless useful to make. Despite all that we have said about teenage pregnancy, a teenage parent is not necessarily a bad parent. We always do what we can not to stigmatise teenage parents in general in such conversations, and I am sure that everyone in the room understands that. Our efforts to reduce teenage pregnancy are not about stigmatising those who find themselves in that situation.

I thank you all for your attendance and your help. I encourage you to observe our inquiry and to continue to participate in it, when you feel it necessary to do so.