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Antenatal young parents: introducing a pathway to enhance health visiting practice.

No conflict of interest declared.

INTRODUCTION

Many young parents will encounter positive experiences in pregnancy and require little additional support from professionals. However, some young parents have additional unmet health needs and are known to experience more social, educational and economic difficulties. The evidence is clear that teenage parenthood can often result in poor health, under-achievement and low earnings for both the mother and her baby (TPIAG, 2010).

In 1999 the National Teenage Pregnancy Strategy (SEU, 1999) was launched. It was a multifaceted strategy that included an action plan to halve the under-18 conception rate by 2010 and provide support to teenage parents to reduce the long-term risk of social exclusion, by increasing the proportion in education, training and employment. Some local areas failed to implement the strategy effectively and as a consequence their teenage pregnancy rate stayed high or increased.

The national teenage pregnancy rate is currently at its lowest level for almost 30 years, having fallen 18 per cent since 1998 (NHS England, 2014).

Recent figures from the Office of National Statistics (ONS, 2015) show that conceptions among under-18s in England are continuing to fall. Pregnancies in this group have reduced by almost 50 per cent across the whole of England since 1998.

However, the UK still has one of the highest rates of teenage pregnancy in Western Europe. In England in 2010 over 32,500 women under the age of 18 became pregnant, approximately 6,000 of whom are under the age of 16. (UNICEF, 2001; NHS England, 2014).

Teenage pregnancy is a significant public health issue in England. Younger parents are more prone to poor antenatal health and lower birth weight babies. Infant mortality is 60 per cent higher for those babies born to mothers aged under age 20 years (DCSF, 2010).

The prevalence of domestic violence is greater among young women under 24 years (ONS, 2015). Many young people view violence as a normal aspect of intimate relationships and 30 per cent of domestic violence starts in pregnancy (Moffit, 2002; NHS 2013). It has also been postulated that as many as 40 per cent of teenage relationships are abusive ones (Home Office, 2010). These statistics show that young parents have additional risk factors both during and after pregnancy.

Teenage mothers are less likely to finish their education or find employment, more likely to be single parents, and 63 per cent more likely to bring their children up in poverty. The children themselves run a much greater risk of poor health, and have a much higher chance of becoming teenage mothers themselves (HDA, 2004; DCSF, 2010).

Research also suggests that the children of teenage parents may have poorer outcomes in terms of educational attainment, emotional and behavioural problems, and higher rates of illness, accidents and injuries (HAD, 2004).

Some studies point to a higher risk of child maltreatment among younger parents (Bucholz 1993; Wakschlag 2000), although it is recognised that this risk is compounded by the environmental factors experienced by many younger parents, including socioeconomic deprivation, lack of social support, depression, low self-esteem and emotional stress (Utting 1993).

Lifestyle choices of this group influence quality of health outcomes. Young parents are 50 per cent less likely to initiate breastfeeding and three times more likely to smoke throughout pregnancy and less likely to stop (in comparison with older mothers) (DCSF, 2007).

Teenage pregnancy has an economic impact. There is a strong economic argument for preventing teenage pregnancy. For every 1 [pounds sterling] the NHS spends on contraception, 11 [pounds sterling] is saved in maternity costs. Teenage pregnancy also costs the taxpayer in terms of benefits and income support. They may get help with parenting, budgeting on a low income and support to get back into education, employment or training (FPA, 2011).

Young parenthood is often viewed as reinforcing social disadvantage because of the perceived consequences in terms of the teenage mother's life chances (Duncan, 2007) and also because of the estimated cost to society. In the UK, the annual cost to the NHS of pregnancy in women under 18 years of age was over 63 million [pounds sterling] (HAD, 2004).

Other economic factors include the cost of domestic violence and of perinatal maternal mental illness (as both are additional potential risk factors for this client group).

It should be noted that the statistics for young parents are difficult to aggregate due to the differences in definitions for this client group. Health, education, local authority and welfare organisations have their own distinct criteria when describing 'young' or 'teenage' parent groups.

BACKGROUND

Local picture

The North East region recorded the greatest number of teenage parent deliveries by population size, at 21.0 per 1,000 (for mothers aged 19 and under)--7.7 per cent of all deliveries in this region were to mothers of this age, the highest percentage of any region in the UK (Health and Social Care Information Centre, 2012).

A scoping exercise identified that although generally the Trust had a low proportion of young parents (under age 19), there were two distinct areas where the figures were disproportionately higher than the UK average.

Both of these areas had been given support from the Family Nurse Partnership (FNP) scheme, however not all the resident young parents received FNP services, due to the strict referral criteria and caseload limitations. At the time of the project, it was uncertain as to whether funding for the FNP scheme would be continued. Having no FNP support would impact greatly on the local health visiting service, particularly in the identified areas of greatest need. This provided impetus and rationale to drive the pathway forwards. The pathway project identified a potential gap in local services, and scope to improve health outcomes for this specific client group.

Evidence base

The health visiting service is currently commissioned by NHS England. This includes the delivery of the Healthy Child Programme (DOH, 2009).

Before the introduction of the Healthy Child Programme (HCP), the Social Exclusion Task Force (2007) recommended that the HCP look beyond the child to their family context, reviewing family health as a whole, working in partnership with adult services and building family strengths and resources.

This view was echoed by the Teenage Pregnancy Independent Advisory Group (TPIAG) (2010). They recommended that Local areas should work in partnership to ensure teenage pregnancy prevention and support for young parents is integrated into locally-decided plans and implemented effectively.

The 2015-16 National Health Visiting Core Service Specification (NHS England, 2014) details the core elements for the commissioning of health visiting services.

This includes ongoing work with families who have complex needs, in partnership with other key services such as early years and children's primary and social care. Other areas include safeguarding children and working to promote the health and development within the six 'high impact areas' (DH, 2014).

The development of a pathway specific to young parents is highlighted in the Core Service Specification and therefore provided some impetus for this project.

PROJECT CONTEXT

Aims and purpose

The overall aim of the antenatal young parents pathway is to improve the quality and level of the health visiting service offered for this client group, in order to achieve better health outcomes. This will include the outlining of a standard service pathway to be adopted by all health visitors working in the Trust. The purpose of this will be to support staff to manage the potential risks associated with this client group, to address health needs using a co-ordinated, multi-agency approach and to build on the evidence base of the HCP (DOH, 2009).

The project was limited to a three-month timescale for the production of a first draft, therefore the methods used to establish it initially were chosen to fit this short timeframe. A 'rag rated' action plan and timelines were established from the outset, using a Project Initiation Document Checklist (Mindtools, 2014) for guidance.

Local health visitor resources were reviewed, and a literature search was conducted to identify current health issues related to this specific client group. Relevant stakeholders were identified and consulted. A change management model was used to approach the development of the pathway, using the 'RAPSIES' change model of Johnson and Scholes (2001).

Monitoring and evaluation The pathway is still a work in progress and therefore evaluation will be ongoing. It is expected that when the pathway is launched, the local 'Patient Experience Survey--Friends and Family Survey Test' (Humber Foundation Trust, 2014) data can be used to assess user experience and quality of service inputs. It is hoped that this will provide feedback on which to inform and improve the service for users. Regular reviews of client feedback will be essential to inform and update the pathway. The author expects to hold regular meetings with relevant stakeholders and service managers to facilitate this and to explore any difficulties resulting from the transference of the pathway directly to practice.

A bi-annual newsletter was devised and launched on the Trust intranet to enable staff to follow events related specifically to the pathway. This is accessible to all staff who work in the Trust.

Electronic client records can be used to specifically measure client's health and wellbeing outcomes (such as data on smoking, breastfeeding uptake and prevalence, or maternal mental health), providing the local electronic records are set up to capture the data. This area is one that needs future development in partnership with the Trust's data performance team.

PROJECT IMPACT AND FINDINGS

Potential challenges identified Engaging with fathers and partners.

Health visitors should always ask about the father and involve them at contacts. Fathers are clearly involved with their children, as four out of five teenage mothers register their babies' births jointly with their baby's father (DCSF, 2009). When fathers do more baby care and housework, mothers experience less stress and depression, fathers are happier and adjust better to fatherhood, and babies do better (iHV, 2014). Health visitors should observe and discuss fathers' needs, experiences and behaviour and make referrals where necessary. When their behaviour is challenging (e.g. in cases of domestic violence, substance misuse) mother-child attachment is less secure (and of course father-child attachment is less secure, too) (Kernan and Smith, 2003), therefore health visitors must be mindful of the influence of fathers and include them in contacts where possible.

Client views of the health visiting service.

A study by Kate Cooper, on the Surrey antenatal young parent pathway project (Cooper, 2012) suggested some common themes of young parent's perceptions of health visitors. They reported that they feel there is an assumption from professionals that their age means they won't parent well. They feel there is an over-reliance on handing out leaflets without relaying the information in a meaningful way. Communication methods for this client group are therefore important. The inventive use of social media, tailored to young parents' needs, could provide a way forward.

Some clients felt that health visitors were closely aligned to social workers (Cooper, 2012). These are issues to consider and require health visitors to build positive relationship with their young parent client group but also to realise how we as a profession are perceived.

Opportunities

Implications for partnership working.

With so many other agencies and partners potentially involved with this client group (for example, youth and education services, midwifery and children's centre staff, looked-after children's team, sexual health services, social care team, etc.) it can be difficult to co-ordinate care around the client. As health visitors are able to work with young parents, until their child is aged at least four years old, they are ideally placed to build positive relationships with this client group and can foster partnership working, using their inherent health needs assessment and leadership skills. Early intervention can help teenage mothers avoid getting pregnant again too quickly. One fifth of births conceived to under-18 conceptions are second or subsequent births (ONS, 2013). If young parents are offered the right support at the right time - for example supported housing - it can increase their rates of participation in society and improve the long-term outlook of both parent and baby (FPA, 2011). Planned partnership working can positively improve health and wellbeing outcomes for young parents and their children (DSCF, 2008).

IMPLICATIONS FOR CURRENT PRACTICE

* To offer this client group an additional early health visitor antenatal contact, jointly with children centre staff at around 24-26 weeks of pregnancy (to promote a skilled and comprehensive Family Health Needs Assessment). This contact can be either in the home or other venue suitable for the client.

* This 24-26 week antenatal contact to be offered to partner as well as the mother (to promote involvement of partners).

* Partners to be included in every health visitor letter correspondence where appropriate.

* A second health visitor antenatal contact to be offered at the end of pregnancy (between 32-39 weeks). One of the two health visitor antenatal contacts is to be conducted in the home, to assess home circumstances, discuss concerns in private (routine enquiry question can be asked if client is alone).

* Utilise new technologies for young parents to access 'up-to-date, "real-time' health information, when they need it. For example, use of appropriate smartphone 'apps' and text message services.

* Changes to the local electronic records system (to enhance data collection and benchmarking, and demonstrate improved client outcomes). For example, 'routine enquiry' question to be included and recorded in the antenatal electronic records.

* Antenatal caseloads on electronic records should be separated into three groups of 'universal', 'universal partnership' and 'universal partnership plus' to reflect the level of health visitor service required following health needs assessment.

* Data performance to show specifics of smoking, breastfeeding, domestic violence and safeguarding data outcomes for young parents, gathered from electronic records.

* Service managers need to consider the potential resource issues for the areas where numbers of young parents are highest. Yearly figures (collated from electronic records data) would give a more accurate picture of where the young parents are living within the Trust. This would enable appropriate allocation of resources.

RECOMMENDATIONS FOR FUTURE PRACTICE

* Health visitors need to explore the scope and content of parent education class provision for young parents, particularly in those areas of high need.

* Auditing local service user views of the health visiting service could inform future planning and development of care, and help market the current role of health visitors to service users.

* Profiling is required on the scoping of the ethnicity and diversity of culture in the Humber NHS Trust area, in order to build a picture of the needs of the local population. Are there any implications for health visiting practice? The 2001 census shows significantly higher rates of motherhood for those of 'Mixed White and Black Caribbean, 'Other Black' and 'Black Caribbean ' ethnicity (ONS, 2015). This is a factor which would need consideration, depending upon the local profile.

* Explore other areas where improved health outcomes can be benchmarked and demonstrated from system one records (for example; statistics on accident prevention, mental health outcomes for young parents).

* A Quality Impact Assessment tool (Portsmouth Hospitals NHS Trust, 2014) could be used to assess the impact of the pathway in more detail and depth.

CONCLUSION

Young parents are a client group who can have complex health needs, sometimes requiring specialist and additional support. This group are worth the health visitor service investment, as their potential poor health outcomes can be the most positively affected, with professional input.

The evidence base for improved health, social and educational outcomes from a systematic approach to early child development has never been stronger and has been described as a powerful equaliser which merits investment (Irwin et al, 2007; Marmot, 2010; Shonkoff, 2011; The Wave Trust, 2013). Health visitors can influence this crucial time by providing their services early and in an engaging way, tailored to young parent's specific needs.

Although evidence shows that teenage pregnancy rates are currently on a long-term downward decline, that trend is not guaranteed and rates could start to rise again if this group is not prioritised. Local investment in the specific health needs of young parents needs to continue.

Health visitors can use their established skills in early intervention and health needs assessment, communication and relationship building to ensure better outcomes for young parents. Developing a young parents' pathway could facilitate the development of measurable values and outcomes of health visiting contacts to this client group.

In following the pathway project recommendations, it is hoped that health visitors will be able to positively improve health outcomes for clients, service commissioners and, in the long term, society as a whole.

Key points

* Teenage parenthood remains a significant public health issue in England.

* This client group can have complex health needs which can be positively affected with appropriate intervention.

* Health visitors can use their specific skills of early intervention and partnership working to positively improve health and wellbeing outcomes for this group.

* Development of a local pathway for this client group can facilitate this process and make outcomes measurable.

REFERENCES

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Wakschlag LS, Hans SL. (2000) Early parenthood in context: implications for development and intervention. In: CH Zeanah editor(s). Handbook of Infant Mental Health. New York: Guilford Press.

LISA JENNISON RGN, RM, RHV, BSc (Hons),

PG Cert.(PT).

Health Visitor, Practice Teacher, Humber Foundation

NHS Trust

CORRESPONDENCE: l.jennison@nhs.net
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Title Annotation:PROFESSIONAL AND RESEARCH
Author:Jennison, Lisa
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Jul 1, 2015
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