Plenary P3 Teenage Pregnancy

Chaired by Pamela McNeil - Jamaica and Christine Ferron - Paris, France.

Diana Birch: I would like to introduce two of my great friends who are chairing this session, Pamela McNeil first of all, who is from Jamaica, from the Women’s Centre, but now it’s the Women’s Centres of Jamaica Foundation because they have become very big and they have branches in a lot of towns and centres in Jamaica, and also in other parts of the Caribbean. In fact their model has been copied in all different parts of the world, Africa and so on, and Pamela will tell you more about her programme tomorrow. The other person who’s chairing this afternoon is Christine Ferron, who is now in Paris, but I met her when she was in Chicago, and then two years ago she came to speak at our conference on drop-outs and delinquents, and at that point she was working actually in Lausanne in Switzerland. So she is truly an international person, and she is actually a psychologist and she’s worked with young people and done a lot of good research, so I’m sure that the session will be very ably chaired. I hope you enjoy it.

Pamela McNeil: Good afternoon. Before we start, I would ask if you could hold your questions until all the presenters have finished their presentations, and then we would have the questions and answer period then. I’m afraid Senor Girard will not be with us because he is not well, but putting on one of her many hats, Diana Birch is going to speak today on adolescent fathers, a very topical and interesting subject.

Adolescent Fathers  Diana Birch

I would like to begin with a quick view of a couple of teen fathers. Teen fathers can give a good impression or a bad impression, and some of the ones we work with have enormous problems and don’t bring a lot of positive into their family, although I’d like to emphasise that generally speaking obviously it’s much better for a family to have a father and we need to encourage teen fathers to be very much involved with their families. These examples are in fact very much involved  - the one on the left is a young father whose partner was aged thirteen when she was first pregnant and fourteen when she was next pregnant, fifteen when she was next pregnant and he in fact more or less abducted her from a children’s home and we had enormous problems with him, he was a very needy individual and we need to remember that when we are looking at teen partners we often do therapy with the girls but we also need to do therapy with the boys as well and include them in all of the work.

The other couple look slightly older but these two actually got together when they were thirteen, and now we are seeing them five babies along. She first became pregnant by him when she was at school and her child was then adopted by her mother and he’s now eleven, and in fact, this guy was OK, he was upset about losing his child. She got pregnant again and she had an abortion. And over the however many years it was, he never forgave her for the fact that she had the abortion and got rid of his child. So in fact this morning in one of our workshops we were talking about the aftermath of abortion and the effect on the girl; and I think we need to remember the effect it also has on the man and on the boy who loses their child as well.

Now just a few facts and figures. Looking at girls and boys at the moment. There is a scatter of the age of first sex of the schoolgirls who were in our first survey. In fact the average age of first sex there was about thirteen and a half, average age of first pregnancy was fourteen and a half, and average age of first child was fifteen and a half at that stage. But with regard to the average age of the fathers -  the average is really a couple of years older because the average is about seventeen and a half, and that’s about typical, although we have a group where the fathers are much older and there’s sexual abuse involved in there also, and a scattering of younger boys.

So what about these boys? What are they like? Well most of them had known the girl for more than six months, and in fact three quarters of them had been the boyfriends of these girls, had known the girls rather for more than six months. So they’re not sort of fly-by-night, predatory boys like we tend to think. There’s an awful lot of scape-goating of the boys in these situations because after all the girl’s left holding the baby. We do a lot of work with the girl’s family and the boys tend to get excluded and if we can say it’s their fault, then we can deal that much better with the family.

So what about the degree of support? Now we have to remember a lot of these kids actually want to support their family, their baby etc., but they’re not allowed to, or they’re too young, they don’t earn. So this is emotional support not financial support. So most of them, nearly 90%, were notified about the pregnancy. Some of them weren’t, sometimes they met their girlfriends in the street a while later pushing a pram, and said ‘oh, what’s this?’, ‘oh it’s your son’, and I’ve counselled a few boys who are really in quite a lot of stress, suddenly finding out they were fathers and not knowing about it, and also feeling guilty because if they’d known, they’d have wanted to support their family. Only 50% involved in the decision-making. But as you see, 59% emotionally supportive, and 18% were actually present at the delivery. Now we have to remember, this is fifteen years ago at the start of the longitudinal study, because we’re looking at progression with all these figures, fifteen years ago it wasn’t that common for fathers to be in on deliveries, you know we were trying to do it but it wasn’t as common as it is nowadays. So to see that nearly 20% of these young fathers were actually there on the delivery actually shows that they were quite supportive doesn’t it?   And of course we had 40% who were just unsupportive, but as you’ll see they don’t all disappear totally.

When we’re looking at decision-making and what the girl decides, what the boy decides etc., very few decided to adopt, and in fact about similar numbers of girls and boys decided either to go for an abortion or to keep the child. And in two thirds, the decisions tallied, the girl and the boy thought the same thing. But in the third where they didn’t, there was a lot of problems. A lot of guilt, a lot of pain, a lot of emotional stress.  I’ve put this picture in here (girl holding a baby and being held by a YSH staff member) because I think we’re often talking about containing the girl and this is the slide I use to talk about containment with our families. But how do we contain the boy? Because very often we can’t even meet him. With the girls that I’ve followed up I’ve tried very very hard to see the partners at various stages and even by trying over a fifteen year period, there were still some that I’d never clapped eyes on. And so, there’s a lot of grief and stress around there that we are failing to contain.

Another point of this picture is what about the abusive boys? Well this was a very disturbed family because this girl got pregnant and she had had an incestuous relationship with three of her brothers, so we never knew which of the brothers was the father, so I’m jumping about a bit but I’m trying to give you both ends of the spectrum. And there again, she was with us for therapy about it but what’s happening with the boys, because obviously there’s a disturbed family background there, disturbed boundaries that makes those boys have sex with their sister. So we need to look at both sides.

When we’re looking at how long boys stay in touch with their children and partners. When I looked at the subject in the first part of the study, going up to two years, I divided the findings into unsupportive, supportive, and the number which were living together. And after two years, about 45% were still in touch with their babymothers and their children, but the ones who were unsupportive at the beginning of course, as is expected, more of those fall out. Very few were living together, even after two years. Obviously a lot of the girls were living at home with their parents to start with and so it’s difficult for a boy to move in, but that number always stays low. And also it’s different boys at different stages. The interesting thing is that there are a few that live with them, even when they’re under sixteen, and I was always amazed to see the number of families who actually did condone having a boyfriend there, sort of sleeping under the same roof with a fourteen year old girl, and we don’t need to talk about definitions of illegal sex and all that, we don’t want to get into that here, but I’m just telling you that’s what happened.

Continuing the study, that’s the fifteen year data, you can see as I say, that at two years about 45%, but it falls off with time so at fifteen years though, still 20% are still in touch with their kids. And that is a pretty high figure really although you know it’s bad that it slopes off, after fifteen years it’s quite a high figure.

And if you look at the number of fathers that are still in touch, it’s also very dependent on the background of the girl. The girls who had families, were more likely to have their boyfriends be in touch, so they’re more likely to be stable relationships. And the girls who had families, the couples that had families, they were more likely to stay together, where the girl had been in care, when their partners had been in care things were very different. And in fact at fifteen years, 20% of the whole population were in touch, but only 2% of those where the girls didn’t have a family. So we’re really perpetuating the problem there. And looking at the childbearing patterns of the girls, it very much depended on the boys. We had some who constantly repeated, had pregnancy after pregnancy after pregnancy, which was the majority, and they tended to have more partners, so there were more boys moving from one relationship to another fathering children.

Some girls just had a single pregnancy, one boyfriend. And then we had ones where she just has one boyfriend, one pregnancy, and leave it at that, and never really had many boyfriends, so her boyfriend never really figured in the family. Then we had constant repeaters, loads of kids, loads of partners, but all very happy. So looking at the number of boys, this was interesting, because half of the girls, just under half had multiple boyfriends, like we said, and were repeating pregnancy. 39% had only one boyfriend, one sexual relationship over the fifteen years, which I think is pretty amazing really, because as I’ve said previously, how many of us in fifteen years can really put our hand on our heart and say we’ve only had one sexual relationship? I mean it’s not really that common these days is it? So these girls are not promiscuous.

What interests me with the fathers is, the 12%  ‘early sub’ I call it. What this means is that you often have girls who come and they’re pregnant, and their boyfriend has dumped them. And another boy comes along and he wants to be a father, and he has a real need to be a father, and he takes on this ready-made family, the girl and the baby because he’s the sort of chap who needs to look after people, and is a carer, and interestingly, these were the boys who were much more likely to stay over the period of time. Of these early substitute fathers they were nearly all still there at fifteen years. They were much more likely to stay than the natural fathers, which I think is very interesting and it just shows the need that some boys have to be fathers is very similar to the need that some girls have to be mothers.

And this is an example of a boy who stuck around for a number of years, actually I was quite embarrassed when I gave a talk at the University of the West Indies in Kingston a few months back, and I showed this slide and one of the doctors in the audience jumped up and said ‘that’s my cousin’. Shows how many families intertwine.

One of the problems is that a lot of these boys grow up fatherless, and that is what is causing the problems. These are all boys that grew up fatherless and have got big problems. What is the family pattern -  we have family structures involving mum and child; some mum and children; some mum, children and dad; some mum child substitute dad; some mum child multiple fathers, and so on. Mother child adult father because the mother herself needs a father.

We talked for a long time about how girls maybe get pregnant because they come from single parent families, they don’t have a father and so they need to go out and find a boy because they don’t know how to relate to men, they’ve got an absence of a father figure in their lives. But, what the fifteen year study showed was how important it was, especially to the first born male children, this absence of father. And I’ll just show you quickly, behaviour problems in the girls - 20%, in the boys - 70%. This is the children of the teenage mums at fifteen years. More boys bullied than girls, more boys having minor crime than girls. The relationship with the mother, worse for the boys than for the girls, as you might expect. Smoking is about the same, alcohol more in boys, drugs more in boys, sex education - the girls are more likely to talk to mum so they’re sex education’s better. Sexual activities - the boys had more girlfriends, the boys had more sex, and the boys - OK they used a bit more contraception but there was still a big gap.

So just finishing, I just want to point out the stairway to a baby that I put in my first book, Are you my sister mummy? You see how it’s even, both sides. Both girl and boy, emotionally immature, social problems, feeling unloved, feeling a failure, being lonely, being drawn together in ignorance of sex education etc., no contraception and having a baby. And I think it’s important to remember this, two sides for that, and there’s the same problems for the boy as the girl.  I just put this picture here really to remind you that families need fathers, and especially young families need all the support they can get and young families need young fathers. And we need to give much more support to young fathers.

McNeil: Thank you very much Dr Birch and I think the emphasis on the need to encourage the fathers I think was excellent. And I’m very glad that she has become Jamaicanised when she talks of the babymother and the babyfather. That’s very Jamaican.

Teenage Mothers and their Children.  Nona Dawson

Hello everyone. Just to pick up that point that Diana was making, about sons, it doesn’t actually come in our research but certainly the literature will tell you that the sons of young mothers don’t fare as well as the daughters. I’m going to briefly report to you the results of a study that we’ve been involved in at the University of Bristol, along with the Institute of Child Health. My colleague Sarah Meadows and I are at the Graduate School of Education and we’ve been working with the ALSPAC team. ALSPAC stands for the Avon Longitudinal Study of Parents and Children. As I say there, it’s a longitudinal cohort study, designed to investigate the effect of the physical and social environment on the health and development of children, and it’s based at the University of Bristol Institute of Child Health and the Director is Professor Jean Golding. This longitudinal study is still going on, it started in ’91, ’92, with 12,000 women who were pregnant, and now we’ve got 1400 babies and there’s been very little drop out. So the kids are all now about seven or eight, that sort of age.

The study that we did though, was based on the women’s pregnancy and up until the babies were two and a half, and we aimed to analyse the ALSPAC database as I say to the age of thirty months and to clarify the characteristics of teenage mothers and older mothers to reveal the factors which might lead to vulnerability and resilience in the development of the young mother and her child, and today I’m just going to talk about the data on the children, and it’s the first look at the data, there’s still more statistical work to do it, and logistic regression, there’s still issues of parity and social background to take into account. And what I’m going to do is to report just very briefly on the characteristics at different stages. The actual real report will be coming out soon and I’m sure you’ll be rushing to read it, it’s part of the NHS Mother and Child Initiative, but it will be coming out soon so look out for it.

I should make a point about this type of data, it’s highly quantitative data, it’s based on questionnaire response, so inevitably the results - we’re looking at trends, so it’s quite depressing when you’re looking at trends, we’re not making any points about individual differences because I’m sure you’ll know, some young mothers and children turn out jolly well, whereas others have difficulties. When we look at the baby at four weeks, the variables which show significant differences between age groups at this age are a fairly small proportion of the total, but which include ones which could be deemed ominous. So for example, the teenage mothers were much less likely to breast feed their babies.

We divided the sample up into the under-seventeen year olds and the seventeen to nineteen year olds, and mothers in their twenties, thirties and forties, and there were some signs of parenting practices which were less responsive to the child in a minority of young mothers, but interestingly, when they were asked to rate their children’s development, the younger mothers tended to be skewed much more towards positive evaluations than the older mothers. Mothers were asked at this stage about their reactions for example to the baby crying, and they were asked to choose one of these options, you know that they’d pick up the child immediately, they’d let  it cry for a while but if it didn’t stop they’d pick them up, or they’d never pick them up until they were ready to do so. And you’ll see, again, if we use this as a sort of indicator of some types of parenting, essentially there were differences there.

When we look at the baby at six months, there were some signs of potential problems then for teenage mothers and their six month old babies. For example, while there were no general health differences with the babies, the children of young mothers were more in need of medical attention in the home. There was still less breast feeding and routine sleeping and feeding were less established with the younger mothers. Also, as we found actually from the data during the pregnancy, our teenage mothers smoked much more than the older mothers during pregnancy, after pregnancy and as did their partners. And when we look at the children, they were spending time in a smoky atmosphere the children of older mothers were not experiencing smoke to such a great degree as the children of younger mothers.

The children of the younger mothers would be much more likely to have had an accident than the children of older mothers. Again, looking at things about ownership of books - I mean the child is very little it’s true - but again we see a difference - here - ‘child having own books’. It’s the children of older mothers who are going to be introduced to books more than the children of younger mothers. There is other data too which I’m not going to be able to present now, there’s all this questionnaire data but there are also children in focus clinics that the Institute of Child Health established. I think it’s just 1200 children that they’re actually watching, how parents work with their children and so on, and they’re seeing all sorts of things that we already see in the literature. And again at this stage, it was the younger mothers’ rating of their child development which tended to be higher, and their expectation of development was more optimistic, they thought their children would be able to do things more quickly than the older mothers.

Analysis of maternal age combined with parity will clarify whether some of these differences are due to practical experience of parenting. You’ll have to wait for that result to happen.

If we look at the babies at fifteen months, you’ll see there that there was considerable variation on each of the variables examined, but where there are significant differences between age groups they are typically in the direction of the younger mother, showing more problematic behaviour. The children were more exposed to smoke, and sometimes more overt difficulties, for example accidents and feeding difficulties. Differences in the mothers’ rating of their children’s social development were not related to maternal age at this point. And younger and older teenagers differ on their ratings of their toddlers’ vocabulary and non-verbal communication. We’re really looking forward to looking at these children from when they’ve started school too, to see what differences there are here.

If we look then at a toddler at eighteen months. At this age, there continue to be some indices of some more mild problems in parenting and development in the children of teenage mothers. These toddlers seem to have somewhat more difficult relationships with their mothers, to be less involved with their mother’s partner, and to have fewer positive amenities such as books. While some of the teenage mothers report good ratings for their child on each variable, and some of the older mothers report problematic ratings on each variable, no single factor could justify a strong diagnosis of problems for the child and mother. The teenage mothers, however, show a fairly consistent trend towards being at the worse end of the variable, on a large number of the variables, which we believe have implications for the health and development of the child. The data suggest that it may be necessary to regard these families as being at increased risk of problems in the health and development of the mother and the child. It’s still possible that the worse socio-economic circumstances and more adverse life events typically suffered by the younger mothers could account for much of this, and we’re going to look at that statistically. It’s probably significant that the oldest mothers, those whose child was born when they were over forty, showed an increased rate of both socio-economic and child-rearing problems over the mothers in their twenties and thirties. Parity, which will generally be higher in the older groups, may also account for some of the trend towards problematic ratings in the younger mothers. Children with older siblings may benefit from both what is provided for their siblings - books or whatever - and from having a more experienced parent. Further analyses will help to clarify how such variables combine.

At thirty months there continue to be small differences between maternal age groups in the experiences and achievement of the children. Children of teenage mothers are somewhat more likely to have had problems with health, more contacts with doctors in the surgery and on home visits, differences in hospital admissions, and accidents are not statistically significant because of the smaller numbers but are still in the same direction. These children are less likely to have a sleeping routine and to cry, fuss and have tantrums more than the children of older mothers. Their mothers find it harder to calm them when they cry, and use less conciliatory methods of dealing with their tantrums. Teenage mothers are more likely to say that their child often cries or has a tantrum for no reason than older mothers do. The few children who are said to show signs of anxious or avoidant attachment behaviour after separation from their mothers are disproportionately from the teenage mother groups.

There may be more signs of minor strain in the relationship between teenage mothers and their children. Older mothers are more likely to engage their children in activities such as going to the local library, learning nursery rhymes, while the children of teenage mothers are more often taken on shopping expeditions. The television is on more in the households of teenage mothers, and children watch more of both children’s and other TV and videos, but less children’s videos. This suggests an environment which has fewer intentional modifications towards being child-centred rather than adult-centred. This raises issues for those working for young mothers and their children in enabling this situation to improve.

 ‘Pregnancy, Parenting and Playtime’. Muriel O’Driscoll

The title of this presentation is intended to aid your reflection on your thoughts and attitudes towards young parents and to challenge professional help programmes, so I’m not giving you answers, I’m probably giving you more questions.

I am a midwife and family planning nurse who was a principal lecturer in midwifery at a university. I also work with young people in various outreach projects and am a stress manager and psycho-sexual therapist in my spare time.

My concern and the reason for choosing this subject is from personal observation of young parents and also from perusal of professional journals, government reports and intervention programmes that seem to have various levels of success. I am not providing answers but just beg you to consider the most effective interventions to give young families where you are the best possible start in life.

Can I start by saying that professionals don't always help, and I hope you’ll agree with me there. Research is generally undertaken by professional researchers who may also be social workers, teachers, midwives, doctors or nurses. Simply by virtue of their own background, educational attainment and their own success they have their own cultural baggage which influences both their interpretation and presentation of research findings. I am not against research in principal but its limitations must be acknowledged. Having lived most of my life in the infamous Toxteth in Liverpool I know the feeling of living in a goldfish bowl as views were sought from the poor unfortunate residents. At one time three separate researchers were investigating mental health problems in the black community and no feed back was ever given. This is an important point for researchers to ensure co-operation with further research there must be feed back given to those who have been studied or whose opinions have been sought.

Researchers and workers with young people must recognise where they are coming from and realise that the aims and objectives are owned by them and are not necessarily the study subject's.

Let me give you some examples of this to show where things can go very wrong. A school nurse was asked to draw up a programme on health education for girls in the lower sixth form. It included the usual topics of STIs, contraception, pregnancy, drugs, smoking.....you know all the usual subjects. When she asked for our help at Wirral Brook we thought that most 16/17 year olds were already accessing our services and persuaded her to let us do a questionnaire to find out what topics the students felt were needed in this programme. We started with a broad menu that included stress as well as many other women's heath topics. The most interesting area was the space left for 'other topics'. These included 25% of responders asking for a session on eating disorders and diet. 20% wanted to discuss suicide attempts, coping with death, depression and self harm. A further 15% asked for how to deal with parents’ problems including divorce, alcoholism and depression and a few wanted sessions on looking after themselves, cooking, legal things about renting, living away from home. After this it seemed a bit naff to talk about condoms when the students had other more pressing problems.

Another outreach programme included a session on 'planning a romantic night out'. The organiser obviously had her own ideas but these were totally out of synch with 15 year old non-achievers who had no role models of romance, meals out or the imagination to realise the concept behind this session. Needless to say it went down like lead balloon. I only use these as examples of bringing our background baggage into working with young people.

Now I want us all to reflect on being a child so as to see if we can see how we learn to be parents. You can talk to your neighbour as long as you promise to stop when I ask you to.

Think back to being a teenager:

Who was your best friend?

What did you talk about?

Can you remember your favourite pop star/ group/ anyone admit to being a Bay City Rollers fan?

What was your 'must have' fashion?

What were the row topics at home?

How did you spend your leisure? Why do we get so annoyed when teenagers say they’re ‘just going out, hanging around’?

Can you remember your first kiss? Boy/girl friend? would he/she have made a good life partner or parent of your children? Sometimes memory plays tricks and we only remember parts of our experiences.

Go further back. What was your favourite toy, games when playing out? (We used to have seasons where I lived, there was the skipping season, the two ball season, rounders, football, whip and top, yo-yo, hula hoop.)

Dolls houses? Action men? Was anyone else disappointed when they got a post office set for Christmas? I still think that Tippi Tumbles has a lot to answer for. First she needed batteries, not cuddlesome and fell over a lot!!

So how and when did we learn to be parents? We need to remember this fact: language development and self image are patterned from birth. And how do we learn to be parents? First of all we learn as children from parents and other role models and this may not always be the best way or not always a good example. We have all heard children and young adults repeating phrases heard at home and repeating patterns of speech and behaviour. Some children do not have parents to learn from or parents may be inadequate and role models are sought elsewhere, maybe from the television. We learn through play, nowadays often from computer games. I was fortunate to teach briefly on a child care course for school leavers and also on a Nursery Nurse Course. A lot of these students on Nursery Nurse courses needed to be taught how to play and it was obvious that some had never had that privilege before.

We also learn from our peers and from their experiences and whether this is selective sampling that our developing awareness screens for us is debatable, whether we only learn from the peers whose images and thoughts fit in with what we want to do anyway, I don’t know. Mel Parr (PIPPIN) writes that there has been a systematic abolition of the 'woman's network during the latter part of this century'. So we don’t have role models at home supporting young women when they become parents. We learn from our grandparents if the extended family is accessible as their memories of old fashioned values may drip into our consciousness.

Later we also learn from professionals, and this is where I take issue with professional teachers, midwives and health visitors at the wrongly named parentcraft classes when really these classes only prepare for labour and childbirth and not for parenting. In research undertaken by midwives there is an identified need of new parents for a 'trusted confidante' and Underwood in 1998 states that there should be early professional intervention in parenthood to assist new parents. Government and voluntary projects exist in some areas to support these research findings. In recent research undertaken by midwives Kelly and Belsky (Royal College of Midwives) the main disagreements of new parents were over money, work, chores and the change to social life, none of which are discussed during preparation classes and are ignored by the professional carers in most areas.

What should young parents know? What would be useful to them as parents who want to do the best for their children? Well first of all we should ask them!

Secondly,  let young parents play. In one of our outreach projects on the Wirral, we employ a community arts worker who allows adolescents to play with paint, making collages, making models. In one centre for excluded pupils the teachers and the Ofsted inspectors were amazed to see a group of excluded pupils, a group of young men asking each other to lend the scissors or the paste and helping each other to find the necessary pictures in magazines to complete a collage.They enjoyed a very happy hour as they became engrossed in play and produced a work of art at the end.

Thirdly, let young parents learn to play with their own children. Can you remember the rhymes, action songs and games? If we don't pass them on they will disappear and that ties in with what Nona was saying just now. And fourth by being an example in our interaction with children from birth onwards, because that is the role of all of us. Our attitude towards babies and children is being noted and if it impresses then it is copied. This means good and bad examples.

Parenting classes and formal or informal education are about supporting children and must include topics like child safety, child development, and the important and ignored subjects of developing coping skills and a sense of control over family life. This is vital for those whose income and lives are controlled by the benefits system. Research is presently being carried out by the Living with Children Project on how to optimise children's coping social skills and how to boost their self image. Some of the suggestions highlighted today may assist these two areas.

I cannot leave this topic without referring to a book I recently read called 'The Myth of the Money Tree' by Collette Dowling, an American, who also wrote the Cinderella complex which some of you may be familiar with. There has been extensive research with adolescent girls in America and she believes that no-one can be truly self confident and in control of their own destiny unless they have learnt to control money and their own budget, however small their income is. Inability to do this is not confined to age, class or ability but learning how to be in control of this vital area will have major impact on other areas. Even for young families on benefit this area, I believe, is vital to build self esteem, but it is another area never addressed in parenting preparation.

So I leave you with this message. We must find out what we can do to help young parents enjoy their children by: asking them what they need to know, helping them to learn through play how to play, helping them to develop social skills, and helping them to manage money. Finding methods to provide this is up to you and it will be different for each area, each culture and your personality and attributes but remember that the best way of teaching anything is by example and enthusiasm. Thank you.

McNeil: Thank you very much Muriel, what a refreshing discourse that was.

Adolescent Pregnancy: the Nepean Experience  Karen Dudley

Thank you for asking me to speak today. I’m Kaaren Dudley and I’m going to talk about programmes we have set up at Nepean Hospital in Sydney, Australia, to actually show you how we became adolescent friendly in our division of women and children’s health. This is a scene of the Blue Mountains which we consider very beautiful and it’s just up the road from our hospital. The Nepean Hospital is the major hospital in the Wentworth area Health Service. It is a tertiary referral centre, with 420 beds, with 57 beds in Maternity, for antenatal and postnatal care. The hospital services a catchment area of 301, 000 people, with an annual birth-rate of 3000 at Nepean Hospital. The birth-rate is up to 4900 in the catchment area. The hospital includes a six-bed Level 3, and 22-bed Level 2 neo-natal intensive care unit. Nepean area is the site for the rowing, canoeing and kayaking events in the year 2000 Olympic games.

The New South Wales midwives started collection of information from all confinements in the state of New South Wales. The need for specific services is highlighted by the high percentage of adolescent confinements, when compared to other areas of Sydney. We have the highest percentage of adolescent confinements at 6% in the Sydney metropolitan area, well above the New South Wales state average of 5%. Contrary to popular opinion, confinements in young women generally occur without significant medical complications, when there is provision of appropriate antenatal care. The only pregnancy-associated complications which are statistically significant are pre-eclampsia PE, and threatened premature labour, TPL. It is quite significant, that when compared to the state average, young women have a high number of normal vaginal deliveries - 80% compared with the older age group of 60%.

The literature suggests that the profile of adolescent pregnancy includes lower socio-economic class, lower educational and job attainments, large families, history of adolescent pregnancy in the family, low self-esteem, and women who were themselves adopted. Of course, this is a generalisation, and adolescent pregnancy can and does occur in any social class, cultural group or geographical area. The main issues or problems associated with pregnancy in young women includes homelessness, mobility issues, financial problems, isolation, mental health issues, such as depression and behavioural problems and family problems. There are other issues or problems associated with pregnancy and young women that will not be included in this short presentation. The Nepean Hospital has implemented a variety of innovative services offered to young pregnant women. The adolescent pregnancy and parenting programme is a multi-disciplinary team called co-ordinating the various services offered to young women. This multi-disciplinary programme utilises an adolescent friendly approach to support young women, their partners and families through pregnancy, birth and the immediate post-natal period. Team members include the adolescent support midwife, obstetricians, perinatologist included there, obstetric registrars, social workers, community nurses, clinical psychologists and psychiatrists, genetic services and the drug and alcohol team. I am employed as the adolescent support midwife and the major focus of my role is to co-ordinate services for young women in the division. I provide antenatal consultations, direct care and support in the interpartum Period and postpartum, consulting and crisis management as required. I refer the young women to other services as necessary. Finally I provide education, support and debriefing on working with adolescents to staff in the division of Women and Children’s Health.

A midwifery antenatal out-reach clinic is serviced weekly at a youth health clinic called the Warehouse. Additionally a midwifery hospital-based clinic is provided in the antenatal clinic for young people to wish to attend there. Postnatal care and lactation advice is provided as needed to the young women. Childbirth and parenting groups are held in the evening. Pregnant young women may bring with them to the groups and clinic anyone that they would like, partners, friends male and female, parents, siblings and grandparents have all attended at different times and often all together.

A lot of the young fathers or expectant fathers often bring their male friends along and do the pregnant women. So often one young couple may bring four or five or six extra people along. All are made very welcome and some learning is had by them all including myself as I continue to learn. Topics included are many including health and life style, conception through to birth, labour, delivery and pain relief, parenting and interesting tours. Some of the tours are undertaken by the group into the delivery suite, near-natal intensive care unit, mother craft unit and the emergency department. Contraception is discussed at length with much humour, especially the different colours, textures and flavours of condoms and how to use them.

The neo-natal intensive care Nepean adolescent parent support group NICNAPS was initiated by young parent and babies admitted to the neonatal intensive care unit. These young parents did not feel that the support group in place to parents of NIC unit admissions would meet their needs for peer support. I facilitated the development of the group with a focus on health promotion and child protection issues. The meeting of NICNAPS have been very informal and lively discussions are common place. The parents have requested guest speakers to provide additional information on parenting and infant care practices. These speakers provide demonstration and stimulate discussion and debate. The initial group visited the emergency department and children’s ward to familiarise themselves with the services provided in these areas. This was a very popular activity.

The babies in our initial group were all breast-fed with some mothers expressing for many weeks before breast-feeding was possible. The young parents are very proud of their babies especially as they have all made their developmental mile-stones at the appropriate corrected gestational age. Parents have formed friendships and some mothers have commenced employment. The initial group now acts as peers support for other young parents who have babies in the NIC unit.

Major goals have been in developing an adolescent approach to young pregnant and parenting women in our division. The Buddy programme was designed and implemented with significant input from young women. The aim of the programme is to familiarise staff working in the division about the special needs of young women and their partners . The programme has a primary health care focus promoting a holistic view of the adolescent, the special needs covered in the programmes are social, medical, emotional and economic.

Twenty four midwifes and nurses from paediatrics, gynaecology, maternity and the near-natal intensive care unit have become Buddies. All these midwives and nurses have the education programme focusing on the need of adolescents. These Buddies are advocates for young people and complement the services provided by the adolescent support midwives.

Some of the more interesting outcomes of the young women in our programme will now be presented. In 1997 to 98 there were a 120 deliveries to women aged 12 to 19 years. 8.5% required delivery by Caesarean section. The indications for Caesarean were antepartum haemorrhage of unknown cause, breach presentation, pre-eclampsia, foetal distress and placental prolapse in labour. One mother with a pelvic congenital abnormality required a Caesarean section. This compares favourably with our rate of 16% in the older age groups. In 1994 the state average for admission to the special care or near-natal intensive care units was 17.8%. At Nepean Hospital in 1997 there were only 12 or 9.3% of babies born to young mothers required admission to the neo-natal intensive care units. The majority of these babies required treatment for respiratory distress. One interesting admission was for an ovarian cyst which measures 10 cm which ultimately we actually aspirated and withdrew fluid and the baby was fine.

The rate of breast-feeding at the time of discharge  for this age group was 56%. This is a particularly difficult group of women in which to encourage breast-feeding. There are many factors that affect the young woman’s decision to breast-feed for example body image, peer group pressure and a history of sexual abuse. I often feel quite guilty about this as I am also a lactation consultant and I feel I could do much better encouraging young women to breast feed. Successful programmes do not adhere to traditional professional boundaries but adapt to meet the needs of those they serve. Successful programmes not only improve the health status of youth but improve social outcomes.

In conclusion the Nepean experience is an example of an innovative and adolescent friendly services which is continuously adapting to meet the need of pregnant and parenting young people. And a final view of our magnificent Blue mountains. Thank you.