research - pregnancy - Abortion and teenage pregnancy

Abortion statistics

In 2000 there were 175,542 abortions performed on women resident in England and Wales.

How the number and rate of abortions has changed?

From 1968 to 1973, the annual numbers of legal abortions for women living in England and Wales increased rapidly and then levelled off at about 100,000 a year. Abortion numbers then rose each year until 1991, mainly because the numbers of women in the population aged 15 to 44 (the fertile ages) grew due to a large increase in the birth rate in Britain between 1956 and 1963. There were more abortions between 1975 and 1990 because there were more women to become pregnant. A further factor in the rise in the number of abortions was the fall in the popularity of marriage among young women. Unmarried women are more likely to have an abortion if they have an unplanned pregnancy. The number of abortions has remained stable between 1998 and 2000. Reasons for this new stability could be due to abortion becoming a more acceptable solution than ever before when contraception fails or women fail to use it properly.

The number of abortions in England and Wales declined between 1990 and 1995, and better use of contraception is likely to have been an important factor in this. There was a 7 per cent increase in the number of abortions in 1996, largely due to the effects of a Pill scare in 1995 about the safety of certain brands of oral contraceptives. This undermined the confidence of many women in hormonal methods of contraception and decreased their use. The abortion rate has continued to rise, possibly because of continued concern about the safety of contraceptive hormones, especially among young women, and possibly because abortion is seen by more women as an acceptable way to manage an unwanted pregnancy. The increased abortion rate in 1996 was widely publicised and may have educated women that abortion is a legal and safe choice.

Who pays for abortions?

Unlike maternity services when a woman wants to continue a pregnancy, abortions are not automatically available through the NHS. On average, throughout England and Wales the NHS pays for approximately three-quarters (74.9 per cent) of abortions. There are significant differences between regions. In some areas the NHS pays for more than 90 per cent of abortions, in other regions it pays for less than 50 per cent. Statistics are published annually by the Office of National Statistics showing the contribution of each health authority to the funding of abortions in their area.

At what gestation do most abortions occur

Almost 90 per cent of abortions are in the first 12 weeks of pregnancy. Just 1.5 per cent are after 20 weeks.

Later abortions are often for the following reasons:
• The woman may not have been able to get a hospital appointment earlier in the pregnancy;
• she may not have realised she was pregnant (this is more common with young women and women approaching the menopause both of whom may have infrequent periods);
• very young women may feel unable to cope and so hide the pregnancy;
• sometimes the pregnancy was originally wanted but the woman's circumstances change (perhaps because she is abandoned by her partner or finds that her parents are not willing to provide her with a home or any other support);
• fetal abnormality is an important reason for late abortion, as many cannot be diagnosed early in pregnancy.

At what age do women have abortions?

The highest number of abortions is among women aged 20-24. However, a great deal of attention has been focused on teenagers because England and Wales has one of the highest teenage pregnancy rates for 15-19 year olds in Western Europe.

One woman in five who has an abortion is married; many others are in stable relationships. Abortion is not only an issue for single women. 47 per cent of women who have abortions have at least one child already.

Why do women from abroad travel to Britain for abortion?

In 2000 almost 10,000 women who lived abroad travelled to England to have an abortion.

Most of these women came from other parts of the British Isles, mainly from Northern Ireland (1,528) and the Irish Republic (6,391). Those from elsewhere in the world came because abortion is available in their countries only up to 12 weeks (France and Italy) or not available at all (the Arab states), or to ensure complete confidentiality.

The numbers have fallen from their peak of 57,000 in 1973 because most other European countries now have abortion laws that are less restrictive than those in Britain.

For more information contact:
BPAS Head Office
Austy Manor
Wootton Wawen
Solihull
West Midlands B95 6BX
Tel: 01564 793225
Fax: 01564 794935

The Reality of Irish Abortion:
Facts and stats: the reality of Irish abortion

BPAS has provided the ifpa with access to data detailing age, gestation and area of residence for the 8.214 Irish clients to whom it has provided abortion services since January 1997.

BPAS statistics analysed by the ifpa reveal the following key headline facts:

39.5% of all Irish clients, since January 1997, have self-referred, indicating that they have not availed of counselling in Ireland before travelling. While this figure is still high it does show that 60% have accessed some form of counselling

79.5% of all Irish clients, since January 1997, have had their abortion at 12 weeks gestation or less. UK Office for National Statistics (ONS) figures for 1996 indicate that this figure was 73% that year.

3.5% of all Irish clients, since January 1997, have had their abortion at 20 weeks gestation or more.

Tables A and B contain age and gestation data for 1997, 1998, 1999 and for January to June 2000. Table C contains data for each of the Health Board areas. County data will only be released for selected counties. In particular we will not release data for any county in respect of which there are less than 35 recorded abortions This is to safeguard the interests of the clients involved.

There will undoubtedly be interest in the number of abortions in Counties Wicklow , Kerry and Donegal given the dependancy of the current government on Independent TDs representing those counties.

Table D provides data for selected counties and shows that the main urban areas and counties Wicklow, Kerry and Donegal all have significant levels of abortion, notwithstanding the current legal position. This means that abortion is a daily reality in the constituencies of leading members of the government and the independent TDs on which it relies.

Table A

Table B

Geography

The following table has been prepared using client address data to calculate the total number of BPAS clients, in 1999 ONLY, drawn from each of the Health Board areas. The percentage distribution of these figures has been applied to the full ONS figure for 1999 to provide an estimate of the full year total for each health Board.

TABLE C

Total figure for Tipperary is divided evenly between the two Health Board areas for North and South Riding.

The total BPAS figure used in all geographical tables for 1999 is 2445. Of the 2,460 clients included in age and gestation tables, we were unable to allocate 15 clients to a county of residence.

Table D (Selected Counties)

In 1999 BPAS recorded 2445 Irish abortions where the county of residence could be determined as compared with total ONS figures of 6214. ONS figures provide no county data.

The BPAS figure of 2445 was equivalent to 39.58% of the ONS total. The estimated figures in column 3 below have been arrived at by multiplying the BPAS figure by 2.541 and rounding to the nearest whole number. This is the only method for county by county estimation currently available.

For Further Information:
Tony O’Brien
Tel: 086 811 5115 (Mobile) or 01 878 0366 (Office)

Email: ifpa@iol.ie

Abortion law

The history of British abortion law

Abortion in England and Wales was first made illegal in the 19th century. Before then English Common Law had allowed abortion provided it was carried out before the woman felt the fetus move ('quickening') when it was believed the soul entered the body.

Abortions performed after quickening were an offence under Common Law but there were no fixed penalties and the woman having the abortion was not necessarily held responsible. In 1803 the law changed and abortion became a criminal offence from the time of conception with penalties of up to life imprisonment for both the pregnant woman and the abortionist.

The Offences against the Person Act 1861

Section 58 of the Offences against the Person Act 1861 made abortion a criminal offence punishable by imprisonment from three years to life, even when performed for medical reasons. No further legal changes occurred in England until 1929. The Offences Against the Person Act is still in place and the current law simply provides exceptions to the 1861 law by clarifying when an abortion can be legal.

The Infant Life Preservation Act 1929

The Infant Life Preservation Act amended the law so that abortion would no longer be regarded as a felony if it was carried out in good faith for the sole purpose of preserving the life of the mother.

The 1929 Act made it illegal to kill a child 'capable of being born live', and set 28 weeks as the age at which a fetus was assumed to be able to survive.

The Infant Life Preservation Act has never applied in Scotland.

The 'Bourne Judgement' 1938

In 1938, Dr Alex Bourne performed an abortion on a 14 year old girl after a gang of soldiers had raped her. Dr Bourne informed the police and was prosecuted. In court, the judge ruled that Dr Bourne had acted in the 'honest belief' that the abortion would 'preserve the life of the mother'.

This opened the way for other doctors to interpret the law more flexibly because it established that preserving a woman's life could mean more than literally preventing her death.

The Abortion Act 1967

The Abortion Act 1967 came into effect on 27 April 1968 and permits termination of pregnancy subject to certain conditions. Regulations under the Act mean that abortions must be performed by a registered practitioner in a National Health Service hospital or in a location that has been specially approved by the Department of Health - such as a BPAS clinic.

An abortion may be approved providing two doctors agree in good faith that one or more of the following criteria apply:
A. the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated;
B. the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;
C. the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman;
D. the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman;
E. there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped; or in an emergency, certified by the operating practitioner, as immediately neccessary:
F. to save the life of the pregnant woman; or
G. to prevent grave permanent injury to the physical or mental health of the pregnant woman.
In relation to grounds C and D the doctor may take account of the pregnant woman's actual or reasonably foreseeable environment, including her social and economic circumstances.

Most abortions of unwanted pregnancies are carried out under grounds C or D because the doctor confirms that it would be damaging to the woman's mental health to force her to continue the pregnancy.

Doctors and other medical staff have the legal right to 'conscientiously object' to taking part in abortions unless this is necessary to save the life or prevent grave permanent injury to the woman.

Human Fertilisation and Embryology Act 1990

Section 37 of the Human Fertilisation and Embryology Act made changes to the Abortion Act. It introduced a time limit of 24 weeks for grounds C and D. Grounds A, B and E are now without limit. Before this change a 28 week limit had applied for all grounds.

The Human Fertilisation and Embryology Act also confirmed that when a woman had a multiple pregnancy it was legal for a doctor to terminate the life of one or more fetuses leaving others alive.

The Abortion Act 1967 and Section 37 of the Human Fertilisation and Embryology Act 1990 do not apply to Northern Ireland.

Teenage pregnancy unit:

http://www.dfes.gov.uk/teenagepregnancy/dsp_Content.cfm?PageID=85

The effective lack of relevant research into causes:

http://www.dfes.gov.uk/teenagepregnancy/dsp_content.cfm?pageId=215

Government social exclusion strategy

http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/TeenagePregnancy/fs/en

Teenage Pregnancy Unit

Developing service checklists: Guidance for local teenage pregnancy co-ordinators

Action Point 27 of the Social Exclusion Unit Report on Teenage Pregnancy requires that:
Ø The local co-ordinator make sure that in their area, professionals and teenagers have a checklist setting out the services available during pregnancy.
Ø This will list the sources of advice on options to keep the baby, adoption or termination. It will also cover counselling, education and training, financial issues, housing and advice on future contraception needs.

1. The guidance includes advice to enable every local area to develop:
By Spring 2001 a checklist referral system for professionals working with pregnant young women
a summary service checklist for young people
By Spring 2002 a youth service directory for young people

2. The guidance has been produced following a seminar held by the Teenage Pregnancy Unit, which involved a number of local co-ordinators who have produced service checklists, and a range of professionals in the voluntary and statutory sector who work with pregnant young women.

3. The guidance also addresses general issues involved in promoting services for young people to increase their uptake of health and related services.
Contents:
Section 1 Background
Section 2 Producing a referral checklist for professionals working with pregnant young women
Section 3 Producing a checklist of services for young people
Section 4 Producing a directory of services for young people

Annex A Referral checklist
Annex B Different approaches to producing checklists
Annex C Different approaches to producing directories
Annex D Increasing the effectiveness of service information
Annex E Research findings

Section 1: Background

3. Increasing young people's uptake of advice, support and information services is an important part of achieving the Government's ten year strategy to halve the rate of conceptions among under 18s and increase teenage parents' involvement in education, training and employment.

4. By collating information about what services are available to young people at the local level, local co-ordinators will be able to identify any gaps and facilitate the planning and promotion of services in a co-ordinated way, through the local strategy.

5. It is especially important to ensure that young women who are or who think they may be pregnant receive information and support from professionals in a co-ordinated and timely manner.

What is meant by a checklist?

6. The Social Exclusion Unit's report does not prescribe exactly how the checklist of services should be produced and it is clear that local areas will need to respond to local needs, in respect of ethnicity and cultural issues, literacy rates etc. It is not anticipated that every area will produce an identical checklist, though some areas may choose to work in partnership with others.

7. We would encourage every area to move towards the production of a comprehensive directory of services, which would include services available during pregnancy and factual information on key issues, such as the law, benefits, housing, employment rights as well as sexual health and relationships. This directory would be aimed at all young people and would provide information for professionals working with young people including young women who are pregnant or young mothers under 18.

8. As a first step, we would expect every local area, by Spring 2001 to produce, a credit-card sized list of key local phone numbers for young people's sexual health and contraceptive services (including emergency contraception, and 'where to go if you think you may be pregnant') and a referral checklist for professionals who provide information, support and advice to young women who are pregnant.

Performance Monitoring

9. The strategy guidance issued in September refers to the need to advertise local services to young people as part of local campaign work. We have asked you to provide information on procedures for ensuring accurate and up to date information on services is disseminated and how directories of services are being produced and distributed.
• We would therefore expect local strategies and three year action plans to include plans to address this action point and for March 2001 reports to indicate likely progress in achieving the specified timescales.

10. Best practice guidance on providing effective contraception and advice services for young people has been posted on the TPU website, and an audit framework is being developed.
• The process for auditing services against this framework needs to be developed in conjunction with the above action and the timescales for progressing this should be included as part of local strategies and three year action plans.

11. Early in 2001 TPU will be issuing a forward timetable of key actions and dates to assist local co-ordinators in planning action in the light of emerging guidance.
• Regional co-ordinators will be asked to review progress in September 2001 and discuss priorities and time-scales with the local co-ordinator.

Involving and consulting young people

12. Producing checklists and directories should be done in consultation with young people. There are a variety of ways to engage young people, and Annexes C and D identify a number of approaches.

Section 2: Producing a referral checklist for professionals working with pregnant young women

13. A young woman who finds or suspects she may be pregnant may turn to one or more professionals (and in a few cases, to none). It is important that professionals have accurate and up to date information and are in a position to refer the young women appropriately.

14. Professionals likely to come into contact with pregnant young women or mothers need to be aware of sources of advice on:
• Counselling on options to keep the baby, adoption, abortion and future contraception needs
• Education, training and employment opportunities and childcare
• Benefits, housing and financial issues

15. Young women may delay contacting services, so when a pregnancy is confirmed it is essential that they receive access to co-ordinated support and advice quickly. Special attention needs to be given to ensuring that sexual health services consider how they ensure access to counselling and other relevant health professionals. Health professionals need to consider how they provide referral on education, financial, housing and benefits advice. Education and training providers will need to consider links with health providers and advice on childcare and financial issues.

16. Practitioners in health, education and social services should be involved in agreeing a referral procedure to ensure that a pregnant schoolgirl is offered help, advice and support in a co-ordinated manner. Annex A provides a list of relevant professionals and an example of a referral flow chart.

17. Representatives from each service should provide details of their role and key contact details by geographical area, as appropriate. Where possible, named contacts should be identified to lead on enquires from, or on behalf of, a pregnant teenager.

18. The local co-ordinator should consider bringing together a working group to develop the referral checklist, and a process for dissemination and updating.

19. An evaluation of the referral checklist should also be developed with relevant professionals.

20. A young woman who continues with the pregnancy will have many information needs and is likely to come in contact with a range of professionals over a two to three year period. Midwives in particular may be in a position to advise on the development of a notebook for the young mother in which she, and the professionals she is in contact with, can record essential information, questions and contact details. Alternatively, professionals might wish to consider developing a young person's guide to becoming a parent, similar to the one produced by Barnardo's Young Parents Network in Belfast (see Annex A for details).

Section 3: Producing a checklist of services for young people

21. The first stage in the production of the checklist is to decide what services you want to identify as the 'gateway' for young people i.e. the place or places you would direct them to for initial professional contact on sexual health or pregnancy issues. Annex B highlights the need for checklists to include information on emergency contraception and where to go if you think you may be pregnant.

22. It may not be practicable to list every available service, but you might want to either give a variety of telephone numbers for young people's services, or perhaps give just one number for a local help-line, who can then provide further information on specific services. If you wish to include a national contact, the ruthinking website details (www.ruthinking.co.uk) can be used. In accordance with the guidance issued in the media pack the Sexwise number should not be included in any publication with an official or adult endorsement or branding. If you are in any doubt about this please seek clearance as detailed in the media pack.

23. Each of the services which you propose to include will need to be contacted and their agreement secured. It is possible that their uptake could be increased. They may get young people seeking advice on issues in which they do not specialise, and they need to know where to refer them.

24. Once you have identified the services to be included on the checklist, you need to decide the format. Some examples of checklists are discussed at Annex B, which identifies some of the pros and cons for each approach.

Section 4: Producing a directory of services for young people

25. Where general youth information directories or guides exist, co-ordinators are advised to work in partnership to ensure that information is included about emergency contraception, confirming a pregnancy, options for termination or adoption, as well as contraception. In the education, training, benefits and housing section, it is important that the rights and entitlements for young parents under 18 are included. This information is subject to change, and up to date information is available from local benefits offices.

26. Where general information directories do not exist, co-ordinators will need to consider in partnership with others (e.g. the youth service, careers service, benefits office etc) options for producing a directory of services for young people.

27. The first stage of producing a directory is to decide upon the scope of the topics and issues to be covered. It will not be possible to provide information on all issues relevant to young people, but key topics need to be identified. Annex D provides information on a number of examples.

28. As with the checklist of services it is important to consider the key services which provide a 'gateway', and include details of services catering for marginalised groups.

29. Unlike checklists, directories give an opportunity to provide basic information on issues or situations as well as service contact details. Some directories are designed in the form of questions or include young peoples' own comments about services (see Annexes C and D). Directories should provide a clear statement about services' confidentiality policy and a description of their ethos.

30. Involving professionals and young people in writing and agreeing sections will help increase ownership of the directory. Annex D explores the importance of co-ordination, young people's involvement, specific situations and added incentives as ways of increasing the effectiveness of service information.

Practicalities

31. Project management
Staffing needs will vary depending on the scale and focus of the guide and the extent of involvement of young people. A team and/ or the appointment of a project worker will need to be considered. It is important that someone has an overview of the project and a common framework for information collection is agreed.

32. Involving young people
The extent of young people's involvement will need to be identified. Some directories have been produced and designed by young people as a project. This level of involvement requires funding to be identified for meetings, residentials, visits and expenses, including childcare and transport. Other directories have involved or commissioned particular groups of young people to undertake specific activities such as service visits and reviews, designing the format or dissemination strategies.

33. Design and layout
The layout of the text and the overall look of the directory is important and needs to have credibility with young people. Young people should be involved to ensure that design and format will attract interest but not be stigmatising. Non standard page sizes, bindings, more than one colour print and design features, such as tabs for different sections should be considered but will have cost implications.

34. Distribution and dissemination
A clear dissemination strategy should be developed, which will determine the necessary print run. Checklists are likely to be produced in greater numbers and have a wider distribution than directories. It is important that the dissemination strategy considers targeted distribution to ensure that young people in care, young men and black and minority ethnic young people are involved and receive copies on a frequent basis.

35. Updating
A directory can become out of date in two ways. The factual information may change i.e. agencies move, close or change their opening times or phone numbers etc and new services and agencies start up. Secondly staff and agencies' ways of working and their approach to young people may change. It is common for directories to be updated on an annual basis. Checklists, on the other hand, have the potential to be updated on a more frequent basis. It is recommended that the date of publication is given and a phone number to ring if it is more than six or 12 months out of date. Local websites are increasingly being developed for and by young people, and these provide an opportunity to provide up to date information. A ring binder format enables inserts to be added. Providing update information in electronic format for professional organisations might be considered as an option.

36. Funding
The Local Implementation Fund and the Local Co-ordination Fund are available to support the development and production of checklists and directories. Where generic directories are produced, it is anticipated that a partnership funding package will be developed.

Annex A
Referral checklist for professionals
Local areas will need first to consider how to establish a referral procedure among professionals and between organisations. Then a view needs to be taken about how best to ensure that professionals are aware of who to contact in order to ensure speedy referral. A sample list of professionals and a referral checklist is provided for adaptation at local level.

The primary target audience for the checklist is professionals. However, some of the information may also be adapted for a pregnant young woman. Professionals involved in supporting a pregnant young woman under 18 will require information on the roles and responsibilities of other professionals, referral procedures and contact details.

Some areas will, in addition, want to consider adapting this information to produce a booklet or leaflet for young women who are continuing with the pregnancy.

For example:
At Forest Health Care Trust, Redbridge & Waltham Forest HA, an adolescent pregnancy and maternity working group was set up and produced a booklet called 'Pregnant at School' for professionals. This listed all key professionals with a description about their roles and responsibilities and some case studies.

For example:
Barnardo's Young Parents Network in Belfast produced a referral checklist as part of a booklet called 'A young person's guide to becoming a parent'. This was written by young parents to provide basic facts and information and useful contacts. It contains sections on community midwives, antenatal classes, health visitors, social workers, schools and welfare officers, being in hospital, breast feeding, coming home, fears and baby blues, money matters, help with health costs and a directory of contacts.
Contact: Barnardo's Young Parents Network, 453 Ormeau Road, Belfast, BT7 3GQ
Tel: 028 90492802

The content of a checklist
The range of professionals involved in supporting a pregnant young woman should be included with a brief description of their roles and responsibilities. The following provides an indicative list which should be adapted to local circumstances. Contact details for a named lead person should be included where possible.

School Nurse
School nurses have a role to promote and maintain the health of the pupils to enable them to benefit from education. School nurses can offer support, counselling and referral for a young woman who thinks she might be pregnant.

Teacher
The guidance on Sex and Relationship Education states that schools should have a clear and explicit confidentiality policy. Teachers should ensure that they act consistently with that policy. In accordance with the SRE guidance and the DfEE guidance 'Teenage Pregnancy: Guidance to Schools, LEAs and Social Services Departments on supporting parents and pregnant girls of compulsory age in education', teachers cannot offer or guarantee pupils unconditional confidentiality. They are not legally bound to inform parents or the head teacher of any disclosure unless the head teacher has specifically requested them to do so. A member of staff who finds out that a pupil is pregnant should ensure that the pupil receives full information about services in her local area, how to access them and has the opportunity to talk through the options.

In cases where a pupil has decided to continue with her pregnancy, the head teacher will need to be informed so that arrangements can be made for her continuing education. The head teachers should tell relevant members of school staff according to school policy and nominate a member of pastoral staff to talk to the young woman and take responsibility for her continuing education. The head teacher should make sure that the pregnancy is dealt with sensitively by both teachers, and pupils within the school. The nominated member of staff is not obliged to tell the pregnant pupil's parents or carers, but they should take steps to ensure that wherever possible the young person is persuaded to talk to them. They should make sure that the pregnant pupil has access to the appropriate local Health and Social Services. In Sure Start Plus areas, the young woman should be given contact details of the Sure Start Plus Advisor. Where possible, the head teacher should respect the young woman's wishes on confidentiality.

Youth Worker
Within the guidelines for the Youth Service, youth workers will help the young woman consider her choices and options. They will help the young woman access confidential services, and will offer liaison with parents and other professionals.

General Practitioner
Free pregnancy tests are provided via GP surgeries. The result of a pregnancy test should be no longer than two to three days. If a young woman is given a longer time-scale she should seek assistance from another GP or clinic service.

Midwife
A midwife is an advocate, a friend and a professional advisor from time of first contact until 28 days after the baby is born. The initial referral is likely to come from social services, school nurse, health visitor, GP or teacher. Antenatal care can be provided in a variety of locations, as midwives recognise that teenagers are often reluctant to attend antenatal classes.

Health Visitors
Health visitors are nurses with special training. They provide care and support for mother and child until the child reaches five. The health visitor is likely to want to make contact with a pregnant schoolgirl in the antenatal period in order to establish a relationship. Initial contact can be made via a home visit, health centre or clinic. The health visitor has a key role in ensuring liaison with other professionals, and planning immediate and long-term support for the mother and child's health and well-being.

Educational Psychologists
The fact that a schoolgirl is pregnant does not necessarily mean she will require psychological intervention. Most girls however will want support to help them think through options for education. The educational psychologist has a role to link with other agencies to ensure the young women has access to counselling.

Social Workers
For young people in the care system social workers provide a source of advice and information to help decide whether to continue with the pregnancy. This is likely to include a discussion about options on adoption and the future care of the baby, and a assessment and support around family breakdown and alternatives to living at home. When there is a perceived risk that a young woman or unborn child is suffering, or is likely to suffer, significant harm, social workers under Section 47 of the Children Act 1989 will make enquiries to enable them to decide whether they should take any action to safeguard or promote the child's welfare.

Housing Officers
Lone parents may be referred to housing departments by social services or approach them directly. Social Services and Housing will undertake a joint assessment of the young woman's housing and support needs. The Government's policy is that all lone parents under the age of 18 who are unable to live with their family or partner should be provided with housing with support, not a independent tenancy. This policy is to be fully implemented by 2003.

Reintegration Officer
Appointed by the LEA to ensure that young people, including teenage mothers attend school or other education facilities. A school age mother should have an individual reintegration plan and panel (see Circular 11/99 for details on reintegration).

Personal Advisors and Learning Mentors
In Connexions pilot areas, partnerships will need to consider how to provide an integrated support package, for example by designating certain personal advisors as specialists in supporting teenage mothers and fathers.

Learning mentors in Excellence in Cities areas and personal advisors in areas with Connexions will work with pupils facing barriers to education. Compulsory school age mothers or fathers will receive support from a learning mentor or personal advisor to help them access learning effectively. The level of involvement will depend on the needs of the individual.

In Sure Start Plus areas, the Sure Start Plus advisor will offer personal support and advice and help with accessing counselling and other services to enable pregnant teenagers to make a well-informed decision about the future of the pregnant. For those who continue with the pregnancy, Sure Start Plus advisors will co-ordinate an individual support package for the young parents, both mother and father. In areas where there are Connexions and Sure Start Plus pilots, the Sure Start Plus advisor will normally act as the young mother's Connexions personal advisor.

The following flow chart is an example of a flow chart written from a professional's point of view. A flow chart from a young person's perspective could also be developed. Local areas will need to design their own versions, inserting named leads and contact details where appropriate.

Helpful reading
Robinson et al (1998) The Really Helpful Directory – services for pregnant teenagers and young parents, second edition The Maternity Alliance and the Trust for Study of Adolescence 1998 ISBN 0 946741 45 X

A directory which provides details of different types of projects in the UK. Residential accommodation, educational facilities, antenatal and parent craft provision and support, information and services. (Please note that the only service advertised for Coventry and the West Midlands is LIFE.)

Youthaid have produced a useful booklet called 'Under 18 and Pregnant', revised in 1997. It contains information on training, employment, education and benefits rights for pregnant young women and young parents. It has not been updated and some of the information is now out of date. ISBN 0 907658 30 X from Youthaid, St John Street, London EC1V 4NT .

Annex B
Different approaches to producing service checklists for young people

Characteristics of service checklists
They vary in size and format. Some are produced as a poster, A4 leaflet or leaflet folded to handy purse or wallet size. Outline information is provided, the name of the service, phone numbers, details of opening times and what is provided. Some checklists are specific to sexual health services. Others include sexual health services among other services such as Citizens Advice Bureau, drug agencies, leisure and benefits agencies.

Example: Nottingham
A Sexual Health Services leaflet which provides comprehensive and clear information on all sexual health services in Nottingham, and specific young people clinics are mentioned. The opening times are provided and the fact that the services are free and confidential is emphasised along the side of the leaflet. It is an attractive bright green and yellow leaflet which folds up to A5 size, including website and national phone line information

Example: Choices 4 Young People, East Kent
A laminated card advertises free, confidential help and advice on sex and relationship services for young people and provides details on opening times and area. The two tone colour cover was designed by young people.10,000 credit cards and 250 posters cost approximately £588 paid by Schering Health Care. The reprint of 40,000 credit cards cost £234.

Example: Young People's health/advice, Brentwood
Laminated credit size card which provide a range of services and phone numbers on one side and information shop details on the other. Cartoon pictures were designed by young people. Cost about £500 for 10,000.

Comment
Checklists need to ensure that they meet the needs of young women who suspect that they may be pregnant. All cards should identify sources of emergency contraception and specify that it is effective if taken up to 72 hours after unprotected sexual intercourse. The checklists also need to provide information about where to go if you think you may be pregnant for pregnancy testing and counselling.

Points to consider:
• Checklists are easy to produce and update.
• Low costs enable large numbers to be printed.
• The phone card style is small, discreet and easy to keep.
• A checklist that provides sexual health services among a range of services may be less stigmatising and be appropriate for distribution through a wide variety of locations.
• If the checklist is clearly about sexual health i.e. has 'sex' emblazoned on the front, it may deter some young people from picking it up and others from keeping it.
• Young people need to have a motivation to keep the card. If you only supply information about contraceptive services the card is likely to have limited appeal to those who have an immediate need for services. Including information on leisure facilities e.g. cinema details, discounts, maps etc increases the likelihood of retention.
Annex C
Different approaches to producing a directory of services for young people
Two types of directory have been considered: issue specific directories and generic youth guides

Sexual health directory
These directories contain information about sexual health, in addition to service information. For example, information is included on different types of contraception, sexually transmitted diseases, different sexualities and advice about of safe sex .

Example: Birmingham Sexual Health Directory
It contains a wide range of information provided in a A4 glossy magazine style format including information on safe sex, using a condom, methods of contraception and STIs. Designed for all who are sexually active. It includes photos, cartoons, a quiz and tick box questions. Local and national services and phone lines are listed at the back.

Comment
A magazine style can provide a wide range of information on sexual health, although its size and boldness may deter its use by young people. It is likely to be expensive to produce and would need a targeted distribution. It would need to contain information about emergency contraception and what to do if you think you may be pregnant.

Young people's guides
These are characterised by covering a wide range of issues relevant to young people, often divided into topic sections such as 'you and your rights', 'travel and transport', 'money', 'home', 'family', 'leisure', 'health and relationships', 'housing and homelessness', 'education, training and employment'.

Example: Kirkless Youth Fax 98 – a rough guide to living
A spiral bound booklet containing 14 sections including, 'you and your rights', 'health and relationships', 'leisure and community', 'housing and homelessness', 'money and benefits', 'education, training and employment'. Each section provides an overview of the issues for a young person and contact details of local and national services. The booklet is produced by the West Yorkshire Fax consortium, including young people from 'Young Batley' Youth Council

Example: Birmingham Rough Guide to Help, Advice and Information 1994 and 1998
This has a similar spiral bound format to the Kirkless Youth Fax. The first version included young people's comments about their feelings about contacting a service, what had happened, what they would say to another young person about it and recommendations for improvement. It includes the age, gender and ethnicity of the young reviewer. It is divided into 11 sections.

The 1998 guide included information about the issues, in addition to a feedback page with young people's comments about visiting the services. It included the first name of the young person and their age. Both editions were produced and developed by young people as part of a youth project. Some young people's involvement was recognised as part of their GNVQ.

Example: Infofax 1999 Greenwich
A filofax with a commercially produced diary followed by sections on health, benefits, entertainment, local councillors and the youth council. It includes a range of help line numbers and local service details. The see through filofax cover is hardwearing and designed for each year's diary to be inserted. It was designed by a girls and young mothers group. It cost about £2.50 each and was distributed to all year 11 pupils on their last day at school.

Example: What Now? Millennium edition, Lancashire
A book format produced by young people linked to a website and the 'What Now' young people information shops run by Lancashire Youth and Community service. It contains sections on education, work and training, money, benefits, relationships, sex and sexuality, drugs, leisure, travel and transport, environment, politics, religions and equal opportunities. Local and national help lines and services are included.

Example: The Manchester Survival Guide 1997
A ring bound format, a bright yellow hard- wearing cover without logos or organisational branding. Produced by the City Centre Project with young people and a advisory group. It covers housing, money and benefits, health, law, education and training, lesbian and gay issues, 'Manchester on the cheap' and poems and prose from young people. Details for local and national services are provided, as well as a feedback sheet and a update form for organisations.

Comment
The generic young people's guides provide a range of information and service details in attractive and long lasting formats. Sexual health is just one aspect of the information provided and does not feature on the cover. This may encourage young people to keep it without fear of embarrassment or stigma.

Where young people's feelings about making contact are included, this may help others to recognise they are not alone in feeling confused and vulnerable. Where young people's views on the service are included, this is likely to help other young people prepare for what will happen and provide peer endorsement.

Services for a young woman who thinks she may be pregnant, including emergency contraception and pregnancy testing, are included in these directories to varying degrees. Issues such as termination, and adoption when covered appear in the section 'relationships and the family' or 'health and relationships'. Employment, education and training issues are usually included, but vary in the extent to which they cover specific issues relevant to a teenage mother.

Useful contact
Selected directories available on loan from the National Youth Agency, 17-23 Albion Street, Leicester LE16GD, Tel: 01162853700, www.nya.org.uk

Annex D
Increasing the effectiveness of service information

Whether you are producing a checklist of phone numbers or a directory of services, it is important to consider:
• which services are promoted;
• what information is provided;
• how young people will be involved;
• how the services promoted are co-ordinated;
• opportunities for promoting services as part of specific situations; and
• added incentives that will increase the effectiveness of the information produced.

Which services should be included?
In identifying the key local services that young people will be directed to, it is vital that you consider the following:

Which services young people are most likely to contact as a 'gateway'. You should involve young people in considering which ones to include, especially for the checklist – it is especially important to identify services required during pregnancy;

The performance and reputation of those services among young people. For example through:
• consultation with young people (you should ensure that those underrepresented in using services such as young men, black and minority ethnic groups and young people in care are consulted);
• consultation with other professionals;
• mystery shopping (where young people visit a service in order to feedback their views and impressions on the experience).

It is particularly important to select services that have a good reputation among young people. The checklist or directory will have little credibility if the services are perceived to be unsympathetic to young people's needs. Only if young people's first contact with professionals is positive will they be likely to seek advice again in the future, or keep referral appointments. A feedback process should be considered, especially outlining who to contact if things go wrong and they do not receive the service expected.
Information about the accessibility of the local services e.g. opening times and days, transport links, and location need to be considered. It is especially important to use young people friendly directions ie use landmarks that will be familiar where possible e.g. turn first right at McDonalds. In Coventry photographs of the actual buildings are used on their leaflet to help young people locate the service.
How do the services cater for young people? For example, do they:
• specify that young people / young men are welcome?
• advertise their confidentiality policy?
• state exactly what services are offered?
• give names for those professionals who are specifically available for young people?
• offer discreet accessibility techniques? (e.g. young people can ring and request a young person's appointment, or use a code word )
• do they provide balanced and unbiased information to young people ? If services or professionals provide a limited service or have a particular perspective or ethos then this should be clearly identified.

Service co-ordination
It is important that there is a co-ordinated approach among professionals to respond to young people. In some areas they have developed a system for youth issues/ enquiries in key departments. For example, Plymouth have a named contact for CSA enquiries, and this approach is due to be adopted by the housing and benefits departments.

In some areas a young person's appointment system is in place. Where this exists young people do not have to specify or identify why they want to see the doctor or counsellor, they just ask for a young person's appointment. Coventry has adapted this in a GP Practice which is part of the condom distribution scheme. A code word approach is used, young people ringing up or presenting themselves 'ask for Jane', which stands for I am a young person and need emergency contraception. Services on the street using buzzer/intercom systems could usefully considered the use of pass words.

Young people's involvement
There are a variety of ways to involve young people in service checklist and directories. They should be consulted and involved in advising on the services to be included, the imagery and language used, ways of distributing and evaluating the use and retention of the information and ensuring that service providers receive feedback.

The project approach used by Birmingham involved working with groups of young people from care, and black and ethnic minority young people to undertake service reviews. School and college groups were involved in researching and visiting services as part of their GNVQ and citizenship curriculum. As part of launching the guide young people in Birmingham were involved in organising a conference to feedback their finding and discuss their recommendations with service providers.

South Essex have asked young people involved in the community health council to undertake a project to design and deliver a semi structured questionnaire about services to local young people.

Coventry used the mystery shoppers approach to test out their GP condom scheme. Young men were involved in visiting services, which were part of the scheme. They feedback their reactions and recommendations for improvement.

In Dudley midwives are working with a young mothers group to produce a news letter for teenage mothers, and young people in care and young offenders are being approached to undertake mystery shopper visits to a range of services.

Plymouth students at the local IT community college designed a website of local services as part of their college project.

A number of directories are linked to youth councils. In Sandwell the Young People's Council are involved in producing a magazine 'Voice 21' and service information will be included. The Greenwich and Bexley filofax was developed by young women and a young mothers group and linked with the Young People's Council. The group helped promote the filofax by visiting schools and talking about their experiences.

Specific situations
In combination with a youth directory or service checklist, it may be relevant to consider specific situations and opportunities to promote services.

Emergency contraception
Coventry have produced a small laminated card on emergency contraception and where it can be obtained. A club goodie pack was produced for clubbers which contained information about contraceptive and sexual health services, condoms and a toothbrush.

Pregnancy Testing
Rotherham worked with local pharmacies to offer free pregnancy tests and an information card. The card folds outwards to direct the person to various services depending if the result was welcomed or not.

Added incentives
Linked to discounts
Coventry pioneered the discount idea as part of their 'Hands on' card for under 21s. It contained a list of participating shops on one side and information services for counselling, mental health, sexual health, alcohol and drugs, homelessness and national numbers were on the other side.

Use of logos
As part of a drug prevention initiative, South Essex Mental Health and Community NHS Trust produced a credit card for young people with a variety of phone lines for different services e.g. health/advice services, leisure centres, social services, housing and homeless support, sex and drug services and the benefits agency. Local Virgin shops paid for the printing of the card, with the Virgin logo and distributed in its shops in Thurrock and Basildon

Attaching a condom
Nottingham included a condom on their leaflet which was given out in cinemas, the condom was detached when distributed in schools

Useful reading
Eggar, Gary, et al (1993) Health Promotion and the Media, McGraw –Hill, Australia Pty Ltd. ISBN 0 07 4700006 £21.95 from Blackwells bookshops www.blackwells.co.uk

Skinner, Steve (1995) Directories and Resource Guides – how to produce them, Community Development Foundation publications, education training Unit, ISBN 0 902406 88 4, available from Community Development Foundation , 60 Highbury Grove London N5 2 AG

Annex E
Research findings on young people and service access

Research about young people and services, when and how they make contact is limited. When asked very few young people reported direct publicity as their primary source of information about services. Other studies identify sources including articles or adverts in newspapers magazines, leaflets, visiting speakers to schools or youth clubs and telephone directories.

In 1995 the Health Education Authority (now the Health Development Agency) commissioned Brook Advisory Centres and the Centre for Sexual Health Research University of Southampton to undertake a study to identify effective pathways through which to promote sexual health services for young people. Interviews with eighteen single-sex focus groups of young people aged 15-21 years were conducted in urban, semi-urban and rural areas throughout England. The participants were selected from a range of social and demographic backgrounds and differed in terms of sexual experience, the frequency with which they used services and the types of services they used.

Know it all?
The research drew together a number of studies to confirm that young people generally 'report a low awareness of basic information regarding sexual health services. Where knowledge is evident, it often consists of substantial flaws, gaps and misapprehensions. Levels of knowledge amongst young people appear, at best, to be insufficient and, at worst, non-existent, and young men have less knowledge about services than women do.'

The research findings however are often at odds with the image young people, and particularly young men, project. Professionals are often presented with young people who dismiss discussing sexual health issues, saying that they have 'done it in school'. Experienced workers are aware that some young people present a sophisticated, knowledgeable and confident image characterised by the 'know it and done it, got the tee shirt' image as a front for insecurity, confusion and uncertainty.

Getting to know?
Young people identify a range of sources which inform them about services, however the primary source of information about sexual health services for young people is the same as for information about sex – friends. Young people rely upon word of mouth for information about services. Information about a service, once on the grapevine can be hard to influence or correct. One young person's reported experience is likely to be influential in encouraging or discouraging others from making contact.

The HEA research reported important gender difference in talking with friends. Young men were much less likely to use friends as a source of advice and information, and less likely to seek advice from sexual health services and ask for help generally. It is important therefore that information about services is perceived as relevant by young men.

Making Contact
Research reveals that young people entering and continuing sexual relationships frequently delay seeking contraceptive and sexual health advice. Some of these reasons are because they are concerned about the type of service offered and also lack of basic information about the services available.

When young people do make contact they tend to be in crisis. The HEA research identified that young people make an assessment of their situation or problem. Only serious situations warrant a visit to a service and seeking professional advice.

Young people also report that unless they are facing a relevant practical issues at the time they are unlikely to be receptive to information about services.

The young people involved in the HEA research reported a high recall of visiting speakers and that this helped make a judgement about the service.

Implications for producing information about services:

Directories and checklists can play a part in countering negative stories on the grapevine by including young people's views of the service with endorsement as well as recommendations. Directories need to communicate a clear message of reassurance, welcome and security regarding confidentiality.

Information about services must clearly indicate that:
• Services are free and confidential
• Welcomes all young people and especially young men
• Don't have to wait until crisis
Information should be:
• Available and accessible on regular and casual basis
• In a format young people can keep, discreetly and with out fear of embarrassment
• Linked to visiting speakers and outreach workers and group visits to services
Reference
'Promoting Young People's Sexual Health Services' report commissioned by the HEA and Brook Advisory Centres, November 1996