While it is acknowledged that not all teenage pregnancies are unplanned or result in a substandard or negative life-course for mother and/or child (Duncan et al, 2010), there is a substantial body of research illustrating poorer outcomes and health inequalities for teenage pregnancies (Cantwell et al, 2011; Browne and Jackson, 2013; Chang et al, 2013). It is more likely that the baby will be born prematurely; have a low birthweight; be admitted to hospital as a result of an accident or gastroenteritis; and have a 60% higher mortality rate than babies born to mothers aged 20–39 (Department for Children, Schools and Families (DCSF) and Department of Health (DH), 2009; Family Nurse Partnership (FNP), 2013). Compared to older mothers, teenage mothers are three times more likely to smoke throughout pregnancy; a third less likely to breastfeed and three times more likely to develop postnatal depression (DCSF and DH, 2009). Teenage mothers often report feeling stigmatised, isolated and embarrassed (Rudoe and Thomson, 2009), which may result in concealing their pregnancy, booking late and having poorer engagement and attendance with antenatal care (DCSF and DH, 2009). Lack of support, education, information and knowledge about pregnancy may also be a factor for these young people (Brook, 2011).
Teenage mothers are defined as a vulnerable group in maternity guidelines (National Institute for Health and Care Excellence (NICE), 2010). Their vulnerability may be further exacerbated because of social factors such as poverty, poor living conditions, lack of education or access to services (Department of Health, Social Services and Public Safety Northern Ireland (DHSSPSNI), 2011; DHSSPSNI, 2013).
There is a growing body of evidence highlighting the impact that intrauterine and early years' experiences have on a child's long-term development and outcomes (National Scientific Council on the Developing Child, 2010). A child's early years' experiences and the environment in which they live have a significant influence on the developing brain (Szyf, 2009; Meaney, 2010). The rapid development in the womb and early years lays down the foundations for longer-term physical, emotional, intellectual and mental development and wellbeing (Allen, 2011). Supporting teenage mothers is therefore of paramount importance during pregnancy and in the early years of motherhood to promote better outcomes for mother and baby.
Teenage pregnancy and public health focus
Teenage pregnancy has been highlighted as a public health issue due to the associated economic, social and health costs and is on many professional and government agendas (DHSSPSNI, 2002; Royal College of Obstetrics and Gynaecology, 2007; DCSF and DH, 2010). Public health initiatives encompass integrated strategies to address not only health improvement for whole populations or specific targeted groups (Gov.uk, 2013), but also to improve people's lifestyles and life circumstances (Naidoo and Wills, 2009; Public Health Agency (PHA), 2013). Meeting the needs of young parents and their children more effectively will improve their life chances (Davis et al, 2013).
Needs assessment is a fundamental part of routine health and maternity care, focusing on both population and individual needs (Cowley, 2008). Identified needs for pregnant teenagers include:
Midwifery involvement
Midwives, as the lead professionals in maternity care are involved in the care of all pregnant women, including teenage mothers-to-be. They are in a unique position to have an impact on maternal and infant health during pregnancy, birth and in the postnatal period (McNeill et al, 2012). As a universal service and through the delivery of primary care, midwives can recognise and respond to the needs of the individual women for whom they provide care.
Midwives also play an important role in health promotion and public health initiatives (Public Health England and DH, 2013). Many maternity public health initiatives are led by midwives, and are based on research and client feedback about the needs of particular groups of women as well as evidence of what works in practice. This has led to an increase in the number of specialist midwives working with particularly vulnerable or specialist groups, for example diabetes specialist midwives and bereavement specialist midwives. There has also been an increasing number of specialist midwives working with teenagers and there is a National Teenage Pregnancy Midwifery Network across the UK to communicate and share best practice (Best Beginnings, 2013). Since 2006 midwives have been working on a public health preventative programme (Family Nurse Partnership (FNP)) in the UK, to help support young, first-time mothers.
Family Nurse Partnership
The FNP is a maternal and early years' public health preventative programme, which provides ongoing intensive support through home visits led by specially trained health professionals, who work with a caseload of women (FNP, 2013). It was originally designed to support young first time, low income mothers during pregnancy and until the child reaches 2 years old (Olds et al, 2004). The programme was developed in America in the 1970s and was introduced in England in 2006 and in Northern Ireland in 2010 (NI Executive, 2010; Allen, 2011) where it is still in the pilot stage with the first cohort of participants currently completing the programme.
This programme is designed to support young mothers (and fathers) to achieve three main aims: to improve their pregnancy outcomes, so that their infant has the best start in life; to improve their child's health and development by developing their parenting knowledge and skills; and to improve parents' economic self-sufficiency (Mejdoubi et al, 2011; Mejdoubi et al, 2013). The programme also works with young mothers to enable them to build a positive attachment and relationship with their infant; understand their infant's needs; make positive lifestyle choices; build the parent's self-efficacy and help them build positive relationships (FNP, 2013). It involves weekly or fortnightly home visits which usually last 1–1.5 hours. Young mothers-to-be are usually recruited into the programme by their midwives if it is clear that they meet the eligibility criteria. They can also be referred onto the programme by social workers, GPs, teen pregnancy services and in some cases can self-refer.
In the UK, the FNP is delivered by health professionals, including nurses, midwives and health visitors. It is not a traditional midwifery role as FNP practitioners have allocated workloads and work intensively with individuals, their infants and, where relevant, with others over a 2–3 year period. The clinical knowledge and skills, coupled with an empowering approach to support and enable women to make informed choices about their care, make midwives well suited to this role. Research also indicates that continuity of care improves outcomes for women and their children and increases worker and client satisfaction (Sandall et al, 2009; Williams et al, 2010).
However the extended role, intense focus and small caseload can be a challenge for midwives and evaluations to date have highlighted the demands of the role, the intensity of the working relationships and the need for flexibility to travel are key issues for staff (Schrader-McMillan et al, 2012). Maintaining continuity of care can also be a challenge with a workforce who may require family friendly working arrangements as they themselves may be mothers or have dependants.
Midwives are trained to provide care to the end of the puerperium, approximately 6 weeks after birth (DH, 2010). The role of a FNP practitioner requires additional knowledge and skills for midwives as it extends beyond the puerperium to 2–3 years postnatally. All FNP practitioners have to undertake specific training to prepare for this role (Robinson et al, 2013). The learning programme is structured and builds incrementally during for the first 15 months of a nurse's recruitment to the role. It consists of a combination of face-to-face learning events (often residential), team-based learning activities, and skills practice (Robinson et al, 2013; Family Nurse Partnership, 2014). The success of the FNP is founded on positive practitioner/mother relationships based on trust and respect, which has been evaluated as the most important factor in maintaining engagement (Sawyer et al, 2013). This is reinforced by the value young people put on staff attitudes (Duggan and Adejumo, 2012) as well as shared goals, trust, acceptance, confidentiality and the ability to communicate effectively (Naidoo and Wills, 2010; Brook, 2011).
The Family Nurse Partnership within a public health focus
The FNP incorporates three principles of public health, namely collaboration, partnership and equity (Cowley, 2008).
Collaboration
One of the six key topic areas in collaboration is ‘Other Health and Human Services’, which supports young mothers to access other services they may need. Therefore, practitioners are required to have a broad knowledge of services available and aid young people to understand and use the range of help and support available and relevant to their needs. In the longer-term this will support young mothers to be more knowledgeable and confident in accessing and using services in the future.
Partnership
Partnership is the cornerstone to this programme, reflecting findings from research about the importance of user participation and involvement in their care (Naidoo and Wills, 2010). The partnership between the FNP practitioner and the young person is one of the most reported factors by participants about the programme's success (Trueland, 2013). The visits cover a number of topics (Table 1), which are explored through a psychoeducational approach (Barnes et al, 2011) and are designed in partnership with young mothers who direct what they want to cover (Belfast Health and Social Care Trust, 2013). This approach promotes choice, empowerment, is woman-centred and tailored to the needs of the individual (Wave Trust, 2011). Through working in partnership and adopting an empowering approach the programme aims to promote, encourage and develop self-sufficiency and self-efficacy. One example is the focus on sex education so young women know how to take control of their family planning and sexual health in the future (Chandra-Mouli et al, 2014; Kuo et al, 2014) so there are fewer unplanned pregnancies.
| Personal health | Building positive health practices |
| Environmental health | Managing home and neighbourhood to ensure healthy child development |
| Life course development | Working towards future aspirations and goals, including education and employment |
| Maternal role | Developing the skills and knowledge to promote the health and development of their child |
| Family and friends | Developing the skills to build positive relationships and enhance social support |
| Other health and human services | Enabling access to other services |
Equity
Equity is an important principle in public health in that it aims to improve and protect health and wellbeing for the whole population, but recognises the need to target specific groups where there is evidence of health inequalities and a greater risk of poorer outcomes (Hurst, 2008). Teenage mothers are recognised as such a group and the FNP aims to reduce health inequalities and improve outcomes for both the teenage mother and her child by engaging a psychoeducational approach and providing intensive support through home visits, materials and activities (Trueland, 2013).
The FNP also aims to improve teenage mothers' access to, and use of, services as well as improving their economic self-sufficiency and building positive relationships with others. It is hoped that a by-product of this is that young mothers will become more involved within their local community. While the FNP is essentially an individually-focused service, it does support the principles of community development in its approach (self-help, ownership and control) and greater integration and engagement of young people with their local community through developing the skills to build positive relationships and enhance social support, and enabling access to other services.
Impact of Family Nurse Partnership
Evaluation of the effectiveness and value for money of clinical interventions and public services are essential (Schrader-McMillan et al, 2012; Olds et al, 2013). Home visiting programmes are costly and governments need to ensure they are justified from an economic perspective (McIntosh et al, 2009). There is evidence of the effectiveness and value for money of the FNP from America based on more than 30 years of research, including three randomised controlled trials (Olds et al, 2004; Olds et al, 2007; Olds et al, 2010; Kitzman et al, 2010). These studies have shown a range of benefits, such as improved antenatal health, fewer childhood injuries and fewer subsequent pregnancies (Nurse Family Partnership, 2011). Many of the outcomes were strongest for the most vulnerable women who were young, unmarried and on low income (Olds, 2007). Several studies also report that the FNP results in significant financial benefits to the individual, the government and wider society (Owen-Jones et al, 2013) with mothers in the programme having increased levels of employment and a decreased dependency on the government for assistance (Olds et al, 2010).
However, it is important to recognise that the context for delivery of the programme between the USA and the UK are very different both culturally and in terms of public service provision. It is therefore important that there is robust evaluation of the effectiveness of the FNP in the UK context. There is a considerable body of evidence to suggest the FNP is an effective initiative in addressing the health needs of teenage mothers in America. While there is some evidence suggesting improved health outcomes for teenage mothers participating in FNPs in the UK, this is by no means conclusive and requires further longitudinal evaluation to measure its effectiveness. There is currently an ongoing randomised controlled trial (RCT) being carried out on the FNP in England, which is due to complete in 2014 (Sanders et al, 2011). The Northern Irish programme is still in the pilot phase but it has been suggested that for every £1 invested in the programme there will be a £2.88 saving in the longer-term (PHA, 2011) although this has yet to be proven. Yearly monitoring is ongoing in Northern Ireland against key indicators, such as breastfeeding, attrition and smoking rates.
Preliminary data from the UK shows a positive influence on smoking cessation, breastfeeding rates and educational attainment and employment status rates (Schrader-McMillan et al, 2012). While feedback and initial impact appears positive, it is not yet possible to conclusively establish firm links between FNP and particular outcomes (Ormston and McConville, 2012). While the final outcomes of RCTs may or may not provide more conclusive evidence, it is important that the UK Government understands that FNP is in its infancy in implementation terms and the long-term benefits may not be seen for several years.
There is an increased focus on the cost of services on the public purse (Arzymanow and Manning, 2013). Demand always has, and some suggest always will, outweigh supply and there is a need for politicians to be honest about what can be delivered (Manning, 2013). It is easier for politicians to support short-term, results-driven projects rather than longer-term, preventative interventions as these do not produce quick tangible results which are popular with voters (Baggott, 2000).
Some critics suggest that investment in initiatives, such as the FNP are diverting resources from core health services (Trueland, 2012). Research into FNP workforce issues (Robinson et al, 2013) found that over 75% of FNP practitioners and 90% of supervisors come from a health visiting background and concerns have been expressed that universal services are losing good staff to the FNP. FNP practitioners have caseloads of 25, while health visitors carry much larger caseloads, potentially in the region of 300–400 service users (Robinson et al, 2013). In a survey of FNP practitioners, some reported feeling other health professionals view FNP as an easy option, however they also stated their work was equally challenging due to the emotional intensity and nature of the work (Robinson et al, 2013).
There are views that the FNP could potentially be integrated with mainstream services, which would promote better understanding of the FNP and learning could be shared with colleagues and inform their practice (NHS Commissioning Board, 2012). While midwives are a small percentage of FNP practitioners, there are similar issues within the midwifery workforce. During the period 2001–2012, birth rates in England have risen by 23%, but the number of midwives has only increased by 19% (Royal College of Midwives, 2013) and diversion of midwives to the FNP could impact on the capacity of the profession to maintain high standards of maternity care which is their core role.
Conclusion
One of the aims of the FNP is to improve pregnancy outcomes and midwives should be effective in supporting this aspect of the programme. However the initiative extends the midwife's role and requires them to develop new knowledge and skills and work in different ways. It is unlikely all midwives would be suited to this role or indeed wish to undertake it. Training and support are essential to help midwives adapt to and undertake this role effectively. There are aspects of the FNP that could potentially be incorporated into mainstream midwifery practice, particularly in antenatal education, which could strengthen preparation of all expectant parents for birth and parenthood.
While there would be resource implications, this approach could potentially extend the reach of improving outcomes for all young first time mothers through existing universal services which in the longer term could be cost effective. Further work would be required to pilot and evaluate such an approach.