Family nurses form a therapeutic relationship with clients

Planned Parenting

20th June 2014

Most people would agree that becoming a parent means embarking on one of the toughest jobs in the world. The struggle to identify every cry and need of a young baby; the patience of a saint to deal with the volcanic tantrum of a toddler – having a child can test the mettle of the most confident and assured of people. But if you’re a teenager, points out Alex Gray, it can be a particularly daunting task…

Every year in England an estimated 30,000 teenagers fall pregnant. For some, it’s a planned event, for others, a contraceptive failure. Research also shows that the likelihood of teenage pregnancy runs higher in areas where there is social deprivation. Young people who are in or leaving care, or underachieving at school are more likely to become pregnant. According to the Department of Education’s Teenage Pregnancy Strategy, while for some young women having a child when young can represent a positive turning point in their lives, for many more bringing up a child is incredibly difficult. It often results in poor outcomes for both the teenage parent and the child, in terms of the baby’s health and development, the mother’s emotional health and well-being, and the likelihood of both the parent and child living in long-term poverty.

Amber (not her real name) is one of the young mums for whom having a child represented an enormous challenge. She was 16 when she fell pregnant, early into a relationship. Amber spent much of her early life in foster homes after her mother abandoned her. Her attendance at school was sporadic and she misused drugs and alcohol. She has been in trouble with the police many times. It was a lifestyle that could have meant her child ending up in child protection. But at 24 weeks of pregnancy, Amber joined a voluntary, free programme called the Family Nurse Partnership, which was to change her life for the better.

The Family Nurse Partnership is a government-run programme that provides intensive support for all first-time mothers aged 19 and under until their child reaches two years old. It’s a big commitment; the family nurse – usually a trained midwife or health visitor – visits the mother on a weekly basis to begin with, and then fortnightly. They expect the same commitment from the mother, and so begins a therapeutic relationship that has at its core the well-being of mother and child. “The theory behind the programme is that there is a window of opportunity in pregnancy when there is the motivation to change,” explains Judith Wright, Family Nurse Partnership Supervisor / Child Health lead at the Herts Community NHS Trust. “Because we begin that therapeutic relationship before the baby is born, there is a much higher chance of helping the mum make the changes that we want.”

Those changes include stopping smoking in pregnancy, better nutrition for the mother, and building a network of support: “Diet, smoking, stress-levels during pregnancy, we now know that these have a huge post-natal impact,” explains Judith. “But the fact of their pregnancy is not a tragedy. In fact, it is a period in time where we know the teenagers will take on the commitment to be the best parents they can be and to change some of the cycles that may have been in their families for years.”

Judith and her team work with a broad spectrum of teenagers. Three quarters are aged 16 to 18, whilst 9 per cent are 15 years and under. Fifty per cent have partners, and just over half were in college or work when they fell pregnant. The team works closely with other agencies, including social care, child centres, and housing, if they are also involved with the young person. Crucially, the programme is open to all. Some need more support than others, but all benefit from the up-to-date guidance the programme delivers. “One of the biggest challenges is that you’re working with a teenager who is still a child themselves,” says Judith. “The first thing we say is congratulations, you’ve decided to go ahead with your pregnancy. A lot of them haven”t been congratulated; they have just felt shame.” Because of her difficult background, Amber has emotional health issues. She can be economical with the truth, manipulative and at times attention seeking. But she wants to be a good mum. The Family Nurse Partnership is helping her to make lifestyle choices which will give her and her child the best possible start in life. It’s a highly structured programme. There’s a lot of work done on foetus development, for instance, followed by ‘baby cues’, helping a mother understand what her baby is trying to communicate: “We know that if a mother feels she can attend to a baby’s needs then she’s more confident and the baby feels more secure,” explains Judith. But the programme also agenda matches the mother. In other words, if she wants to go back into education or work, the family nurse will talk them through the various childcare arrangements available to them. “We’re not there to tell them what to do,” states Judith. “We’re sharing information with them, but we always ask first, is it ok if I tell you about this? And we’re open and honest about our role in safeguarding the child, having built that relationship we can challenge if that’s not happening.” The programme also welcomes the involvement of fathers and family members, as much as possible accommodating the timetable of the girls for meetings.

Amber faced a series of challenges during her pregnancy and beyond. She was made homeless, she split up with her partner, and took an overdose, but the family nurse was there every step of the way. Family nurses see themselves as the ‘scaffolding’ around the young mother’s life, and a lot of work is done on raising the aspirations and self-efficacy of the girls. “As well as raising their self-belief and hope,” adds Judith. “we do a lot of goal setting: where do would you like to see yourself in the future? What steps are you going to take to get there? These girls want to get off benefits, they want to carry on their education, they want to work and provide a secure home for their baby.”

Outcomes are improved for both young mother and child

And the approach is working. The evaluation of first ten pilot sites carried out by Birkbeck, University of London found that mothers participating in the Family Nurse Partnership: stopped smoking in pregnancy or smoked fewer cigarettes, initiated breast-feeding at a high rate; coped better with pregnancy, labour and parenthood; had increased confidence and aspirations for the future; were returning to education and taking up paid employment; were very positive about their parenting capacity and reported high levels of warm parenting. In addition, Family Nurse Partnership children appear to be developing in line with the general population. Babies and toddlers in this situation usually fare much worse. Because of its success, expansion of the programme has been rapid. There are currently 13,000 available places within 97 sites and the government is committed to increasing that to 16,000 by 2015. In Hertfordshire, the programme, which currently runs north Hertfordshire, Stevenage, Welwyn Garden City and Hatfield, is about to be expanded to include West Hertfordshire covering Watford and Hemel Hempstead.

Amber is settled and back with her partner. She is calmer, has begun to believe in herself as a mother and her now two-year-old boy is developmentally on track with his peers. “You can’t put it down any particular bit of the materials or how we deliver, I think it’s the relationship. It’s not giving up on her, believing in her,” says Judith. “I strongly believe that she would have struggled to parent her child if the family nurse hadn’t been able to see the potential in her.”

Judith is enthusiastic about the process. “I love working with teenage mums. It brings a lot of challenges but they can be really good parents. They’re not laissez-faire, they don’t want the baby to be their friend, they are good at routines and boundary setting. As family nurses we are so privileged to be able to share that journey with them, while helping them be the best parents they can be.”

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