PENGENDALIAN KEHAMILAN DAN PENGGUGURAN DIKALANGAN REMAJA

1. PENGENDALIAN KEHAMILAN DAN PENGGUGURAN DIKALANGAN REMAJA DR ROHANA RAMLI PAKAR O&G, HSB

2. Scope of lecture… Introduction Statistics – global and local data MDG 5 – challenges Teenage pregnancy – risks & implications Management of teenage pregnancy & abortion Prevention strategies

3. DEFINITION • Teenage pregnancy is defined as a teenage girl, usually within the ages of 13-19, becoming pregnant. • Early – below 18 years • Late – above 18

4. Worldwide about 14 million adolescent girls give birth, while about 4.4 million have abortions. Source: People’s Daily (2007)

5. Year Births per 1,000 females Australia 1999 18.1 Canada 1997 20.2 France 1993 7.9 Greece 1995 13.0 Hong Kong 1996 5.8 Italy 1995 6.8 Japan 1996 3.9 Malaysia 1996 13.4 Netherlands 1996 4.1 New Zealand 1998 29.8 Singapore 1997 7.0 Sweden 1996 7.8 United Kingdom 1996 29.7 United States of America 1998 51.1 (ABS, Births Australia – Cat. No.3301.0) Table 1: Pregnancy rate for women aged 15 to 19 years worlwide

6. Statistik ibu tunggal tanpa nikah di Malaysia • Di Malaysia, perangkaan Jabatan Pendaftaran Negara bagi tahun 1999 hingga 2003 mendapati bilangan anak luar nikah yang dilahirkan oleh adalah 70,430 orang dan Selangor mencatatkan bilangan tertinggi iaitu 12,836 orang. • Ini diikuti Perak (9,788), Kuala Lumpur (9,439), Johor (8,920), Sabah (8,435), Negeri Sembilan (4,108), Pahang (3,677), Kedah (3,496), Pulau Pinang (3,412), Melaka (2,707), Kelantan (1,730), Perlis (691), Sarawak (617) dan Terengganu (574). (Mohd. Tamyes 2007).

7. Statistik bilangan bayi yang dilahirkan oleh ibu hamil tanpa nikah mengikut Jabatan Pendaftaran Negara bagi tahun 1999 - 2003

8. Millenium developmental goals 5 (MDG 5) United Nations Development Programme - Malaysia Target 5a: Reduce by three quarters the maternal mortality ratio5.1 Maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel Target 5b: Achieve, by 2015, universal access to reproductive health 5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning 

9. Adolescent Maternity Threatens Achievement of the Millennium Development Goals (MDGs) by 2015 • Since adolescent pregnancy leads to an increased infant and maternal mortality rate, achievement of the following goals will not be met if current trends continue: • Reduce by three-quarters the maternal mortality rate • Reduce by two-thirds the under-five mortality rate • Since in many parts of the world, pregnant girls are not allowed to remain in school, achievement of this goal will also not be met: • Eliminate gender disparity in all levels of education Source: Millennium Project (2005)

10. 30 peratus remaja `terjebak’… Kajian i-Kon membabitkan 100 remaja di sekitar Kuala Lumpur dan Shah Alam, berusia lingkungan 15 tahun ke 30 tahun yang terdiri daripada pelajar, penuntut institusi pengajian tinggi dan sebahagiannya sudah memasuki alam pekerjaan Hasil kajian mendapati: 31 peratus mengaku sudah melakukan seks 23 peratus daripadanya melakukan perbuatanitu ketika belum mencecah usia 15 tahun!

11. Penemuan lain kajian i-Kon: • 57 peratus remaja mengaku pernah bercium, terutama dengan teman istimewa; • 69 peratus remaja pernah berpeluk dengan teman istimewa; • 80 peratus remaja berpegang tangan dengan teman istimewa; • 55 peratus remaja pernah menonton filem lucah; • 43 peratus remaja pernah melayari laman web lucah; • Majoriti remaja iaitu 81 peratus mendapatkan maklumat mengenai seks daripada buku dan majalah (bukan bahan bacaan lucah); • 72 peratus remaja mendapat maklumat seks daripada rakan; • Kira-kira 30 peratus ke 40 peratus remaja mendapat pengetahuan mengenai seks daripada video, majalah dan laman web lucah; • 59 peratus remaja bersetuju penggunaan kondom adalah antara kaedah perancangan keluarga yang berkesan;

12. ALOR SETAR 14 Nov. – Seorang bayi lelaki yang dipercayai baru dilahirkan, ditemui ditinggalkan di dalam sebuah beg di bawah sebatang pokok di belakang Klinik Kesihatan Alor Setar, di sini hari ini. Bayi yang masih bertali pusat itu dijumpai seorang wanita yang melalui kawasan tersebut pukul 12 tengah hari, sebelum menyerahkannya kepada Klinik Kesihatan Alor Setar di sini. Bayi lelaki ditemui dibuang… • INSPEKTOR Najahah Abdul Fatah mendukung bayi yang ditemui di kawasan letak kereta Klinik Kesihatan Kota Setar untuk dibawa ke Hospital Sultanah Bahiyah untuk pemeriksaan semalam. 

13. Teenage pregnacy … • Likely to result in high impact on • Physical • Emotional • psychosocial • most of the time • Unplanned • Unwanted

14. Implications of Adolescent Pregnancy • Social exclusion • Greater reproductive health risks • Increased risk of poverty • Increased risk of maternal and infant mortality Source: Guttmacher Institute (2006)

15. Predisposing Factors for teenage pregnancy • Living with a single parent • Mothers with an adolescent pregnancy • Having older sexually active siblings • Having pregnant/parenting teenage sisters • In a lower SES family / poverty • Being a victim of sexual, physical or emotional abuse • Living in stress, depression and conflict at home

16. TEEN PREGNANCY: LIFE OUTCOMES ON A TEEN MOTHER, HER CHILD AND SIBLINGS • A teen mother is more likely to: • · drop out of school • · have no or low qualifications • · be unemployed or low-paid • · live in poor housing conditions • · suffer from depression which may result in suicide • · live on welfare

17. b) The child of a teen mother is more likely to: • · live in poverty • · grow up without a father • · become a victim of neglect or abuse • · do less well at school • · become involved in crime • · abuse drugs and alcohol • · eventually become a teenage parent and begin the cycle all over again

18. c) The younger sibling of a teen mother is more likely to: • · accept sexual initiation and marriage at a younger age • · place less importance on education and employment

19. The impact of teenage pregnancy • Premature delivery • Small for gestational age (SGA) infant • Anaemia • Hypertensive disorders and its complications • Obstructed labour and operative deliveries • Induced abortions • STDs

20. TEEN PREGNANCY: STIs, HIV AND AIDS • As a result of unprotected sex, young people are also at risk of sexually transmitted diseases and HIV infection. • The highest rates of STIs worldwide are among young people aged 15 to 24. • Two in five new HIV infections globally occur in young people aged 15 to 24. • Surveys from 40 countries show that more than half their young people have misconceptions about how HIV is transmitted. • Married adolescent girls generally are unable to negotiate condom use or to refuse sexual relations. They are often married to older men with more sexual experience, which puts them at risk of contracting STIs, including HIV.

21. Abortion or Termination of pregnancy • Teenage pregnancy is often viewed as unplanned and unwanted. • Approximately 40% of teenagers in the UK terminate their pregnancies. • Teenagers are more likely to have later terminations, are more likely to resort to unskilled practitioners and dangerous methods and, when complications do arise, they are more likely to present late. • Forbidden by Islamic Laws

22. Who is more likely to abort? • Those who are more educationally ambitious • From higher socioeconomic backgrounds • Are from less religious families • Have parents and peers who support abortion (Hofferth & Hayes,1987)

23. Teenage abortion risks • Damage to Uterus • Infection and sepsis • Drug Reactions • Bleeding • Discharge • Chronic pelvic pain • Pelvic Inflammatory Disease

24. Managementof teenage pregnancies • General measures • we must ensure that teenage mothers receive supportive care and are directed towards the social support they need. • Smoking cessation should be targeted • attendance at an antenatal clinic encouraged. • In addition, effective postnatal counselling, particularly regarding contraception, can help prevent subsequent pregnancies and STIs.

25. Antenatal care • Adolescents should be encouraged to attend for antenatal care from an early stage as attendance is frequently poor. • Gestational age should be confirmed with early ultrasound wherever possible, although many teenagers present late. • Take opportunity to offer advice on nutrition and adverse habits such as smoking and alcohol use. • Social support is important and many teenagers may benefit from an early referral to a specialist midwife or social worker. • Information regarding antenatal care and labour should be provided in a format that is accessible and easily understood. • Caregivers should be sensitive to the potential challenges presented by written information, as a significant number of teenagers have literacy difficulties.

26. Care during labour and delivery • Where age is the only risk factor, management is usually the same as for other labouring women. • However, in very young adolescents there is an increased likelihood of obstructed labour because of a small, immature pelvis.

27. Postnatal management • Teenage mothers are more likely to have unhealthy habits that place the infant at greater risk of inadequate growth, infection and chemical dependence. • Below the age of 20 years, the younger the mother, the greater the risk of her infant dying during the first year of life. Infant feeding, growth and safety need to be observed. • Special attention, particularly discussion regarding financial issues, returning to school and contraceptive advice.

28. Care of the newborn • The newborn is at increased risk of neglect, abuse and dumped • Breastfeeding rate may be low • Risk of malnutrition • Discussion on adoption if not keen to take care of the baby • Shelter homes for unwanted babies

29. How to reduce teenage pregnancy? Preventive strategies Education - sexual health & religion Parental involvement Peer group support –rakanmuda, PROSTAR Community programme – sports, recreational activities Government – law enforcement Family planning

30. Education is Key • Education should be started before the age of 14, when young people become sexually active. • Information should be provided for teenagers about avoiding unintended pregnancies, including detailed information about contraception and its side effects. • There should be better management and training for nurses, so they can deal sympathetically with teenagers requiring contraception and provide the necessary information and education campaigns that take away the stigma of teenage sexuality, so that adolescents are not afraid to ask for contraception. • All teenagers should not just be allowed to remain in school and to return to school after birth, but they should be strongly encouraged to do so. Source: People's Daily (2007)

31. FAMILY PLANNING AND YOUNG PEOPLE: CHALLENGES • Many societies, including in Malaysia, disapprove premarital sex. • Young people have limited or no access to education and information on reproductive sexual health care. • Modern contraceptive use among adolescents is generally low, and decreases with economic status. • Fewer than 5% of the poorest young use modern contraception. • Young women consistently report less contraceptive usage than men, evidence of their unequal power in negotiating safer sex or restrictions on their access to services (such as lack of information, shame, laws, health provider attitudes and practices, or social norms).

32. Cont. • Young people may hesitate to visit clinics because of lack of privacy and confidentiality, inconvenient locations and hours, high costs, limited contraceptive choices and supplies, and perhaps most importantly, negative or judgmental provider attitudes. • Laws and policies also may restrict adolescents’ access to information and services, for example, by limiting family planning to married people or requiring parental or spousal consent. • A basic challenge in advocacy, especially in traditional societies, is the taboo on public discussion of sexual issues, including the fact that many young people are sexually active before marriage.

33. The Boys • Often forgotten • A research gap • Who are they? • Research shows that they have a very similar profile to the girls.

34. Key strategies for reaching and serving youth include: • developing youth-friendly services; • involving youth in program design, implementation, and evaluation; • training providers to attend to the special needs and concerns of adolescents; • encouraging community advocacy efforts to support youth development and promote positive adolescent health behaviors • implementing programs that provide complete and accurate sexual health information • incorporating skills-building exercises into youth programs to help young people improve their self-esteem, develop their communication skills about sexuality, and strengthen their ability to negotiate safer sexual practices.

35. Recommendations • Focus on women and girl’s reproductive health and education outcomes. • Provide Emergent obstetric care. • The provision of reproductive health care services to teens requires sensitivity to the special needs of this age-group including knowing about laws about confidentiality and services for birth control, pregnancy, abortion, and adoption. Source: Stanhope and Lancaster (2006)

36. Successful Pregnancy Prevention Programs • Include collaborative approaches by the teens, their families, teachers, health professionals, businesses, the faith community, lawmakers, and other community organizations. Source: Brandis, Sattley, and Mamo (2005)

37. The most effective prevention is avoidance of sex before marriage Teach the girl to say NO

38. Every minute, somewhere in the world a young mother dies from complications in pregnancy and childbirth. Four million babies die each year within their first 28 days of life, and another 3.3 million are stillborn. Millions of lives could be saved using the knowledge we have today, but the challenge is to transform this knowledge into action. Source: World Health Organization (WHO) (2006)

39. Towards Safe Motherhood “ A woman’s ability to have a SAFE and healthy pregnancy and childbirth.” UPDATE ON CONTRACEPTION COURSE

40. THANK YOU