THE TRUTH ABOUT TEENAGE PREGNANCIES

DR NIK RUBIAH NIK ABDUL RASHID MD (UKM)/ MCGP(MAL)/ FRACGP (AUST)/ MPH (UKM) FAMILY HEALTH DEVELOPMENT DIVISION MINISTRY OF HEALTH MALAYSIA 17th FAMILY MEDICINE CONFERENCE 2013 4-6/7/13 KUANTAN, PAHANG

TABLE OF CONTENT
STATISTICS ON ADOLESCENTS - socio demographic profile - morbidities and mortalities - teen pregnancies and maternal mortalities WHAT WORKS RECOMMENDATIONS LESSON LEARNT FROM MATERNAL MORTALITY REVIEW

MASALAH REMAJA

STATISTIK
Populasi Remaja Tahun 2012
Lelaki 2,797,200 Perempuan 2,660,100 Jumlah 5,457,300

i.

Perkhidmatan Kesihatan Remaja

Lelaki Kedatangan Remaja 10-19 tahun ke fasiliti kesihatan (2012) Perempuan Jumlah

1,689,918
67,547 Kecederaan dan keracunan (42.9%)

1,801,422
79,460 Kehamilan & faktor berkaitan kehamilan (40.5%).

3,491,340

ii. Bilangan Kemasukan Remaja 1219 tahun ke Hospital (2011) & Penyebab Utama

147,007

Trend of Top 10 Morbidity for Outpatient Attendances among Adolescent 10 to 19 at Public Health Facilities 2012 (P) Morbidity Diseases of the respiratory system n, % Male Morbidity n, % Female 838,514 (46.55%) 258,123 (14.33%) 134,609 (7.47%) 115,849 (6.43%)

817,404 Diseases of the respiratory system (48.37%) 222,950 (13.19%) Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 118,592 Disease of digestive system (7.02%) 111,318 Diseases of the Skin and Subcutaneous (6.59%) Tissue

Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified Diseases of the Skin and Subcutaneous Tissue

Morbiditi utama pesakit luar lelaki/perempuan Disease of digestive system 1. respiratory infection 2. Nonand specific signs and Certain infectious parasitic diseases symptoms

104,341 Factors influencing health status and (6.17%) contact with health services
88,577 Certain infectious and parasitic diseases (5.24%)

102,703 (5.70%)
88,797 (4.93%)

Factors influencing health status and contact with health services Injury, poisoning and certain other consequences of external causes Diseases of the eye and adnexa Diseases of the Musculoskeletal System and Connective Tissue Diseases of the ear and mastoid process

non specific sign symptoms mungkin 58,264 85,996 Injury, poisoning andand certain other (5.09%) consequences external causes disebabkanofmasalah berkaitan dengan (3.23%) perkembangan remaja 47,586 Disease of the genitourinary system (2.82%)
47,204 (2.62%)

Latihan HEADSS/ kesihatan & kaunseling remaja 28,154 45,235 Diseases of the eye and adnexa (1.67%) (2.51%) perlu di tingkatkan utk meningkatkan pengesanan
27,860 Diseasesmorbiditi specific 46.55%) of the Musculoskeletal System and (1.65%) Connective Tissue 29,101 (1.62%) 5
1,801,422

STATISTIK
Seks di kalangan remaja :
0.9% (1994) ; 2.2% (2004) ; 6.5% (2010) 13 (2006), 14 (2008), 15 (2009)
- Jabatan Statistik - Kajian LPPKN/ KKM

Kadar kesuburan spesifik (ASFR) remaja berumur 15-19 tahun.

Pengetahuan mengenai STI/ organ reproduktif remaja 13- 24 yr Contraceptive, CPR, 2004

47.0 % 59.6% 0%
- LPPKN, 2004

51.9% (all methods); 35% (modern methods)

- LPPKN, 2004

Kadar Incidence HIV Remaja 1319 thn

1.147 / 100,000 populasi 13-19 thn (2010) 1.46/ 100,000 populasi 13-19 thn (2011)
- Bah. Kawalan Penyakit 2012

Kadar Incidence STI Remaja 13- 19 thn

1.12/ 100,000 populasi 13-19 thn (2010) 1.06/ 100,000 populasi 13-19 thn (2011)
- Surveillance data Sektor HIV/AIDS- Bah Kawalan Penyakit

Penyebab kematian Utama Remaja

Kemalangan - 34.8% daripada semua kematian remaja

- Jabatan Perangkaan, 2008

STATISTIK
Prevalen merokok (remaja 13-15 tahun) Prevalen remaja pernah merokok (ever smokers) 33.1% (2003), 30.0% (2009).
(2003) Lelaki Perempuan 36.3% 4.25% (2009) 30.9% 5.3%.
- Global Youth Tobacco Surveys (GYTS)

Morbiditi mental (5-15 tahun)

13% (1996) ; 19.4% (2006) ; 20.0% (2011)

- Tinjauan Kesihatan dan Morbiditi Kebangsaan

Kes Rogol Melibatkan Suspek < 18 tahun Jumlah tangkapan Jenayah Juvana < 18 tahun Statistik Kelahiran Anak Tak Sah Taraf melibatkan Ibu <20 tahun

342 (2006) ; 342 (2008) ; 709 (2010)

- PDRM 2011

5,439 (2011) ; 4,662 (Jan- Okt 2012)

- PDRM 2012

14527 (2009) ; 14743 (2010) ; 14964 (2011)

- Jabatan Pendaftaran 2012

Source: World Health Statistic 2013, WHO

6.5

Source: http://www.statistics.gov.my/portal/download_Eco nomics/files/DATA_SERIES/2011/pdf/21Perangk aan_Penduduk.pdf Department of Statistics, Malaysia, 2011 Others includes non citizens

Sumber : 1. Kajian Penduduk dan Keluarga Malaysia, LPPKN, 1994 & 2004 2. National Health and Morbidity Survey III, MOH, 1996 3. Premarital sexual intercourse among adolescent in Malaysia, Lee et al , 2006 4. Health Status of Youth in Malaysia, MOH, LPPKN, 2010

Trend Remaja Hamil (10 -19 Tahun) Di Malaysia Bagi Tahun 2010 (Jul-Dis) 2013 (Jan-Mac)
2012 Purata 1,500 kes sebulan 4,183 (22%) tidak berkahwin. Jan Mac 2013 1,048 (25%) tidak berkahwin

10 Sumber: Reten Manual Statistik Remaja Hamil JKN 2012

STATISTIK REMAJA HAMIL (10-19 TAHUN) MENGIKUT NEGERI BAGI TAHUN 2012 Negeri paling tinggi remaja hamil: Perak, Selangor, Johor, Pahang, Sarawak & Sabah

Perlu tingkatkan pengetahuan, sikap dan pengendalian kesihatan SRH dan Kemahiran Kesihatan Mental

11

Sumber: Reten Manual Statistik Remaja Hamil JKN 2012

MATERNAL DEATH BY AGE GROUP, 2001-2005

Age Group
15-19 20-24 25-29 30-34 35-39

2001
n 5 17 41 45 36 % 3.0 10.0 24.1 26.5 21.1 n 15 29 27 37

2002
% 11.4 22.2 20.6 28.2 n 4 10 24 39 26

2003
% 3.3 8.2 19.6 32.0 21.3 n 2 18 26 34 31

2004
% 1.6 14.7 21.2 27.6 25.2 n 6 11 31 31 29

2005
% 4.8 8.8 24.8 24.8 23.2

40-44
45-49 Total

20
6 170

11.8
3.5 100.0

21
2 131.0

16.0
1.5 100.0

16
3 122

13.1
2.5 100.0

11
1 123

8.9
0.8 100.0

15
2 125

12.0
1.6 100.0

Sources : Report on The Confidential Enquiries into Maternal Death in Malaysia 2001-2005, (CEMD), 2008

BIL. KEMATIAN REMAJA HAMIL 13-19 TAHUN MENGIKUT KLASIFIKASI 2009-2013

13 Sources : Family Health Development Division, MOH 2013

17 DEATH AMONG ADOLESCENTS (13 19 yr), 2012

Negeri (8) (4) (2) (1) (1) (1) Sabah Johor Sarawak Kelantan Negeri Sembilan Kedah

Warganegara Bangsa Status Perkahwinan Unbooked Bayi mati Causes

10/ 17 (59%) Melayu (5), Iban (3), Bajau (2), Suluk (5), Cina (2) 6/17 (35.3%) tidak berkahwin 6/17 (35.3%) unbooked 11/17 (65 %) abortion, IUD 9 Preventable (53%) 8 Non Preventable (47%)

Sources : Family Health Development Division, MOH 2013

17 DEATH AMONG ADOLESCENTS (13 19 yr), 2012

State District Age Citizen Ethnic Marital Status Student / Work Antenatal Booking Cause Tawau 16 NC (legal) Bajau M Sandakan 16 NC (legal)* Iban M
(not register)

Sabah
Kota Kinabalu 19 NC (IIlegal)* Bajau M Kota Kinabalu 17 C Suluk M Tawau 17 NC Suluk M Lahad Datu 17 NC Suluk M Lahad Datu 19 NC Solu, Philliphine M

Sandakan
17 NC Suluk M

NW
(housewife )

NW
(housewife)

NW
(housewife)

NW
(housewife)

NW
(housewife)

NW
(housewife)

NW
(housewife)

NW
(housewife)

22/52 (GP) PPH

8/52 (KD) Unkown

No ANC Bleeding Placenta Preavia Major

Preventable

16/52 (hosp) ARDS with sepsis

Acute Pulmonary Oedema

NonPreventable

Eclampsia in Pregnancy

Puerperal Sepsis with Aspiration Pneumonia

Preventable

16/52 (hosp) Leptospirosis

Preventable

Preventabl e

NonPreventable

Preventable

Preventable

NonPreventable

Baby Outcome

Baby alive (Home)

IUD (antenatal)

Baby alive (Home)

Baby alive (LSCS)

FSB (LSCS)

Antenatal

Baby alive (LSCS)

MSB (Hospital)

Sources : Family Health Development Division, MOH 2013

17 DEATH AMONG ADOLESCENTS (13 19 yr), 2012

State
District Kulai

Johor
Kluang Muar

Age
Citizen Ethnic Marital Status Student / Work

18
C Chinese Not Married W (kedai runcit)

19
C Malay Not Married W (Factory)

18
C Malay Not Married NW (housewife)

13
C Chinese Not Married Student (Form 1)

Antenatal Booking
Cause

No ANC
Haemorhagic Shock Preventable

No ANC
Pueperal Sepsis

16/52 (KK)
Efective Endocarditis with PE Preventable

22/52 (Hosp)
Pelvic Fx w Massive retroperitoneal bleeding assoc. wabruptic Non preventable Antenatal

Preventable

Preventable

Baby Outcome

Abortion (Hosp )

MSB (Home delivery)

Baby alive (Hosp)

Sources : Family Health Development Division, MOH 2013

17 DEATH AMONG ADOLESCENTS (13 19 yr), 2012

State
District Bintulu Swak* Song

Kedah
Baling

Kelantan
K. Krai

N9
Sremban

Age
Citizen Ethnic Marital Status Student / Work

16
C Iban Not Married Student

19
C Iban M NW (housewife) 6/52 (home) Unknown (non obstetric causes) Non preventable Antenatal

18
C Malay M NW (housewife) 16/52 (KK) Dengue

19
C Malay M NW (housewife) 11/52(KK) Endocarditis

19
C Malay Not married W (berniaga) 32/52 (KK) Candidiasis & DIVC Non preventable Baby alive (Hosp)

Antenatal Booking Cause

14/52 (Hosp) Paraquat Poisoning Non preventable Abortion (Hosp)

Preventable

Non Preventable IUD (antenatal )

Preventable

Baby Outcome

IUD (antenatal)

Sources : Family Health Development Division, MOH 2013

MATERNAL MORTALITY RATE (MMR) AMONG ADOLESCENT 10-19 YR, 1995-2010

Tahun
1995 1996 2009 2010

Frequencies
4 4 6 9

Live birth
13,110 13,565 18,911 19,018

MMR
30.5 29.4 31.72 47.32

Sources : 1.CEMD Report Malaysia 1997-2000, 2008 2. Family Health Development Division, MOH 2013

Example: Risk and protective factors

WHO 2001

Strengths-based model

Cahill, Beadle & Coffey 2010

Risk and protective factors exist at multiple levels

Macro/institutional Community

School/work Family Health risk behaviour in adolescence Positive Youth Development

Peers

Individual

Adapted from Blum and Mmari 2005

RECOMMENDATION
Individu
Memperkasakan Remaja (Pendidikan Agama, Sexual Reproductive Health) Kemahiran Asertif (Stress Mx, Anger Mx dll) Melibatkan diri dengan aktiviti positif

Ibubapa
Increase Connectedness to Family Increase Connectedness to Home Parenting Skills & Communication Skills Pendidikan Agama

Sekolah
Mewujudkan suasana pembelajaran yang menyeronokkan Mengkaji kurikulum sekolah (Akademik vs Kemahiran) Increase Connectedness to School - Budaya Penyayang Memperkukuh & menguatkuasa undang-undang (buli, ponteng sekolah)

RECOMMENDATION
Masyarakat
Memperkukuhkan dasar & polisi sediaada (breastfeeding, cuti bersalin, Taska) Memperkukuh Institusi Keluarga - sokongan pelbagai agensi (working hours, housing) Menyediakan pasarana penjagaan kanak-kanak child care yang berkualiti (dual income parents)

Sumber Maklumat
Mengutamakan nilai-nilai murni dalam kandungan media cetak dan elektronik Kempen Gaya Hidup Sihat terutama kepada kumpulan yang berisiko tinggi

LESSON LEARNT FROM MATERNAL MORTALITY REVIEW

1. High index of Suspicion Female TRO pregnancy/ ectopic / STI/ HIV/ risk behaviours LNMP 2. Social History Married status/ family problem / social support 3. Medical History Heart Problem/ Diabetic Prenatal care Advice on contraception/ implant 4. Strengthen Adolescent Health Services Good Antenatal/ Postnatal Services / follow up Staff trained, non judgmental, friendly, confidentiality, privacy Good referral system, Intersectoral and interagency collaboration.

CONCLUSION
The Truth About Teenage Pregnancies?
The numbers are rising Their needs are still not met Need to provide holistic interventions - risk and protective factors - strength base model (enhance individual resilience) - ecological model (multiple level:micro, system, macro)

Source: World Health Statistic 2013, WHO