dr. nik rubiah 040713 (latest)

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

Lelaki Perempuan Jumlah

i. Kedatangan Remaja 10-19 tahun

ke fasiliti kesihatan (2012) 1,689,918 1,801,422 3,491,340

ii. Bilangan Kemasukan Remaja 12-

19 tahun ke Hospital (2011) &

Penyebab Utama

67,547

Kecederaan dan

keracunan (42.9%)

79,460

Kehamilan & faktor berkaitan

kehamilan (40.5%).

147,007

STATISTIK

Lelaki Perempuan Jumlah

2,797,200 2,660,100 5,457,300

• Populasi Remaja Tahun 2012

• Perkhidmatan Kesihatan Remaja

Trend of Top 10 Morbidity for Outpatient Attendances among Adolescent 10 to 19 at

Public Health Facilities 2012 (P)

Morbidity n, %

Morbidity n, %

Male Female

Diseases of the respiratory system 817,404

(48.37%) Diseases of the respiratory system

838,514 (46.55%)

Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

222,950 (13.19%) Symptoms, signs and abnormal clinical and

laboratory findings, not elsewhere classified

258,123 (14.33%)

Diseases of the Skin and Subcutaneous Tissue 118,592 (7.02%)

Disease of digestive system 134,609 (7.47%)

Disease of digestive system 111,318 (6.59%)

Diseases of the Skin and Subcutaneous Tissue

115,849 (6.43%)

Certain infectious and parasitic diseases 104,341 (6.17%)

Factors influencing health status and contact with health services

102,703 (5.70%)

Factors influencing health status and contact with health services

88,577 (5.24%)

Certain infectious and parasitic diseases 88,797

(4.93%)

Injury, poisoning and certain other consequences of external causes

85,996 (5.09%)

Injury, poisoning and certain other consequences of external causes

58,264 (3.23%)

Diseases of the eye and adnexa 47,586

(2.82%) Disease of the genitourinary system

47,204 (2.62%)

Diseases of the Musculoskeletal System and Connective Tissue

28,154 (1.67%)

Diseases of the eye and adnexa 45,235

(2.51%)

Diseases of the ear and mastoid process 27,860

(1.65%) Diseases of the Musculoskeletal System and Connective Tissue

29,101 (1.62%)

Total (Out of 20 morbidity) 1,689,918 Total (Out of 20 morbidity) 1,801,422

5

Morbiditi utama pesakit luar lelaki/perempuan 1. respiratory infection

2. Non specific signs and symptoms

‘non specific sign and symptoms’ mungkin disebabkan masalah berkaitan dengan

perkembangan remaja

Latihan HEADSS/ kesihatan & kaunseling remaja perlu di tingkatkan utk meningkatkan pengesanan

morbiditi specific 46.55%)

STATISTIK

Seks di kalangan remaja : • 0.9% (1994) ; 2.2% (2004) ; 6.5% (2010) - Kajian LPPKN/ KKM

Kadar kesuburan spesifik (ASFR)

remaja berumur 15-19 tahun.

• 13 (2006), 14 (2008), 15 (2009)

- Jabatan Statistik

Pengetahuan mengenai STI/ organ reproduktif remaja 13- 24 yr

• 47.0 % – 59.6% 0%

- LPPKN, 2004

Contraceptive, CPR, 2004 • 51.9% (all methods); 35% (modern methods)

- LPPKN, 2004

Kadar Incidence HIV Remaja 13-

19 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).

- 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

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

- PDRM 2011

Jumlah tangkapan Jenayah Juvana < 18 tahun

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

- PDRM 2012

Statistik Kelahiran Anak Tak Sah Taraf melibatkan Ibu <20 tahun

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

- Jabatan Pendaftaran 2012

(2003) (2009)

Lelaki 36.3% 30.9%

Perempuan 4.25% 5.3%.

Source: World Health Statistic 2013, WHO

9

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 6.5

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

10

Trend Remaja Hamil (10 -19 Tahun) Di Malaysia Bagi Tahun 2010 (Jul-Dis) – 2013 (Jan-Mac)

Sumber: Reten Manual Statistik Remaja Hamil JKN 2012

2012

• Purata 1,500 kes sebulan

• 4,183 (22%) tidak

berkahwin.

Jan – Mac 2013

• 1,048 (25%) tidak

berkahwin

STATISTIK REMAJA HAMIL (10-19 TAHUN) MENGIKUT NEGERI

BAGI TAHUN 2012

11

Negeri paling tinggi remaja hamil: Perak, Selangor, Johor, Pahang,

Sarawak & Sabah

Perlu tingkatkan pengetahuan, sikap dan pengendalian kesihatan

SRH dan Kemahiran Kesihatan Mental

Sumber: Reten Manual Statistik Remaja Hamil JKN 2012

MATERNAL DEATH BY AGE GROUP, 2001-2005

Age Group

2001 2002 2003 2004 2005

n % n % n % n % n %

15-19 5 3.0 - - 4 3.3 2 1.6 6 4.8

20-24 17 10.0 15 11.4 10 8.2 18 14.7 11 8.8

25-29 41 24.1 29 22.2 24 19.6 26 21.2 31 24.8

30-34 45 26.5 27 20.6 39 32.0 34 27.6 31 24.8

35-39 36 21.1 37 28.2 26 21.3 31 25.2 29 23.2

40-44 20 11.8 21 16.0 16 13.1 11 8.9 15 12.0

45-49 6 3.5 2 1.5 3 2.5 1 0.8 2 1.6

Total 170 100.0 131.0 100.0 122 100.0 123 100.0 125 100.0

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

13

BIL. KEMATIAN REMAJA HAMIL 13-19 TAHUN

MENGIKUT KLASIFIKASI 2009-2013

Sources : Family Health Development Division, MOH 2013

17 DEATH AMONG ADOLESCENTS (13 – 19 yr), 2012

Negeri (8) Sabah

(4) Johor

(2) Sarawak

(1) Kelantan

(1) Negeri Sembilan

(1) Kedah

Warganegara 10/ 17 (59%)

Bangsa Melayu (5), Iban (3), Bajau (2), Suluk (5), Cina (2)

Status Perkahwinan 6/17 (35.3%) tidak berkahwin

Unbooked 6/17 (35.3%) unbooked

Bayi mati 11/17 (65 %) – abortion, IUD

Causes

9 Preventable (53%)

8 Non – Preventable (47%)

Sources : Family Health Development Division, MOH 2013

17 DEATH AMONG ADOLESCENTS (13 – 19 yr), 2012

State Sabah

District Tawau Sandakan Kota Kinabalu

Kota Kinabalu

Tawau Lahad Datu Lahad Datu Sandakan

Age 16 16 19 17 17 17 19 17

Citizen NC (legal) NC (legal)* NC (IIlegal)*

C NC NC NC NC

Ethnic Bajau Iban Bajau Suluk Suluk Suluk Solu, Philliphine

Suluk

Marital Status

M M

(not register)

M M M M M M

Student / Work

NW

(housewife)

NW

(housewife)

NW

(housewife)

NW

(housewife)

NW

(housewife)

NW

(housewife)

NW

(housewife)

NW

(housewife)

Antenatal Booking

22/52 (GP)

8/52 (KD) No ANC 16/52 (hosp)

- - - 16/52 (hosp)

Cause PPH Unkown Bleeding Placenta Preavia Major

ARDS with sepsis

Acute Pulmonary

Oedema

Eclampsia in Pregnancy

Puerperal Sepsis with Aspiration

Pneumonia

Leptospirosis

Preventable Preventable

Non-Preventable

Preventable Preventable

Non-

Preventable

Preventable Preventable

Non-Preventable

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 Johor

District Kulai Kluang Muar

Age 18 19 18 13

Citizen C C C C

Ethnic Chinese Malay Malay Chinese

Marital Status

Not Married Not Married Not Married Not Married

Student / Work

W

(kedai runcit)

W

(Factory)

NW

(housewife)

Student (Form 1)

Antenatal Booking

No ANC No ANC 16/52 (KK) 22/52 (Hosp)

Cause Haemorhagic Shock

Pueperal Sepsis Efective Endocarditis with PE

Pelvic Fx w Massive retroperitoneal bleeding

assoc. wabruptic

Preventable Preventable Preventable Preventable

Non

preventable

Baby Outcome

Abortion

(Hosp )

MSB

(Home delivery)

Baby alive

(Hosp)

Antenatal

Sources : Family Health Development Division, MOH 2013

17 DEATH AMONG ADOLESCENTS (13 – 19 yr), 2012

State S’wak* Kedah Kelantan N9

District Bintulu Song Baling K. Krai S’remban

Age 16 19 18 19 19

Citizen C C C C C

Ethnic Iban Iban Malay Malay Malay

Marital Status Not Married M M M Not married

Student / Work Student NW

(housewife)

NW

(housewife)

NW

(housewife)

W

(berniaga)

Antenatal Booking

14/52

(Hosp)

6/52 (home) 16/52 (KK) 11/52(KK) 32/52 (KK)

Cause Paraquat

Poisoning

Unknown (non obstetric

causes)

Dengue Endocarditis Candidiasis & DIVC

Preventable Non

preventable

Non

preventable

Non Preventable

Preventable Non

preventable

Baby Outcome Abortion

(Hosp)

Antenatal

IUD

(antenatal )

IUD

(antenatal)

Baby alive

(Hosp)

Sources : Family Health Development Division, MOH 2013

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

Tahun Frequencies Live birth MMR

1995 4 13,110 30.5

1996 4 13,565 29.4

2009 6 18,911 31.72

2010 9 19,018

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

Peers

Individual

Adapted from Blum and Mmari 2005

Health risk behaviour in adolescence

Positive Youth Development

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)

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

RECOMMENDATION

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