Mapping of Teenage Birth Delivery in Selected UNFPA Areas

Executive Summary Early childbearing creates health risks for both mothers and newborns. The University of the Philippines Population Institute 2014 study on Teenage Pregnancy in the Philippines states that teenage mothers compare poorly with mothers from older age groups in a number of reproductive health indicators. For one, they tend to have the shortest birth intervals of all age groups. Taking into account the fact that their bodies are not yet ready for the physical demands of childbearing, having closely spaced births exposes young mothers to further health risks. With these risks it is viewed that that teenage mothers and their babies can be protected during delivery with skilled birth attendance in a health facility. The NDHS 2013 however, show that only 64% of births among the mothers aged 15-19 are delivered in a health facility. In February to May of 2016, the Center for Health Solutions and Innovations Philippines, Inc. (CHSI) provided technical assistance to UNFPA to map teenage birth locations in their program sites. The results of this study will be used by UNFPA to inform its programming for effective promotion of teen births in facilities. The main objective of the preliminary study is to map birthing facilities and locations for teenage girls with ages 19 years old or younger, who gave birth from January to December 2015, as recorded in the Local Civil Registrar in selected areas in UNFPA sites of Quezon City, Sarangani, North Cotabato, and Sultan Kudarat. A total of 3,200 teen birth records were documented for the period of January-December 2015. The records review took place between February to May 2017. Of the 3,200 cases in this mapping study, 1,018 were acquired from Local Civil Registrars in Sarangani, North Cotabato and Sultan Kudarat. The Quezon City Local Civil Registrar did not allow access to the records, so Postpartum Consultation Records were used instead to acquire the 2,182 birthing records in District II. The mapping showed that teen mothers mostly delivered in different types of hospitals (42%). However, 36% delivered in birthing clinics (both private and public) and 13% gave birth at home. For first time teen mothers, most gave birth in a public hospital followed by birthing clinics. As teens have more children they give birth in birthing clinics, less in the hospital and more in the home. Generally, teens were attended by physicians in hospitals, midwives in birthing centers, and hilots in their homes. Further studies need to look into influencing factors on location of deliveries that include order of child to be delivered (or number of children of the teen mother); and age of teen mothers as younger teens, who are more at risk, were less likely to give birth in hospitals.

Table of Contents Executive Summary ................................................................................................................... 2

Introduction ............................................................................................................................... 4

Study Rationale and Methodology ............................................................................................. 5

Steps for Data Gathering ........................................................................................................ 5

Limitations of the Study ......................................................................................................... 5

Results ....................................................................................................................................... 6

I. Maps of Teen Births by LGU ............................................................................................ 6

II. Profile of Teen Records from Local Civil Registrars and Quezon City Facility Records ... 10

III. Teen Birth Profile by Type of Facility .......................................................................... 13

IV. Profile of Validation Facilities ..................................................................................... 18

Summary of Findings ................................................................................................................ 21

Annex I: Maps of Teen Births by LGU ........................................................................................22

Introduction According to the Philippine National Demographic and Health Survey (NDHS 2013) one in ten young Filipino women age 15 to 19 is already a mother or pregnant with first child. Early childbearing creates health risks for both mothers and newborns. A UPPI study in 2-14 (Teenage Pregnancy in the Philippines: Trends, Correlates and Data Sources) states that teenage mothers compare poorly with mothers from older age groups in a number of reproductive health indicators. For one, they tend to have the shortest birth intervals of all age groups. Taking into account the fact that their bodies are not yet ready for the physical demands of childbearing, having closely spaced births exposes young mothers to further health risks. The WHO Factsheet for 2-14 state that babies born to mothers under 20 years of age face a 50% higher risk of being stillborn or dying in the first few weeks versus those born to mothers aged 20-29. The younger the mother, the greater the risk to the baby. Newborns born to adolescent mothers are also more likely to have low birth weight. With these risks it is viewed that that teenage mothers and their babies can be protected during delivery with skilled birth attendance in a health facility. The NDHS 2013 however show that only 64% of births among the mothers aged 15-19 are delivered in a health facility. To trace where teenagers are giving birth, an important data source is the Local Civil Registrar (LCR) that collects vital statistics such as births, death and marriages in the population. However, it should be noted that the UPPI 2014 study estimated that in 2000, the level of completeness of birth registration in the Philippines was 78 percent, i.e., only 78 per cent of 5-year-olds at the time of the survey have been registered in the birth registry (have a birth certificate, whether or not it was physically with the household at the time of the survey). Nevertheless, the records or registry of live births at the LCR will allow a general picture of where teenagers are giving birth.

Study Rationale and Methodology This preliminary study was commissioned by UNFPA to map teenage birth locations in their program sites. The results of this study will be used by UNFPA to inform its programming for effective promotion of teen births in facilities. Facility-based delivery is not a simple linear cause-and effect of availability of facilities, but depends on a complex relationship of various factors such as accessibility, cultural attitudes, the skills and morale of service providers in attending to pregnant teenagers, and so on. To begin program formulation for safe delivery among teenagers, there is a need to document facility deliveries among teenage mothers. The objective of this preliminary study is to map birthing facilities for

teenage girls with ages 19 years old or younger who gave birth from January to December 2015, as recorded in the Local Civil Registrar in selected areas in UNFPA sites of Quezon City, Sarangani, North Cotabato, Sultan

Kudarat.

In selected municipalities for each province, 10% of the teen records will be sampled for validation with the facility records. This is to provide a sense of level of consistency between LCR and facility records. Of the sampled records, two home deliveries will be validated at the address as stated in the registration papers. The municipalities were selected with considerations for urban and rural distribution, peace and order situation and access to municipal-wide records.

Steps for Data Gathering

1. Record review of all teenage births and recording of place of delivery (facility) 2. Random sampling of 10% of the teen records for validation at place of delivery (in

sampled municipalities) 3. Validation of all sampled records at the recorded birthing facility. For home deliveries in

the sample, at least two sample records at address of delivery are validated. 4. Mapping and profile of teenage birth deliveries

Limitations of the Study This mapping exercise relied solely on local registrar records in their available state, all hand written entries in ledger form. The ledgers could only be reviewed within the premises and encoding per record had to be completed onsite. Entries were taken at face value, hence any errors and inconsistencies within records were taken as is. Entries were not validated for veracity, except for the place of delivery and only for the sampled records.

Results

I. Maps of Teen Births by LGU

II. Profile of Teen Records from Local Civil Registrars and Quezon City Facility Records

A total of 3,200 teen birth records were documented for the period of January-December 2015. The records review took place between February to May 2017. Of the 3200 cases in this mapping study, 1,018 were acquired from Local Civil Registrars of selected municipalities in Sarangani, North Cotabato and Sultan Kudarat. The Quezon City Local Civil Registrar did not allow access, so Post Partum Consultation Records were used instead to acquire the 2,182 birthing records in District II of Quezon City. Table 1. Teen Records Mapped for each Municipality and City District

Province/City Sample Municipality % of Total

Quezon City District II 68%

Sarangani Malungon 6%

North Cotabato Aleosan 3%

Arakan 2%

Midsayap 10%

President Roxas 2%

Sultan Kudarat Kalamansig 4%

Lebak 5%

Total 3,200 100%

Figure 1. Number of Teen Birth Records per Municipality/District

A third (32%) of the Birth Records reviewed show the teen mothers to be under 18 years of age. The average age is 17.86 years and the median age is 18 years old. This mean and median age is similar across all the 4 sites. Figure 2. Age Distribution of Teen Mothers.

Figure 3. Proportional Distribution of Teen Mothers under and above 18 years of age by Province

n=696 n-156 n=61 n=111

n=1486 n=373 n=119 n=198

NCR mean age 17.8 Cotabato mean age17.95

Sarangani mean age17.81

S. Kudarat mean age17.82

Under 18 18 & Older

2 5 19112

334

552

1024953

1223

2176

0

500

1000

1500

2000

2500

10 13 14 15 16 17 TOTALunder 18

18 19 TOTAL 18& older

Teen Mothers mostly delivered in different types of hospitals (42%). However, 36% delivered in birthing clinics (both private and public) and 13% gave birth at home. Figure 4. Teen Birth Deliveries by Type of Facility

Teen births were delivered mostly in public hospitals, except in Sultan Kudarat were most of the deliveries took place in birthing clinics. In the tables below, in the Sarangan, North Cotabato and Sultan Kudarat, “public hospital” refer to provincial hospitals; whereas in Quezon City the “public hospital” (with total of 1,044) refer to the following: Type of Public Hospital No. of Teen Births

National (Specialty) Hospitals - 12 DOH (NCR regional) Hospitals- 924 City (LGU) Hospitals- 78 Outside NCR Hospitals 31

In Cotabato, “public hospital” all refer to provincial hospital. Across all sites, a substantial proportion gave birth at home, with highest percentage in North Cotabato.

Private Hospital4%

Public Hospital33%

District Hospital1%

Municipal Hospital4%

RHU/Health Center0.4%

Birthing Clinic 36%

Home13%

NO INFORMATION3%

Table 2. Number of Teen Birth Records per Site by Type of Facility.

TYPE OF FACILITY

Quezon City N=2182

Sarangani N=180

North Cotabato

N=529

Sultan Kudarat N=309

N % N % N %

Private Hospital 70 2% 52 10% 14 4%

Public Hospital 1044 32% 174 33%

District Hospital 13 <1% 16 3%

Municipal Hospital 1 <1% 134 74% 3 1%

RHU/Health Center 14 3%

Birthing Clinic (public, private)

789 24% 31 17% 104 20% 241 78%

Home 179 6% 15 8% 169 32% 51 17%

NO INFORMATION 86 3%

III. Teen Birth Profile by Type of Facility Younger teens mostly gave birth in public hospitals (provincial/city) followed by birthing clinics (Table 3). This trend was reversed with the older teens. The same proportion of younger and older teens gave birth at home. Table3: Teen Birth by Type of Facility and Age of Mother

TYPE OF FACILITY Below 18 years old n=1025

18 -19 yeas old n = 2175

% n % n

Private Hospital 4% 45 4% 92

Public Hospital 45% 462 35% 756

District Hospital 1% 10 1% 19

Municipal Hospital 6% 58 4% 80

RHU/Health Center <1% 5 <1% 9

Birthing Clinic (public, private) 27% 280 41% 885

Home 13% 137 13% 277

NO INFO 3% 28 3% 58

Among teen deliveries with fathers under 18 years old, these were mostly at home, followed by birthing clinics (Table 4). For births with older fathers, the deliveries were mostly in birthing clinics followed by home. Table 4. Teen Birth by Type of Facility and Age of Father

TYPE OF FACILITY

< 18 yrs old n=26

18 -19 yrs n=140

20 -24 yrs n=531

25 -49 yrs n=241

No AgeInfo n=2262

Private Hospital 15% 9% 5% 5% 4%

Public Hospital 19% 17% 16% 16% 47%

District Hospital 8% 2% 2% 1%

Municipal Hospital 9% 15% 12% 12% 0.2%

RHU/Health Center 1% 1% 0.2%

Birthing Clinic (public, private)

23% 37% 39% 39% 36%

Home 27% 21% 25% 25% 9%

Only 10% of the teen birth records had information on marital status (based on date of marriage). The rest were blank or had no information recorded and so could not be ascertained as non-marriage. No analysis was made based on marital status.

The distribution of deliveries by sex of child did not differ (Table 5). It may be noted that most of the teens may not have prior information on the sex of the child to possibly influence the decision on where to have the delivery.

Table 5. % of Teen Birth by Type of Facility and Sex of Child

TYPE OF FACILITY Female n= 489

Male n=529

No Info n=2182

Private Hospital 6% 7% 5%

Public Hospital 17% 17% 46%

District Hospital 0.8% 2% 2%

Municipal Hospital 14% 12%

RHU/Health Center 2% 2%

Birthing Clinic (private/public) 34% 38% 36%

Home 25% 22% 8%

No Info on Facility 3%

For first time teen mothers, most gave birth in a public hospital followed by birthing clinics (Table 6). As teens have more children they give birth in birthing clinics, less in the hospital and more in the home.

Table 6. Teen Birth by Type of Facility and Order of Birth of Child

TYPE OF FACILITY 1 n=2643

2 n=465

3 n=54

4 -6 n=12

No info n=26

Private Hospital 5% 2% 2% 842%

*Public Hospital 41% 25% 20% 17% %

District Hospital 1% 0.4% 4%

Municipal Hospital 5% 3% 2%

RHU/Health Center 0.4% 0.9%

Birthing Clinic (private/public)

34% 46% 54% 50% 31%

Home 11% 21% 22% 36% 8%

No Info on Facility 3% 2% 8%

Registration records note occupation mostly as housekeeper or housewife (Table 7 and Figure 5). It should be noted that in many cases these two may be synonymous, and in some cases, housekeeper may mean domestic help. For the purpose of this study, both terms were kept distinct as per record. Almost all the housewives gave birth in birthing clinics. For the others it was birthing clinics followed closely by public hospitals. A third of the housekeepers gave birth at home. Table 7. Teen Birth by Type of Facility and Occupation of Teen Mother

TYPE OF FACILITY housewife n=88

housekeeper n=727*

student n=27

other n=2

No info n=2356

Private Hospital 8% 26% 3%

Public Hospital 3% 22% 30% 44%

District Hospital 1% 2% 4% 1%

Municipal Hospital <1% 6%

RHU/Health Center 2%

Birthing Clinic (private/public) 91% 35% 33% 50% 35%

Home 5% 29% 7% 50% 8%

No Info on facility 4%

Figure 5. Type of Facility and Occupation of Teen Mother

Across all types of occupation of fathers, the most proportion of deliveries was in birthing clinics (Table 8 and Figure 6). It should also be noted that employees and students had none or the least proportion of home births.

Table 8. Teen Birth by Type of Facility and Occupation of Father

TYPE OF FACILITY driver n=62

employee n=39

farmer n=447

fisher n=49

laborer n=131

student n=32

Private Hospital 16% 10% 7% 3% 22%

Public Hospital 23% 23% 19% 2% 33% 22%

District Hospital 2% 2% 2% 3%

Municipal Hospital 1% 1%

RHU/Health Center 2% 4%

Birthing Clinic (private/public)

50% 62% 34% 82% 36% 50%

Home 10% 5% 36% 16% 21% 3%

0

10

20

30

40

50

60

70

80

90

100

Housekeeper = 727 Housewife = 88 Student=27 Other =2 NO INFO=2356

Private Hospital Public Hospital Municipal Hospital District Hospital Health Center Birthing Home HOME

Figure 6. Type of Facility and Occupation of Father

Physicians were recorded as assisting teen births in all types of facilities (Table 9). Nurses and midwives mostly in birthing clinics and “hilots” at home. Conversely ( see Table 10), in hospital deliveries almost all the attendants were physicians. In the RHU and birthing clinic deliveries, majority were attended by midwives. A few midwives facilitated deliveries in homes.

Table 9. Teen Birth by Type of Facility and Birth Attendant

TYPE OF FACILITY physician n=1621

nurse n=26

Midwife n=1165

Hilot n=383

Partner n=2

No info n=3

Private Hospital 8% 0

Public Hospital 75% <1%

District Hospital 2% 0 <1%

Municipal Hospital 9%

RHU/Health Center <1% 1%

Birthing Clinic (private/public)

1% 100% 95% 1%

Home 3% 99% 100% 100%

No Info on facility 5% <1%

Table 10. Teen Birth by Birth Attendant and Type of Facility

TYPE OF FACILITY

Private Hospital n=175

Public Hospital n=1201

District Hospital n=29

Municipal Hospital n=134

RHU/Health Center n=23

Birthing Clinic n=1157

Home n=409

Physician 100% 99% 97% 100% 7% 2%

Nurse 2%

Midwife <1% 93% 95% 8%

Hilot 3% <1% 92%

Partner <1%

0

10

20

30

40

50

60

70

80

90

100

Driver=62 Employee=39 Farmer=447 Fisher=49 Laborer=131 Student=32

Private Hospital Public Hospital District Hospital Municipal Hospital Health Center Birthing Home HOME

Data reflected in Table 11 show that most of the births were registered by the father, mother or relative. Health care workers including hilots registered births from hospitals, but births in homes were registered by the relatives of the child. Table 11. Teen Birth by Type of Facility and Registrant (in relation to child)

TYPE OF FACILITY

Midwife n=4

BHW n=3

Hilot n=5

Mother n=270

Father n=479

Relative n=68

Private Hospital 6% 8% 16%

Public Hospital 19% 25% 6%

District Hospital <1% 2% 3%

Municipal Hospital

1% <1%

RHU/Health Center

5%

Birthing Clinic (private/public)

25% 20% 42% 46% 19%

Home 75% 100% 80% 26% 18% 56%

IV. Profile of Validation Facilities In order to establish confidence in the recorded place of delivery in the Local Civil Registry, records were sampled for validation with the facility records. Only 3 of the 112 sampled records were not validated as recorded, with 2 of the home births later reported as facility births. Table 12. Teen Birth by Type of Facility and Validation of Birth Record

TYPE OF FACILITY Number Sampled

Validated Not Validated

Dropped

Private Hospital 9 1 0 8

Public Hospital 25 11 0 14

District Hospital 0 NA NA NA

Municipal Hospital 12 12 0 0

RHU/Health Center 1 1 0 0

Birthing Clinic (private/public) 35 32 1 2

Home 30 26 2 2

For the sampled records, a total of 19 validation facilities were identified with 2 private hospitals, 3 public hospitals, 1 district and 1 municipal hospital, 3 health centers and 9 birthing clinics. In these validation facilities, some data were also gathered in terms of teen births and maternal deaths.

Table 13. Number of Validation Facility/Place of Teen Birth by Type and by Site

PROVINCE/ CITY

Municipality/ City District

Private Hospital

Public Hospital

District Hospital

Municipal Hospital

RHU/ Health Center

Birthing Clinic

Home TOTAL

Quezon City District 2 16 16

North Cotabato

Arakan 1 1 4 6

Midsayap 1 11 13 6 31

Sarangani Malungon 12 6 18

Sultan Kudarat Kalamansig

12 12

In the validation facilities, where available, the birth records for the year were noted. The total number of births and teen births were noted for 19 facilities (Table 14). The proportion of teen births to the total births ranged from 3% to 36%. It can be noted that a higher proportion of teen births are recorded in facilities with less number of total births. Table 14. Type of Validation Facility, Total Number of Births and Proportion of Teen Births

TYPE OF FACILITY Total Births Total Teen Births % of Teen Birth

Private Hospital (2) 256 33 13%

65 2 3%

Public Hospital (3)

2869 474 17%

2604 483 19%

998 148 15%

District Hospital (1) 644 39 6%

Municipal Hospital (1) 845 306 36%

RHU/Health Center (3)

932 141 15%

88 9 10%

86 25 29%

Birthing Clinics (9) (private/public)

1319 78 6%

764 60 8%

598 50 8%

597 99 17%

571 74 13%

571 74 13%

468 32 7%

128 29 23%

81 8 10%

Only 1 of the facilities included in the validation reported a teen maternal death for 2015, and this was in a public hospital (Table 15). Table 15.Type of Validation Facility and Maternal Deaths, Teen Maternal Deaths

TYPE OF FACILITY Maternal Deaths

Cause

Public Hospitals

6

1 Teen

Eclampsia (2);

uterine atony (1);

hyperglycemic crisis secondary to poorly controlled diabetes mellitus type II (2);

cardiogenic shock sec. to cardiac arrythmia (1)

Hypovolemic shock sec. to severe anemia sec. to chronic disease

1 gravida cardia

Birthing Clinic 1 hypertension

In the 19 validation facilities, counseling was a common ASRH service (below). Availability of commodities were only reported in birthing clinics (mostly post-partum services).

Table 16.Type of Validation Facility and Available ASRH services

TYPE OF FACILITY ASRH SERVICES

Private Hospital (2)

Prenatal

Free laboratory services

Buntis Day every thursday

Counseling

Public Hospital (3)

Free laboratory services for teenage pregnant mothers

Has AJA room for counseling U4U activities in public schools

Counseling

Counseling

District Hospital (1) FP Counseling (during confinement)

Municipal Hospital (1) Counseling

RHU/Health Center (3)

Free laboratory services for adolescents

Has AJA room for counseling U4U in public schools

Post Partum Counseling

Counseling

Birthing Clinic (9) (private/public)

FP counseling

FP services - IUD, DMPA

FP counseling

FP services – PPIUD

Counseling

General health (FP) classes

Counseling

Summary of Findings

Teens mostly give birth in public hospitals, birthing centers and their homes. While it is the policy for teen births to be considered as high-risk deliveries, only 48% of teen births are delivered in hospitals

Teens are attended by physicians in hospitals, midwives in birthing centers, and hilots in their homes.

For further study, influencing factors on location of deliveries that need to be looked

into include

- Order of child to be delivered (or number of children) – teens move towards birthing clinics and giving birth at home as they have more children. - Age of Teen Mother – younger teens, who are more at risk, were less likely to give birth in hospitals -Type of services provided to teens after delivery particularly post partum FP

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Annex I: Maps of Teen Births by LGU