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17th Family Medicine Conference | 4 to 7 July 2013 | The Zenith KuantanSymposium 8TRANSCRIPT
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