Adolescence (or Teenage):

 It is the period between the ages of 10-19 years that encompasses time
from puberty onset to full legal age (WHO, 2002b).
 This phase of life spurts physical, mental, emotional and social development
where the individual learns about life making major decisions that leads
down a career path.
 During this time teenagers feel a lot of peer pressure.
 Adolescence is generally a complex period where a number of factors may
lead to sexual behaviors and reproductive health (RH) risks.
 This is due to teenagers being less experienced and less informed on,
accessing RH services (Tufail, 2008).

Teenage Pregnancy (TP):

 Pregnancy can occur after menarche which usually occurs around the age of
12 or 13 years. But, it does not signify that the girl’s body is ready to give
birth.
 If an adolescent girl becomes pregnant or gives birth before 19 years then it
is known as teenage pregnancy.
 It is high risk situation for both mother and child because of their
vulnerability to many health challenges (Singh, 2012).
 Teenage pregnancy – Key facts
 About 16 million adolescent girls give birth every
year – most in low- and middle-income countries.
 An estimated three million girls aged 15-19 undergo
unsafe abortions every year.
 In low- and middle-income countries, complications
from pregnancy and childbirth are a leading cause
of death among girls aged 15-19 years.
 Stillbirths and newborn deaths are 50% higher
among infants of adolescent mothers than among
infants of women aged 20-29 years.
 Infants of adolescent mothers are more likely to
have low birth weight.
 “Pregnancy and childbirth are the number one killer
of 15-19 years old”(Girleffect, 2012).
 The WHO (World Health Organization) defines
adolescent as individuals within the age group of
10-19 years.
 Teenage pregnancy is a rising public health issue
being faced by many countries globally; Nepal is not
alone in this fact.
 Adolescents make up about 23% of the population
in Nepal (UNICEF, 2003).
 The consequences of teen motherhood
 Less likely to complete high school or college
 More likely to be a single mother
 More likely to have more children sooner on a
limited income
 More likely to abuse or neglect the child

Hoffman, D. (2006). By the Numbers: The Public Costs of Teen Childbearing. Washington, DC: National Campaign to
Prevent Teen Pregnancy
 Risks to children of teen mothers
• Growing up without a father
• Low birthweight and prematurity
• School failure
• Insufficient health care
• Abuse and neglect
• Poverty
• Incarceration (boys)
• Teen motherhood (girls)

Hoffman, D. (2006). By the Numbers: The Public Costs of Teen Childbearing. Washington, DC: National Campaign to
Prevent Teen Pregnancy
 Causes of Teenage pregnancy
 Limited education and employment opportunity
 Societal pressure
 Lack of knowledge to avoid pregnancy – lack of
education on safe sex
 Sexual violence
 Inability to exercise safe sex
 Consequences of Teenage pregnancy
 Unsafe abortion
 Complications from pregnancy and childbirth -
leading cause of death
 Still birth
Trends of Fertility in Nepal
-NDHS, 2011
 Age specific and total fertility rates, the general fertility
rate and the crude birth rate (NDHS-2011)
Age Group Residence Total
Urban Rural
15-19 42 87 81
20-24 135 197 187
25-29 82 134 136
30-34 38 78 71
35-39 16 39 36
40-44 0 16 14
45-49 2 5 5
Total Fertility Rate 1.6 2.8 2.6
General Fertility Rate 60 102 96
Crude Birth Rate 16.6 25.5 24.3
Source: NDHS, 2011
Risks to Adolescent Mother and Baby

1. Pregnant adolescents are more likely of having

preterm, low birth weight babies;

2. Girls under 15 years are at greatest risk;

3.Young first time mothers being more likely to die

during childbirth;

4.Babies born to adolescent mothers have high

rate of neonatal mortality
Source: WHO, UNFPA, 2006
Relative Risk of Adverse Outcome by
Maternal Age(WHO, 2008)
 Research Result on Complications of
Teenage Pregnancy
Complication Number Percentage

Anemia 102 56.67

Preterm Delivery 20 11.11

Abortion 58 32.22

Source: Kafle, 2010

 Age of Mother and Neonatal Complications

Neonatal Complications 15-19 years 20-24 years Total

( n=168) (n= 401) (n=569)
Birth Asphyxia 1(0.6) 1 (0.2) 2 (0.4)
Still Birth 1(0.6) 3(0.7) 4 (0.7)
Neonatal Death 1(0.6) 5(1.2) 6(1.1)
Intrauterine Death 4(2.4) 8(2) 12(2.1)
Respiratory Distress 1(0.6) 1(0.2) 2(0.1)
Neonatal Sepsis 5(3) 8(2) 13(2.3)
Jaundice 1(0.6) 1(0.2) 2(0.4)
Faetal Distress 5(3) 23(5.7) 28(4.9)
Meconium Aspiration 3(1.8) 2(0.5) 5(0.9)
Poor Cry and Sucking 7(4) 12(3) 19(3.3)
Others - 3(0.7) 3(0.5)
None 139(82.7) 334(83.3) 473 (83.1)
Total 168(17.2) 401(16.7) 569(16.9)
Source: Pun, 2011
 Social Impacts of Teenage Pregnancy
Social Impacts Number of Percentage
Respondents
School Dropout 33 28.4
Bearing the health risk 29 25
Handicapped in Getting job 21 18.1
Polygamy Marriage 16 13.8
Separation 6 5.2
Divorces 2 1.7
Widowed 1 0.9
Infertility 8 6.9
Total 116 100
Source: Kafle, 2010
Prevention teenage marriage and pregnancy

 reducing marriage before the age of 18

 creating understanding and support to reduce
pregnancy before the age of 20
 increasing the use of contraception by adolescents at
risk of unintended pregnancy;
 reducing coerced sex among adolescents;

 reducing unsafe abortion among adolescents;

 increasing the use of skilled antenatal, childbirth and

postnatal care among adolescents
The strengthening of National Health sector response to adolescents’
health and development could be done through application of following
WHO’s systematic strategy (Source: WHO, 2009).
National Level
• Situation Analysis/ Rapid
• Programme Review
• Health Sector strategy development within a multi
sectorial strategy
• National Quality Standards development
• Approved national standards dissemination to the
regional/ district level
• National plan development and national scale up
plan
Recommendations
- Collaboration intensively with Ministry of education, Ministry of
Justice, Ministry of labor for developing and implementing programs
related to girls education retention, prohibition of early marriages and
gender based violence.
-Media should be use for generating awareness by designing related
programs such as drama, focus group discussions.
-Development of Information Education Communication (IEC) materials
including flyers could be made in coordination with National Health
Education Information Communication Centre.
-Availability of AFHS in school and health services and outreach
programme for out of school adolescents for awareness, counseling and
gynecological checkups in coordination with media and health facilities.
- Making contraceptives available to youth in gathering areas. Provision
of awareness on abortion legalization and services on safe abortion in
coordination with private partners.
Regular provision of training to peripheral health workers on dealing
with ARH problem and counseling skills as they are the first line of
contact in coordination with National Training Centre (NTC).
 Family and Community level
• Involving particularly men and mothers’ in law for
ensuring their acceptance and support for
adolescent reproductive health service utilization
with the help of media.
• Dissemination of information about teenage
pregnancy, its complications to pregnant
adolescents and community for avoiding early
marriages through media, public discussion.
• Provision of life skills and sexuality education for
increasing decision making power, autonomy to
adolescent girls.
• Newly wed adolescent should be targeted for
delaying their first pregnancy.
 Ministry of Education level
 Provision of adolescent reproductive health (ARH)
lesson in school through health workers like doctors or
nurse who can talk about sexuality topics for delivering
the ARH.
 This should be done in coordination with Ministry of
health and Population (MoHP).

 Revision of curriculum following guideline of UNESCO.

Capacity building and regular training of teachers on
dealing adolescent sexual and reproductive health
issues who will handle the subject matter in absence of
HWs in coordination NTC and MoHP.
 Designing and incorporation of importance of female
education in order to retain girls in school.
Safe Medical Abortion
 WHO, 2004

As a preventable cause of maternal mortality

and morbidity, unsafe abortion must be dealt
with as part of the MDG on improving
maternal health and other international
development goals and targets
 Introduction
 termination of a pregnancy before the foetus
has attained viability, i.e. become capable of
independent survival in extra-uterine life
 Safe Abortion Service
Refers to termination of unwanted pregnancies
through safe technique with
 effective pain management;
 post procedure family planning information and
 service are being provided to avoid further
unwanted pregnancies
Comprehensive Abortion Care Services
 include examination by the trained doctor or
health worker,
 counseling on abortion and family planning
options and services,
 abortion service using Manual Vacuum
Aspiration (MVA) or Medical abortion (MA) or
other methods,
 effective pain management and other
reproductive health services if needed
 Strategies
 To generate evidence on unsafe abortion - prevalence
 To develop improved technologies and implement
interventions to make abortion safer;

 to translate evidence into norms, tools and guidelines;

 to assist in the development of programmes and

policies that reduce unsafe abortion and improve
access to safe abortion and high-quality postabortion
care.
 Medical Abortion (MA)
 involves the use of pharmacologic agents, such as
Mifepristone and Misoprostol,
 to expel the products of conception
 Used together, these medications stimulate uterine
contractions and
 cause expulsion of the products of conception
 Manual Vacuum Aspiration (MVA) is the main
procedure used for safe abortion in Nepal

 MA using Mifepristone and Misoprostol is a safe, cost-

effective and acceptable option for terminating
pregnancies
 Safe medical abortion In Nepal
 officially introduced MA in the fiscal year
2065/066 (2009 AD) in six districts (Jhapa,
Dhading, Chitawan, Tanahun, Surkhet and
Kailali) on a pilot basis

 Gradually scaled up

 Since then medical abortion has become an

alternative method of first trimester
termination of pregnancy.
 Treatment Protocol used for MA
Day 1
 Mifepristone (200 mg)- oral under supervision
 Instruction for not taking food for next two hours
 Advice to attend the clinic after 48 hours of
ingestion of Mifepristone
 Inform about the possible side effect
 Treatment Protocol- Day 3
 800 microgram misoprostol (200 microgram
tab four tabs) inserted high into the posterior
fornix of vagina
 Allow to rest for half an hour
 Explain possible side effects
 Discharge home after half an hour of insertion
of misoprostol with emergency contact
number.
 FP counseling
 Arrange time for follow up in two weeks
Prevention of Mother To Child
Transmission
(PMTCT - HIV)
 Introduction
 one of the routes of transmission of HIV is from
mother to child

 occurs when an HIV-infected woman passes the

virus to her baby during pregnancy, during
labour and delivery, or during breastfeeding
 not every baby born to an HIV-positive mother will
be infected by the virus
 because the placental membrane between the
fetus and the mother remains intact during
pregnancy
 The placental membrane forms a barrier between
the blood of the mother and the fetus, limiting the
transmission of HIV
 Risk of transmission
 If mother becomes sick – eg nutritional deficiency,
lower immunity
 Virus increases- increases the likelihood of the
virus crossing the placental barrier
 during delivery- at a time when the cuts and
abrasions occur
 through breastfeeding (although the risk is not as
high as that during delivery)
Likely HIV outcome in untreated women
 Prerequisite for PMTCT

HIV testing and counseling for PMTCT

1. Opt-in approach
2. Opt- out approach
Interventions for PMTCT
1. Antiretroviral treatment / Prophylaxis
2. Breastfeeding
3. Family Planning
1. Antiretroviral Treatment
 Using ARV drugs for ART or PMTCT
 ARV Drugs for ART – for life of a mother,
treatment, combination of medicine
 ARV Drug for PMTCT – for preventing mother
to child transmission of HIV, Prophylactic,
single or combination of drugs, short time
ARV Drug for PMTCT
 Nevirapine
 given to the mother at the onset of labour,
and
 a single dose given to the baby after delivery
 Should be given if mother is using ARV Drugs
for ART.
2. Exclusive Breastfeeding
 NOT recommended for HIV-infected women
 Avoid breastfeeding if AFASS criteria is met
(WHO)
A- Acceptable
F- Feasible
A- Affordable
S- Sustainable
S- Safe
 Four interventions for PMTCT in
community
1. Prevention of new HIV infections in parents-to-be
2. Prevention of unwanted pregnancies in HIV-
infected women
3. PMTCT using ARV drugs
4. Care and support of HIV-positive mothers and
their families
 Reference
http://labspace.open.ac.uk/mod/oucontent/view.p
hp?id=452761
Maternity waiting homes
Background
Improve access to obstetrical services
1)Bringing medical services to women in need-
“flying squads”
2)Bringing women who need them to medical
services - emergency transport
3)Decentralization of care so that women have easy
access to skilled obstetric care – Maternity waiting
homes
Introduction
 residential facilities where women who live remotely
can wait before giving birth at a hospital or health
centre

 Women can wait for the onset of labour in maternity

waiting home

 Advocated as a way of overcoming geographical

barriers in resource poor settings and improving access
to care and maternal and neonatal outcomes.
Aim of Maternity waiting homes
• to provide a setting where high-risk women
can be accommodated during the final weeks
of their pregnancy near a hospital with
essential obstetric facilities

• To reduce maternal and perinatal mortality by

improving access to skilled birth attendance
and emergency obstetric care, particularly for
women in rural and remote areas
 Elements of MWH
 Definition of risk and selection of women
 Community Level Health Service - Responsibility
for Identification and Referral
 Skilled Obstetric Services
 Community and cultural support
 Barriers in utilization of MWH
 Poor amenities – eg overcrowding, lack of
lighting system, health care providers etc
 lack of privacy
 costs of staying in a maternity waiting home
may exceed the costs of home delivery
 Lack of transportation
 Lack of respect from staff