Pregnancy in adolescent and youth
Elimination of child marriage by 2030 is targeted in SDG
child marriage is illegal in Ethiopia as stated in the revised criminal and family laws of Ethiopia (2005)
the prevalence of child marriage in Ethiopia is 40%
14.1% of girls married by age 15, and 40.3% by age 18.
Nationally, 13% of the married teenager’s age group 15-19 has already begun childbearing
EDHS data has shown that there was an insignificant decline in the prevalence of teenage pregnancy between 2000 and 2016 (a decline from 16% to 13%)
Child Marriage and its magnitude
Child marriage:
Marriage before the age of 18
A violation of the human right
Forces girls into poor life prospects, increased risk of violence and abuse….ill health, or early death
One-third of the world’s girls are married before the age of 18 and 1 in 9th before the age of 15
Western and Sub-Saharan Africa have a high prevalence
Niger has the highest prevalence of child marriage
Bangladesh with the highest number of girls under the age of 15 while Ethiopia stands third with Guinea and India for similar ages
Childbearing before physical development is complete
Early childbearing has numerous and serious consequences for the health and well-being of girls and their babies
In Ethiopia the age at first sex and marriage converge at approximated age of16.4 years (PMA,2015)
Ethiopia stands third with the prevalence of child marriage ( graph below shows magnitude for 2016 EDHS, women 15-19 began childbearing by region, national is 13%)
Contributing factors for child marriage
◆Social norms and tradition
◆Economic factors
◆Customary and religious laws that ignore the practice
◆Lack of alternative opportunities
◆Inadequate law enforcement
◆Discrimination against girls
◆Inequalities between girls and boy
Consequences of child marriage
◆Limited opportunities for career and vocational advancement
◆Missed opportunities for entrepreneurship and economic empowerment
◆Family dispute, school dropout, predispose to abuse
◆Predispose to mental health, STI/HIV, disability
◆Higher risk of having obstetrics complications
Addressing child marriage and its consequences
Multisectoral engagement to enforce the law of age at marriage Example: health facility board with other sectors Male engagement as a partner and program implementation
Make quality FP services accessible and acceptable Social BCC- wider awareness creation on family planning & contraception Child marriage is violation of the Ethiopian Family Code and human right
Ending child marriage, help end intergenerational cycle of poverty Mitigation through intersectoral collaboration
Pregnancy in adolescents
Predisposing factors for adolescence pregnancy
◆Early sexual debut◆Coercion/sexual violence –forced sexual violence◆Low assertiveness & poor decision-making capacity to negotiate safe sex◆Most adolescents have their first intercourse without contraceptives◆Lack of information and low level of knowledge on sexuality◆Poor access to RH services including contraceptionLess common contraceptives use among AY, why?
The unexpected and unplanned nature of the sexual activity
Lack of full information on contraceptives & fear of confidentiality Fear of judgmental attitudes and resistance from providers etc
Provision of SRH information & services
◆National AYH and other strategies ensure right for an informed choice for safe and effective contraceptive
◆Healthy adolescents are eligible to use currently available contraceptives and age is important for irreversible methods
◆Counseling for contraceptive method
◆Remind sexually active adolescents about dual protection
◆SRH info and education can help postpone the initiation of sexual debut
◆Parental guidance at home and education at school is important
◆Effective counseling will help an adolescent make a voluntary choice
Method counseling should address
◆Effectiveness in pregnancy
◆Effectiveness in HIV/STI prevention
◆Possible risks and benefits to health
◆Common side effects
◆Return to fertility after discontinuing the method
◆Obtaining supplies for use (where relevant)
◆Follow up information
Special consideration for FP services for Adolescent ( smart start counselling approach)
Married adolescents:
Be cognizant of the many adolescents seeking contraceptive services are married
Emphasize the benefits of Healthy Timing and Spacing of Pregnancy.
Smart start is a method of helping young couples to delay their first pregnancy?
Use the smart start counselling approach to delay their first pregnancy
As they are in open relationship the risk of STI/HIV is an important sensitive must be discussed issue
Why SMART Start, steps
◆Narrow Window period between marriage and pregnancy
◆Predetermined path marriage followed by child bearing
◆Sparce in rural setting and poorly served with high risk for complications
Step 1. Program introduction to key stakeholders
Step 2. Estimating the number of adolescent girls
Step 3 .Orienting the WDAs on SMART start and involve in married adolescents identification
Step 4. once married adolescent/couples identified facilitate counselling session
NB: It is about the future of recently married adolescent, economic empowerment
Role of AYH provider on smart start
Support the health extension workers on Smart Start
Counselling for family planning (unmarried adolescents)
Unmarried adolescents:
It is their basic right to get effective SRH information and services, support for voluntary informed decision
Adolescents may not be well prepared on their SRH
Suspicious of the public health facilities…hostile or judgmental providers
Provide friendly respectful services
Discuss abstinence & importance of condoms,& STI/HIV
Discuss intimate partner sexual violence
Service providers should be aware of the medical eligibility criteria as well as follow up appointment
Abortion
Abortion
Termination of pregnancy (TOP) before fetal viability, conventionally before the 28th week from the last normal menstrual period (LNMP).
If LNMP not known, a birth weight of less than 1000gm
Unsafe abortion is a procedure for TOP performed by person lacking the necessary skills or in an environment not in conformity with minimal medical standards, or both (WHO)
Magnitude of unsafe abortion
Globally, each year 210 million women become pregnant, 25% end in an induced abortion
50% of these induced abortion are unsafe
About 1% of them die as a result
Contribution of unsafe abortion to maternal deaths
Globally - 13%
Ethiopia – 6 to 9% in 2013 (32% in 2000, UNICEF)
Adolescents are more vulnerable for unsafe abortion than adults (WHO)
Abortion rate
Why adolescent/youth seek abortion?
Education: fear of expulsion, drop out
Economic factors: pregnancy, delivery and raising a child
Social acceptance: pregnancy before marriage
No stable relationship
Contraceptive failure
Coerced sex: intimate sexual violence (IPV), forced sexual debut
Magnitude: Ethiopian context, Incidence study, Changes in Morbidity and Abortion Care
Contributing factors for unsafe abortion
◆Lack of knowledge on RH information & services
◆Delay in seeking care
◆Resorting to unskilled providers
◆Use of dangerous methods
◆Legal obstacles
◆Service delivery factors – negative provider’s attitude, limited availability of the service, high cost of care
Consequences of unsafe abortion
A. Medical:
Cervical or vaginal lacerations, Anemia, Hemorrhage
Uterine and/or bowel perforation,
Tetanus, pelvic Infection, sepsis, death
Long-term complications
Infertility, Spontaneous abortion & Increased risk of ectopic pregnancy
B. Psychological:
Guilt and in some cases depression
C. Socio-economic:
Dropping out of school
Discontinue/change job
Migrating to another place
Prostitution
Types of abortion care
1. Post-abortion care (PAC): for spontaneous abortion or following attempts to terminate
Emergency treatment, counseling, family planning/contraception
Linkage (integration), community service provider partnership (HEW, HDA, peer promoters…)
2. Women-centered comprehensive abortion care:
Includes all components of PAC, and
Safe induced abortion care as permitted by law
It has three key elements:
A. Choice
The right and opportunity to select between options
The right to determine if and when to become pregnant
The right to continue or terminate a pregnancy
The right to complete and accurate information
B. Access
Trained, technically competent providers
Up-to-date clinical technologies
Easy-to-reach services, preferably local
Affordable and non-discriminatory care
C. Quality
Respectful and confidential services
Tailored to each woman’s individual needs
Using international standards of care
Offering referrals for other reproductive-health services
Types of abortion care…
Provider’s value:
◆Identify their personal beliefs and values about abortion
◆Separate their beliefs and values from those of their clients and focus on their clients’ needs
◆Respect to all women, regardless of their age, marital status, SRH behaviors and decisions
◆Treat women with empathy— view the situation from their perspectives
Four Key Rights Related to Abortion Services
The key rights
◆The right to life
◆The right to privacy
◆The right to information and education
◆The right to decide whether or when to have children
Support Rights in an Abortion-Care Setting
Have empathy and respect for women.
Maintain positive interactions.
Respect privacy and confidentiality.
Adhere to the voluntary, informed consent process.
What is Values Clarification?
“VC is the process of examining one’s basic values and reasoning for the purpose of understanding oneself, to discover what is important and meaningful”
Interdependent processes of reasoning, emoting, and behaving
“Valuing occurs when the head and heart…unite in the direction of action” (John Dewey, 1939)
Clarified Versus Un clarified Values
A person who is confused or unclear about his/her values will tend to act in immature, overtly confirming or dissenting ways
The clarified person will exhibit characteristics of Maslow’s “self-actualized person”, acting in a calmly confident, and purposeful way
(Kinnier, 1995)
The legal provisions for safe abortion service:
1. The termination of pregnancy by a recognized medical institution within the period permitted by the profession is not punishable where:
The pregnancy is a result of rape or incest; or
The continuation of the pregnancy endangers the life of the mother or the child or the health of the mother or where the birth of the child is a risk to the life or health of the mother; or
The fetus has an incurable and serious deformity; or
The pregnant woman, owing to a physical or mental deficiency she suffers from or her minority is physically and mentally unfit to bring up the child.
2. In case of grave and imminent danger which can be averted by an immediate intervention, an act of terminating pregnancy in accordance with the provision of Article 75 of this code is not punishable
Interpretation of the law
Rape or Incest
On disclosure of the woman
The word of the woman is enough
Not required to submit evidence
Not required to identify the offender
Minors & mentally disabled shall not be required to sign a consent
Parental consent for adolescents not required
No proof of age for adolescent is required
For Medical/Health Condition: Follow knowledge of standard medical indications necessitate TOP to save life or health of the mother, in good faith
Provider shall not be prosecuted if the information provided by the woman is later found to be incorrect
Timing and place for terminating a pregnancy
TOP as permitted by the law
Public facility or private facility fulfilling the pre-set criteria
All public & private health facilities, for GA of <12 wks from LNMP
TOP between 13-24 weeks for fetal deformity and others to be done in a 2ndary or tertiary level of care
TOP between 24-28 weeks for fetal deformity and other to be done in a 2ndary or tertiary level of care
DE should be done only up to 18 Weeks in a referral hospital
Safe abortion service
Providers responsibilities
Understand the law & the guideline
Recognize their domain of responsibilities (Abortion care tasks by provider category)
Acquire basic knowledge and skills
Distinguish between their own values & clients rights to safe reproductive services
Provide Services as per the law, guidelines and level of responsibility
Adolescents with unsafe abortion
◆Peculiarity of adolescents with unsafe abortion
◆Primi-gravida, unmarried and outside of a stable relationship
◆Have a longer gestation up to the time of abortion
◆Have used dangerous methods to terminate pregnancy
◆Have ingested substances that interfere with treatment
◆Have resorted to illegal providers
◆Delay in seeking help even after complication
◆Come to the health facility alone or with a friend, rather than with the partner
◆Have more entrenched complications
Note: AYH service providers should always try to get information about menstrual history from female clients
Management of abortion in adolescents & youth
◆Prevention: should be the mainstay of the care
◆Prevention of unwanted pregnancy:
◆educate them on sexuality, use of contraception/ condom
◆Avail contraceptives: Condoms and EC on demand
◆Engage boys, teachers, family and community
◆prevent IPV, violence on dating and forced sexual debut
Safe abortion care service
◆Emergency treatment:
◆evacuation and treat a life-threatening complications
◆Referral as deemed necessary
◆Post abortion FP/Contraception
◆Inform, educate and counsel on all methods
◆Give preferred method as necessary
Link
◆STI Rx, cervical cancer screening
◆Post treatment follow-up
SUMMARY
Unsafe abortion is common among adolescents
There is an updated legal provision for safe abortion care
There is a need for service providers’ value clarification
Health care providers shouldn’t be a cause for unsafe abortion by their discriminatory attitudes towards adolescents seeking abortion care
Adolescents must be provided with SRH information and pregnancy prevention services
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