 Welcome to the Stop COVID-Dets webinar series brought to you by the University of the Philippines. The Stop COVID-Dets shorts make it easier for you to go to the presentations that you are interested in. I'm Dr. Raymond Sarmiento, Director of the National Telehealth Center. And I'm Dr. Susy Pineda Mercado, Adjunct Faculty of the National Telehealth Center. Together, let's stop COVID-Dets. So my presentation will be mostly focused on how we can respond to the different vulnerabilities and needs of our teen pregnant girls. So just as a summary, these are the unique vulnerabilities of our young girls, especially for those who are younger than 15 years old. The bodies are not well developed, so they're short. We also have a very high stunting rate among our adolescents, that's about 26%. So they're short, the pelvis are narrow and small, so that's why they are more prone to obstructed labor. Also 37% are nutritionally at risk. So they have anemia, they're underweight, and so they tend to have low birth weight babies. And when they have a repeat pregnancy, which happens in 15% of all our pregnancies, you set up an intergenerational cycle of malnutrition. And we know the impact of malnutrition not only in terms of physical impact, but also on the mental and IQs of our children and adolescents and adults. So those are the things that are really important. The interval between births for young girls is very short, 17 months. The advice right now is to have three years in between pregnancy. So you see how compromised they are in terms of nutrition. Now this was also emphasized by Dr. JP, but again I would like to emphasize that coercion is in the picture, especially if you have very young girls. Automatic, if they're younger than 14, you have to ask about relationships and the age of the guy who got her pregnant. Because the PSA statistics itself shows that 17%, 2 out of 3 infants born of teen moms were actually fathered by much older men. And also mentioned was ITV, that's intimate partner violence. We also need to screen for this because this is quite common. And it's no wonder that the postpartum depression can be high in this age group, in this particular segment of adolescents. This is data from abroad, but I think we need to make our own studies here in the Philippines. And what is also difficult is that they have pre-pandemic access is always very late. So usually we get them when they're in the second trimester, sometimes in their third trimester because of course they try to hide the pregnancy. So they try to hide it because of the fear of reprimands and stigma. And they don't think well so that the families don't become bigger. So really it sets them up for all these disadvantages. Now this is, in the next few slides I'll talk about our teen mom program which we set up in 2000. And this is basically remember the levels of prevention are two. Primary level which there's a lot of plans like Dr. JT mentioned that's preventing the first pregnancy. Our program in TGH actually is more on preventing the subsequent pregnancy. Because they are prone to rapid repeat pregnancies. About 20 to 40% of them can have another pregnancy in the next two years. So this is actually mainly a partnership between Perinatology, OB and Pediatrics and Adolescent Medicine. But you see that we involved a lot of the subspecialties and services in the hospital. So because the needs of pregnant adolescent are multiple. So it's Perinatology for the obstetric care, contraceptive services, very important nutrition. And medical subspecialties like cardiology because we do have a population of RHD patients or those with chronic kidney disease or SLE lupus who get pregnant. And we have been seeing also an increase in the number of those in multiple congenital anomalies. So we call in genetics also for counseling and other services. But what sets this program apart from any obstetric program for teen pregnancy is the psychosocial supports. We do the psychosocial assessment, we do the health education together with OB. Social workers play a very important role. Child protection also comes in because usually if we ask the age of the partner if it's a gap of four or more years, we actually do a referral to child protection. And if we detect depression or suicidal thoughts, we also have a referral to child and adolescent psychiatry. So it's an interprofessional service. Now, the thing here is that approach is also unique to use the adolescent-friendly approach which is basically strengths-based, non-judgmental, respectful, focus on the adolescent's confidentiality and supportive of the emerging capacities. For instance, you see this picture, we interview them alone. So that is respectful for confidentiality privacy and also this teaches them to deal with health workers on their own. Now, what is important is that we screen for both the strengths and the risks. So we do the HEADS interview and we ask about relationships at home, education, have they dropped out, their activities, much time on the internet but where they're meeting their partners, use of drugs which is alcohol, tobacco and other drugs, violence in the relationships, depression and suicide. And with this information, we are able to do counseling and referrals to MSS, Metasocial Services and Child Protection Unit. And we also engage the adolescent in these major decisions. So decisions like when you raise the child on your own with your family, do you involve your boyfriend or your partner? Are you thinking about adoption? They do think about adoption, we also involve MSS because there's a lot of preparations here. But most of our adolescents actually opt to raise the baby with their families. Stay with your parents or cohabit with the partner. We discourage cohabiting because that sets them up for another pregnancy and they are unable to go back to school. Resume or quit school so it's so important to get them back to school. We tell them that the school doesn't have any right to kick them out. That's against the law and we can contest that. And of course we talk about decisions about having another baby. Is it something in their agenda? Would you like to prevent that? What are your thoughts here? And we give them options about the use of contraceptives. And the emphasis here is really for them to understand. Long acting, reversible contraceptives like implanon and IUD give them the space. They can prevent pregnancy for three years. That's enough time for them to finish school, to breastfeed, for their bodies to recover. So this is very important that they understand how important it is to prevent a rapid repeat pregnancy. Now we also empower them with information as well as skills. So we do health classes that cover these topics. And this picture shows a class on infant care. We demonstrate, we ask them to do the actual diaper changing, et cetera. And also we emphasize breastfeeding because breastfeeding rates among adolescent women, mothers are quite low. There's a lot of challenges for them. So we really support them in terms of information and skills. Now we also supplement the lessons with brochures. We go through a birth plan because they have to plan where they're going to give birth. Are they prepared with the money? Is the field health ready? They have the bag with the clothes, et cetera, and the provisions. Now because remember they can't plan as well as adults. And so we need to help them build the skills in planning and decision making. Okay, so in 2014, in gender health, Visayas Health with USAID funding actually set up similar clinics. They called it Program for Young Parents, no PYP. So this is less stigmatizing than a teen mom. And by the end of 2018, they actually had 33 clinics across the Visayas. I think there are two in late, Iberianci and Abuyog. And there's a big one in Iloilo. So this was recognized by DOH and actually given an award by NEDA. So although I don't know what's happened here because the funding ended, but we really are hoping that the hospital would really pick it up. And DOH should pick it up and enable the other hospitals to have this program. So it can be replicated. Okay, so I'm almost done, just a few more slides. Now this is, Dr. JP mentioned problems with access, but this is really data from the NCR households by UNICEF, survey done in December 2020. And it shows that fewer women were getting pregnant women, women were receiving fewer antenatal care, check up. So this is pre-COVID, dark blue, 99% were able to get four visits. Now in the COVID times, pandemic 61%. So if you don't go toward check ups, you are less likely to take iron and polyacid tablets. This is also a little bit alarming especially for teen pregnancies. Women are less likely to give birth at hospitals where they need to be for adolescents and more likely to give birth at other health facilities. Although at this time, home births had not increased. But remember, this is NCR data. We don't know what's happening in the provinces. Mentioned already was the access to sexual reproductive services like FB, very low to start with now lower. And this is for all women. So it's much lower for young girls. And remember the restrictive laws and provisions of the RPRH that you need consent to be able to access contraceptives. So that's something also that we need to think about. Okay, so in our experience in PGH, we noted a very marked decrease in the number of teen pregnancies that we girls with teen pregnancies seen in our teen mom clinic. So in 2019, we were able to serve 228 young mothers. But in 2020, just 43 of them showed up. And this is understandable because we had to close and the services shifted to COVID efforts. My fellows mentioned that they are starting to come in again. So this month we had, I think, nine referrals instead of the usual two or three. Okay, so what happens is that they are admitted in the wards. Some of them, very few of them, though, have had COVID. My fellows were able to see them with precautions, of course. And they noted that the isolation is very, very tough for the young girls. And especially because they don't have gadgets. They don't have cell phones to keep in touch with their family. So it's very, very isolating. It's very difficult for these young girls. We just gave birth and they're in an isolation ward. Now, we also noted that there's an increase of sick babies left at the ICU. Of course, our statistics are skewed because we are a referral center. But for instance, we saw six mothers last month. Four of them had premature babies and then we had one who had congenital malformations. So that's just an observation. So no big data yet. Now, it's just coming in. Now, what happened is that we shifted our, remember we have health classes? We shifted to online. So we also shifted our postpartum follow-ups online. Now, the thing is that it's very difficult to gather them. Number one, it's difficult to gather them. They don't have the gadgets. They don't have the connectivity. And even though we start the calls and if our fellows are giving them load, they don't show up. Now, for instance, this is a screenshot. The ones, these are the patients too. And then the rest are doctors. So in this particular call, six said they would go but only two appeared. So you can see the, and there's a lot of effort that goes into setting up an online consultation. Now, this is a postpartum visit just to follow up on how the baby's doing, the breastfeeding, how she's feeling, et cetera. So we try to do that. Although we see this as an opportunity also because we're able to follow them up. No, which was very difficult pre-pandemic because they would not come back to us. So those are the limitations also of the program. Now, the challenges, I think I mentioned, it's a physical access to the services and of course access to online services because we've shifted, no? Okay. Key points basically just to summarize the unique vulnerabilities of our adolescents. It's both medical and psychosocial. We do have comprehensive existing comprehensive pregnancy program which is open for people, DOH to pick up. It's been picked up. Our challenges are obvious, no? Access to pre-natal, contraceptive services and online services. It's a big, big challenge. Although it is also an opportunity for them to access our services and for us to reach them. So what can we do? Dr. J.P. has had a lot of plans and it was very concrete and really say good luck and please, let's really move this forward, no? So for us, it's improving the connectivity both inpatient, if they're isolated, outpatient, of course family planning services should really be strengthened also. Have the COVID vaccine available for our teen pregnancy, no? When they're admitted in the hospital and other vaccines also should be available. Comprehensive sexuality education. We should take care of the restrictive loss of the RPRH, remember? Even though they have already given birth but they're below 18, they cannot give consent for contraception. That's really ridiculous, no? And of course, expanding adolescent friendly services which the DOH has been really trying hard but we need to try harder. Thank you, thank you so much for the opportunity to share my insights. We hope that you learned as much as we did from that excellent presentation. We also hope that you will join us every Friday from 12 noon to 2 p.m. Manila time on Zoom, Facebook or YouTube. So stay safe, stay connected and see you online.