Teen pregnancy

Objectives
Solve the medico legal issues in teen

pregnancy
Focus on medical problems that can arise in
an adolescent pregnancy
Identify psychosocial issues that a teenager
will face during and after a pregnancy
Prevention teen pregnancy

Teen pregnancy

Teen pregnancy
Early births around the world
Fewer than 10% of girls have a baby before the age of 18 in (lowest first);

Japan, Germany, Poland, France, China, Tunisia, Sri Lanka, Great Britain,
Morocco, Burundi, Philippines, Rwanda, United States of America, Thailand
10-20% of girls have a baby before the age of 18 in: Turkey, Peru, Trinidad,

Tobago, Egypt, Indonesia, Paraguay, Brazil, Ecuador, Sudan, Pakistan,

Dominican Republic, Colombia, Namibia, Bolivia, Zambia, Mexico
20%-30% of girls have a baby before the age of 18 in: Zimbabwe, Ghana,
Botswana, Yemen, Kenya, Guatemala, India, United Republic of Tanzania, Togo
30%-40% of girls have a baby before the age of 18 in: Madagascar, Burkina
Faso, Senegal, Nigeria, Malawi. Central African Republic, Uganda
40%-50% of girls have a baby before the age of 18 in: Cte D'Ivoire, Liberia,
Mali, Cameroon, Bangladesh .More than 50% of girls have a baby by the age of 18
in Niger.
Sources: Alan Guttmacher Institute. 1998. Into a New World: Young Women's

Sexual and Reproductive Lives.

UNICEF. 2001. Innocenti Report Card - A league Table of Teenage Births on Rich
Nations. Innocenti Research Centre, Florence.

Teen pregnancies in
Malaysia
Teen pregnancies on the rise with 111 reported

this year
As of April, the department has already seen 111 such
cases. This number is a dramatic increase compared
to the 131 cases throughout last year. In 2008, there
were 107 teenage girls who got pregnant.
They were placed at Taman Seri Puteri, a rehabilitation
centre and shelter that provides training for
youngsters, especially teenage girls who face social
problems.
The star online archives

Teen pregnancy

Teen pregnancy case ..

MJ, a 15-year-old female adolescent, presents

to your clinic for a sore throat. Behind closed

doors, the clinical nursing assistant checks
vital signs and asks a standard clinic intake
question about MJ's last menstrual period
(LMP). MJ reveals that her period is late and
she would like a pregnancy test!

Case Cont
Further history reveals that MJ is a Form4

student living in KB . She has been dating for

the past 6 month, a 20 y/o Malay man who is
working in a computer shop near KB mall. They
had unprotected sex couple of time but this is
the first time she missed her period. She is
afraid she might be pregnant.
Her parents both are running a Kadai makan

and they are not aware of her life after school..

Case cont
What would you do next?
A) You would order a UPT test
B) You would call her parents to inform..
C) Yell at her that she has cheated her

parents
D)Ask her to come with her parents..

Medico legal
aspect
of
Teen pregnancy

Medico legal Cont

There are two legal issues need to be resolved

before we focus on any medical problems,

1) She is under 18
2) She is under 16

Medico legal Cont

Is permission from parents/guardian
required before treating the
adolescents?
Yes, permission from parent/guardian is

required to treat adolescents aged below

18 years

Children below 18 years old cannot

give consent to medical procedures

and treatment (Childs Act 2001)

Case cont
What would you do next?
A) You would order a UPT test
B) You would call her parents to inform..
C) Yell at her that she has cheated her

parents
D)Ask her to come with her parents..

If JM hesitates
Calm down the patient
Respect patient autonomy
Ask why/what she is afraid of
ask about her parents actual or anticipated

reactions
Offer help, "Do you need help telling
parents/guardian about your pregnancy?"
Explain JM the legal issue that she need
parental consent to get any medical help
Get her permission to call her parents

Breaking a bad news

You called her parents.
Parents arrived to your clinic , they were anxious and

furious at their daughter.

S setting up the interview

P - perception
I - invitation
K - knowledge
E emotions and empathy
S strategy and summary
First half of your morning went by convincing them and

finally you ordered the UPT which came positive

16 and preg Cont

What would you do next?
JM is under 16
BASED on MALAYCIAN CHILD ACT 2001

She has no privilege yet to consent her

SI
Consider as Statutory rape

16 and preg Cont

STATUTORY RAPE is defined as sexual

intercourse with a female below the legal age

of consent. It is different from other types of
rape in that force and lack of consent are not
necessary for conviction. A defendant may be
convicted of statutory rape even if the
complainant explicitly consented to the sexual
contact and no force was used by the actor.
(International Academic Journal)

16 and preg Cont

Nadesan and Omar (2002) writes, the

consenting age for sexual intercourse in

Malaysia is 16 years old. As such, statutory
rape is defined as sexual intercourse
(regardless of whether WITH or WITHOUT
consent) with a girl BELOW 16 years old.
This definition is according to Section
376 of the Malaysian Penal Code or Act
574 )

16 and preg Cont

What is your responsibility?
Inform the child protector
Encourage the victims parents to file a police

report
If parents are not comfortable/hesitating, get
the child protector involved in this case
Make sure it is reported to the police either
way

16 and preg Cont

Protector means
(a) the Director General;
(b) the Deputy Director General;
(c) a Divisional Director of Social Welfare,
Department of Social Welfare;
(d) the State Director of Social Welfare of
each of the States;
(e) any Social Welfare Officer appointed
under section 8
Child Act 2001

16 and preg Cont

Duty of Child protector
investigate matters where it is alleged that a
teenager is at risk of harm
refer teenager and families to services that
assist in providing the on going safety and
wellbeing of children
take matters before the Court if the teenager's
safety cannot be ensured within the family
supervise teenager on legal orders granted by
the Court
provide and fund accommodation services,
specialist support services, and adoption and
permanent care to children and adolescents in
need

16 and preg Cont

Duty of medical officer or medical practitioner
27. (1) If a medical officer or a registered medical
practitioner believes on reasonable grounds that a child he is
examining or treating is physically or emotionally injured as a
result of being ill-treated, neglected, abandoned or exposed, or
is sexually abused, he shall immediately inform a Protector.
If suspect the child is abused should inform

immediately to Child Protector

(2) Any medical officer or registered medical practitioner

who fails to comply with subsection (1) commits an offence

and shall on conviction be liable to a fine not exceeding five
thousand ringgit or to imprisonment for a term not exceeding
two years or to both.
Those who fail to inform, commit an offence -

fine RM5000 or 2yrs imprisonment or both

Child Act 2001

Case Cont
The child protector agrees to file the police

report
You explained the procedures to the parents
and about to leave the room, JMs mother
begins to weep and explains you her fear of
social stigma. She wants to get that baby
aborted
How to handle the situation?

Medico legal Cont

Is abortion allowed in Malaysia?
Abortion is legal in Malaysia in the following

situations only:
When a woman's life is in danger
When a woman's physical health is in danger
When a woman's mental health is in danger
A woman must consent to an abortion, and
she must have a medical professional's
authorisation.

One more SEQ ( request

abortion)
Greet
Rapport
ICE ( worries/reason for the request)
Explain JMs parents that you are legally bound

abortion in a healthy mom is against the law

Give other possible options
- adoption
- marriage
- send her daughter to womens shelter until she
deliver then give the baby for adoption
Offer support : family counseling, referral to
psychologist

16 and preg Cont

Parents agree to keep the daughter in woman

shelter until delivery, you arranged them

meeting the child protector and ask your
assistant to schedule her for booking.

JM is placed in shelter Raudhatul Sakina

JM had her booking done at 10 weeks POA but

she is referred back to you for a low Hb level9.5

Health problems
associated with
adolescent
pregnancy

Health problem Cont

Pregnant teens are at much higher risk of having serious medical

complications such as:

Placenta previa

Pregnancy-induced hypertension
(PIH occurs in about 5% of the population of pregnant women)

Premature delivery
( STI , UTI, PIH )

Significant anemia
(insufficient amount of healthy caloric intake,
% of anemia high in 15-19 year old than women from 20-44)
WHO 2006. pregnant adolescents- delivering on global promise of hope

Health problem Cont

Low weight gain
Preeclampsia
Substance abuse induce complications

-smoking ( low birth wt, still birth, premature

birth)
-alcohol (fetal alcohol syndrome)
-drugs (high rate STI, HIV)

The risk of dying from pregnancy related

causes is in many countries twice as high for

adolescents aged 15-19 as for older women

Health problem Cont

Mental Health Risks
Teenage pregnancy is usually a crisis for the

pregnant adolescent.
Depression is common among pregnant teens.
Feelings of anxiety and fear also increase in
teenage parents as well as pregnant teens.
WHO 2006. pregnant adolescents- delivering on global promise of hope

Case Cont
JMs anemia is corrected with iron

supplements and proper diet advice. She

manages to pass her 38 weeks follow up. That
night she calls that she is leaking fluid with
blood stained mucus plug. She is advised to
go to the hospital right away and you call the
ambulance for her.
What you think has happened?

Premature rupture of membrane

Case Cont
She is kept on bed rest with monitoring fetal

surveillance she is induced when the cervix is

favorable
Her second stage of labor is prolonged..
What would be the cause?

Health problem Cont

Prolonged and obstructed labour is more

common in first time mothers .

Prolonged labour can also lead to obstetric
fistula, a major cause of disability.

Health problem Cont

Prolonged obstructed labour

- small pelvis
- immature pelvis
-abnormal lie

Health problem Cont

Obstetric fistula
Labour may continue for days without

intervention.
Pressure from the baby's head can cause
necrosis, leading to a tear between the vagina
and bladder (vesico-vaginal fistulae VVF) or
between the vagina and rectum (recto-vaginal
fistulae).

Health problem Cont

Obstetric fistula affects 50 000 to

100 000 women a year.

WHO estimates that 2 million women
are living with unrepaired obstetric fistulae.
If a fistula is not promptly repaired, the disability
can ruin a womans life.
Many are declared unclean and deserted by
husbands or families.
Studies in Africa have shown that 58-80% of
women with obstetric fistulae are under the age
of 20, with the youngest aged only 12 or 13
years.

Health problem Cont

Puerperal sepsis
Mothers who experience complicated childbirth

without access to hygienic health services are

prone to infection after childbirth.

Puerperal sepsis is one of the main causes of

maternal mortality among adolescents. The risk

of puerperal sepsis or postpartum infection
increased in cases of long or obstructed labour.
3

WHO 2006. pregnant adolescents- delivering on global promise of hope

Risks to the Infant

9.6 percent of young mothers has a low birth

weight baby.
Low-birth weight babies are more than twenty
times as likely to die in their first year of life versus
a normal-weight baby.
Low birth weight and pre maturity raise the
probability of infant death, blindness, deafness,
mental retardation and cerebral palsy.
Lack of access to medical care and lack of
immunization or vaccination
Sudden infant death syndrome (SIDS)

Risks to the Infant

Studies have shown rates of newborn death to average about

50% higher to adolescent mothers versus mothers in their 20s

(Macro International 2008).
Health risks to the mothers, a combination of physical and
socioeconomic factors place babies of youngest mothers at
higher risk of dying.
Studies have shown an independent adverse effect of early
pregnancy on newborn health, even after controlling for a
range of other factors (Conde-Agudelo et al 2005; WHO 2007).
A large U.S. study found a 55% higher risk of neonatal death
to babies of mothers aged 10-15, a 19% higher risk in babies
of 16-17 year-olds, and a 6% higher risk in babies of 18-19
year-olds.

Risks to the Infant

Mental Risks of Infants born to Teen Mothers

Increase risk of behavioural problems
Increase risk of developmental delay and learning

disabilities.
Less likely to receive early and continuing cognitive
and social stimulation, resulting in underdeveloped
intellect and lower rates of academic achievement.

Psychosocial
issues

Consequences Associated With Teenage

Pregnancy
Teen Mothers are more likely to drop out of high school than

females who delay having children, resulting in social isolation

from their peer group.
Only 41% of teenagers who have children before age 18
graduate from high school compared to 61% of teens from
similar social and economic backgrounds who delayed
childbirth until age 20 or 21.

With an incomplete education a teenage mother my lack

necessary job skills.

Teenage parents are more likely to rely of family support or

public assistance to meet her and her child's basic need s.

Consequences Associated With Teenage

Pregnancy
Over 75% of all unmarried teen mothers go on welfare

within five years of the birth of their child.

Teens may not have acquired the necessary positive

parenting skills and life skills necessary to cope with

the stress and joy of having and raising a child.

Increased exposure to domestic abuse and violence.

The United States estimates the total ANNUAL cost

associated with Teenage Pregnancy to be 7 BILLION

dollars.

JM delivered a baby boy which was given to adoption,

she came with her mother for the 6 weeks follow up.
After the physical exam, you have advised her
mother to start JM on contraception which would
prevent her from future pregnancy. Her mother
refused to accept the option. She said her daughter
learnt her lesson by going through this 10 month of
shelter life. She will never ever going to do the same
mistake, she has promised her already. You have no
choice you have documented the conversation. And
gave a 2 week apt to come back to discuss about
that matter again. They didnt show up for their apt.

According to the National Campaign to Prevent

Teen Pregnancy, nearly 1 in 4 teen mothers will

experience another pregnancy within two
years of having their first.
Nearly one-quarter of teen mothers have a

second birth before turning 20

(Another chance, Lorraine.V 2004)

Factors associated with

additional birth to teen
mothers
Age
Race/Ethnicity
Marital Status
Education
Cognitive Ability

"For

too long, when an

adolescent becomes
pregnant, we have
pointed
the finger at her. It is
time we
pointed the finger at
ourselves. If a girl gets
pregnant that is because
we
have not provided her
with
the information,
education,
training and support she

Prevention
Providing continuous support for contraceptive use can

reduce repeat pregnancy

Teenage mothers often do make a concerted effort to
avoid a repeat pregnancy in the early months after the
birth of their baby, but they can have difficulty
maintaining this preventative behaviour.
Efforts to prevent repeat pregnancy amongst teenage
mothers need to focus on providing contraceptive
services immediately after birth, followed by
individualised support and monitoring for at least two
years.
Long-acting contraceptives (such as implant) have been
proven to reduce the risk of rapid repeat pregnancy.

Prevention
Immediate postpartum or postabortal IUD

placement ensures reliable contraception and

significantly reduces the risk of repeat abortion.
The risk of expulsion is higher with immediate
postpartum placement, but it is a preferred
option if there are barriers to delayed
postpartum placement.
UD expulsion risk may be increased somewhat

by young age, nulliparity, and prior IUD

expulsion, but data are limited

Prevention
In the Contraceptive CHOICE study
Efficacy analysis at 12, 24, and 36 months

found that among participants using OCPs, the

contraceptive patch, or the vaginal ring, the
risk of pregnancy was 20 times higher than
with IUDs or the implantwith risk particularly
high in women aged <20 years compared with
older women. Among users of IUDs and the
implant, unintended pregnancy rates were
similarly low across ages.

Case Cont
After a year and a half passed by, JM showed up

in your clinic on a Monday morning said she is in a

new relationship. She learnt her lesson from her
last pregnancy .Now, she asks her boy friend to
wear condom but the condom broken. Her friend
told her to get a morning after pill to prevent
pregnancy
What is your approach?

Case Cont
She is 17 now!
She can consent for her SI,
Under 18
Need parental consent for further

management???

Gillick competence
What is it?
Can We apply this law in this situation?

Gillick competenceis a term originating

inEnglandand is used inmedical lawto decide

whether a child (16 years or younger) is able to
consent to his or her own medical treatment,
without the need for parental permission or
knowledge

the parental right to determine whether or not

their minor child below the age of sixteen will

have medical treatment terminates if and when
the child achieves sufficient understanding and
intelligence to understand fully what is proposed."

Gillick competence

References
http://www.cdc.gov/teenpregnancy/
http://www.who.int/maternal_child_adolescent

/topics/adolescence/en/
http://www.medscape.com/viewarticle/714795
_3
http://en.wikipedia.org/wiki/Gillick_competenc
e
Betsy B. Kennedy et al. Intrapartum Management
Modules: A Perinatal Education Program