ROLE OF INDIVIDUAL PEDIATRICIANS & ADOELSCENT EXPERTS ROLE OF IPA & MEMBER SOCIETIES

1. Preventing Early Pregnancy and Pregnancy-Related Mortality and Morbidity in Adolescents in Developing Countries: The Place of Interventions in the Pre pregnancy Period ROLE OF INDIVIDUAL PEDIATRICIANS & ADOELSCENT EXPERTS ROLE OF IPA & MEMBER SOCIETIES Dr Swati Y Bhave IPA Technical advisor for Adolescent health - 2008 to date Regional Vice-president IAAH-International Association of Adolescent Health- 2010 to date President IAP 2000 & Chairperson of IAP task force on Adol health 2000-5

2. Life course perspective for prevention of Early pregnancy -1 Life course perspective is specially important for reducing problem of early pregnancy and pregnancy-related mortality and morbidity in adolescents in developing countries. Two categories of “pregnancy-focused” programs DOWN STREAM PROGRAMS - provision of effective care and support in the ANC, childbirth and PNC MID STREAM PROGRAMS - provision of effective promotive, preventive, and curative care in the pre- pregnancy period

3. Life course perspective for prevention of Early pregnancy -2 • Now is added a third program. Here PEDIATRICIANS AND ADOLESCENT EXPERTS and IPA & MEMBER SOCITIES HAVE A GREAT ROLE TO PLAY • Adolescence has been described as a time of opportunity and of risk. • UPSTREAM PROGRAM - the provision of promotive and preventive care that contributes • School age children and adolescents—both male & Female • for being well nourished, healthy, knowledgeable about their health, • and motivated and empowered to protect their health.

4. Life course perspective for prevention of Early pregnancy -3 This adds two layers of inter­vention packages FIRST LAYER - package of promotive, preventive, & curative interventions - pre-pregnancy period, SECOND LAYER - package of promotive and preventive interventions to school-age girls and boys even before reproductive capacity has developed. This layered approach will contribute to minimizing this risk and maximizing the opportunity that this special life phase brings [24].

5. Background of early pregnancy • Pregnancy and child ­birth are planned and wanted in very few • Under pressure to marry and to bear children early. • Do not know how to avoid a pregnancy • Unable to obtain condoms and contraceptives • Unable to refuse unwanted sex or to resist coerced sex. • Less likely than adults to be able to obtain legal and safe abortions • Unable to obtain skilled prenatal, childbirth, and postnatal care. • OUR ROLE IS TO GIVE LIFE SKILL EDUCATION( LSE) AND FAMILY LIFE EDUCATION (FLE) since SEXUALITY EDUCATION is taboo in many countries

6. PCC - Preconception care: Maximizing the gains for maternal and child health What can be our role ? As Individual practicing Pediatrician & IPA member socities National & Regional Pediatric socities Dr SWATI Y BHAVE, INDIA IPA Technical Advisor on ADOLESCENT HEALTH

7. OUR role in preconception care? • As pediatricians we can get actively involved to look after children and adolescents • Preconception care aims primarily at improving maternal and child health – also brings health benefits adolescents, women & men as individuals in their own right (not just as  potential parents). • Many  nutritional, environmental, mental health interventions as well as interventions aiming to reduce psychoactive substance use and interpersonal violence improve health and well-being girls & boys, women & couples - irrespective of their plans to become parents.

8. WE can play a great role in delivery of the PCC PCC Package • Nutritional conditions • Tobacco use • Genetic conditions • Environmental health • Interpersonal violence • Mental health • Vaccine preventable diseases • Substance and medication use • Too-early, unwanted and rapid successive pregnancies • Sexually transmitted infections (STIs) and HIV WHO-SEARO Dr Rajesh Mehta WHO SEAR

9. Preconception care has a positive effect on a range of health outcomes: Child mortality Maternal mortality OUR ROLE By ENSURING Healthy childhood & Adolescence we can ensure healthy adult hood in both boys and girls. We can reduce intergenerational adverse effects related to malnutrition. By having a healthy adolescent girl with a healthy sexual and reproductive health we ensure a healthier outcome of pregnancies and new borns. Still births/ birth defects low birth weight preterm birth Macrosomia Neonatal hypoglycemia Mental retardation Goitre Cretinism Hypothyroidism Childhood cancers Type 2 diabetes and cardiovascular disease in later life congenital and neonatal infections vertical transmission of HIV/STIs underweight and stunting Reduced breastfeeding Diarrhoea

10. We have a great role to play in the health of pregnant adolescents and the health of the next generation

11. We have a great role to play modifiable risk factors that increase the risk for several “congenital conditions”

12. Evidence-based interventions: Selected examples Areas addressed by the preconception care package Nutritional conditions • Screening for anemia • Supplementing iron and folic acid • Information, education and counseling • Monitoring nutritional status • Supplementing energy- and nutrient-dense food • Screening for diabetes mellitus • Management of diabetes mellitus • Counseling people with diabetes mellitus • Monitoring blood glucose (also in pregnancy) • Promoting exercise • Salt iodization OUR ROLE - WE all can contribute to this as they form of our day to day practice

13. Evidence-based interventions: Selected examples Areas addressed by the preconception care package Genetic conditions • Screening for anemia • Taking a thorough family history • Family planning • Genetic counseling • Carrier screening and testing • Appropriate treatment • Providing community-based education • Community-wide or national screening among populations at high risk • Population-wide screening OUR ROLE - WE all can contribute to this as they are included in our clinical practice

14. Evidence-based interventions: Selected examples Areas addressed by the preconception care package Too-early, unwanted and rapid successive pregnancy • Keeping girls in school • Influencing cultural norms that support early marriage and coerced sex • Creating visible, high-level support for pregnancy prevention programmes • Educating girls and boys about sexuality, reproductive health and contraceptive use • Building community support for preventing early pregnancy and for contraceptive provision to adolescents • Enabling adolescents to obtain contraceptive services • Empowering girls to resist coerced sex • Engaging men and boys to critically assess norms and practices regarding gender-based violence and coerced sex • Educating women and couples about the dangers to the baby and mother of short birth intervals • Providing contraceptives OUR ROLE – We may not do this in our routine practice but those interested in adol Medicine can contribute greatly

15. Our Role Facts • Advocacy Awareness Education • Prevent early marriages • Keep Adolescent girls in Schools to Complete Education • Sexuality education & Life skill training • to prevent too early and risky sex • Empower girls to learn Negotiating skills to say no to coerced sex and sexual abuse • This will reduce early and unwanted pregnancies and STI’s Four out of ten women report that their pregnancies are unplanned. Perinatal deaths are 50% higher among babies born to adolescent mothers. Up to 10% of pregnancies among women with untreated gonococcal infections result in perinatal death.

16. Our Role Facts • Maternal under nutrition and iron-deficiency anemia account for at least 20% of maternal mortality • Female genital mutilation increases the risk of neonatal death by 15% - 55% • In the absence of interventions, rates of HIV transmission from mother to child are between 15 and 45% • Deal effectively to prevent childhood and Adolescent Anemia. • Advocacy Awareness and education for prevention of female genital mutation. • Prevention of risky sexual behaviour to reduce HIV

17. Our role -for Country Action- we can work on the following areas

18. IPA ROLE - WHO support to countries WHO supports regions and countries in implementing a step-by-step processes to improve availability of and access to preconception care interventions Create regional/national platforms and partnerships to advance preconception care interventions. Introduce professionals in countries to international experience, research, evidence and good practices. We can undergo -WHO training packages for PCC At our country level Provide a methodology to analyze and understand the strengths and weaknesses of the preconception care system in place, and opportunities for improvement. Explore various delivery strategies for preconception care interventions, and their comparative advantages in terms of coverage, feasibility, acceptability and cost. Adapt the package of preconception care interventions to regional and country priorities, and health systems contexts. Explore and document innovative ways to deliver preconception care outside the traditional maternal and child health programmes, while recognizing the importance of integrated delivery mechanisms. Develop a roadmap to make changes over time. Monitor, evaluate and document progress.

19. “Healthy Transitions” for Adolescents in SEAR Rationale and Opportunities for Pre-Conception Care for 10-19 years age Dr Neena Raina Dr Alfrida Silitonga Dr Rajesh Mehta Child and Adolescent Health WHO - SEARO

20. ‘Healthy Transitions for adolescents’Ensuring health across life-course • Healthy adolescence • Healthy adulthood • NCD prevention • Reduction in Tobacco and harmful use of alcohol related problems and cost • STIs and HIV prevention • Healthy reproductive health outcomes • Reduction in prevalence of prematurity, LBW, Birth Defects • Reduction in maternal, fetal, neonatal and child mortality Dr Rajesh Mehta WHO SEAR

21. Health problems start during Adolescent period • Heterogeneous groups and circumstances with variable needs: • Boys and girls • Urban and rural • In school and out of school • Unmarried and married: Pregnant and mothers • At home and homeless (on streets) • In employment (formal and informal • Age parameter: 10-19 years • Confounding factors: • Biological: Early or late onset of puberty • Social-cultural factors • Experiencing rapid growth and development: • Physical: Body image and form • Sexual: Reproductive capacity • Mental: Mind • Emotional-psychological • Social • Formative Phase: • Attitudes • Behaviours Dr Neena Raina WHO SEAR

22. We know that specific interventions are effective and can be delivered to Adolescents Multi-sectoral approach Dr Neena Raina WHO SEAR

23. Dr Neena Raina WHO SEAR

24. Life course – when to intervene? OUR role AFHS/ ARSH

25. Collaboration with Governmantal programs other- India • Annual check up and referral • Nutrition supplementation,WIFS • Immunization • RSH education, Sanitary Pads • Life skills development • Sanitation, Potable water Dr Neena Raina WHO SEAR

26. Acknowledgement I have modified the slides to emphasize the role of IPA and individual members I thank Dr Chandra Mouli WHO HQ Geneva Dr Nina Raina WHO SEAR New Delhi Dr Rajesh Mehta WHO SEAR New Delhi The basic slides for this lecture have been taken from the presentations given during W

27. IPA Adolescent Medicine Open House Meet with and join the IPA Technical Advisory Group on Adolescent Medicine • Sunday, August 25, 2013 • 15:00 -16.00 (3:00- 4.00 PM) • Room 207