annex 1 - baseline assessment report -final
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Baseline Assessment Report for the
Adolescent Safe Motherhood Project, Balangiga and Tacloban City, Region
VIII, Philippines
Prepared by - Tenaw Bawoke, Medical Coordinator
Tacloban City,
February 2015
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1. Background: Typhoon Haiyan (local name Yolanda), the strongest typhoon
recorded, struck the Philippines last November 8, 2013 and caused massive
loss of lives and immense destructions in the Visayas Region of the country.
It was then followed by lots of landslides throughout the affected
regions. As it exited the Philippines, it has left at least 6,201 people dead
immediately and thousands remain missing. The number of casualties
continued to rise with local officials estimating as many as 10,000 people may
have died in Tacloban City alone. According to the report from the National
Disaster Risk Reduction Management Council of Philippines, an estimated
16,078,181 people have been affected by Typhoon Haiyan leaving 4,095,280
people displaced. It is estimated that approximately 221,849 pregnant
women and 147,899 lactating mothers in all disaster-hit areas have been
affected and potentially lack access to essential maternal health and newborn
services. According to World Health Organization (WHO), three months post
Typhoon Haiyan, it was predicted that there would be more than 70,000
births across the typhoon-affected areas, of which about 8500 (12.1%) will
be from adolescent mothers under 19 years old. Teenage pregnancies are
considered high risk pregnancies that could lead to serious medical
complications.
In response to the above mentioned catastrophic damage, as part of its
comprehensive post Typhoon Haiyan response interventions, International
Medical Corps has planned to address the needs of adolescent girls (teenage
pregnant women and lactating mothers) through the Safe Motherhood project.
This project, to be implemented during Feb-Oct, 2015 is planned to ensure that
adolescent girls in Tacloban City and Balangiga Municipality have access to
information and services about sexual and reproductive health including
antenatal care, skilled delivery services/basic emergency obstetric care,
postnatal care, voluntary family planning services and appropriate care for their
newborns in an adolescent friendly health facility.
The Safe Motherhood Project, funded by UNICEF, aims to improve
accessibility of pregnant adolescents and their newborns to quality maternal
and newborn healthcare services at the Main Health Center in Tacloban City
and Rural Health Unit of Balangiga in Balangiga Municipality with the
objective of:
a) Providing quality antenatal care services to pregnant adolescent girls b) Providing quality basic essential obstetric care services to pregnant
adolescent girls c) Providing quality neonatal care services to pregnant adolescent girls d) Providing quality postnatal care services to pregnant adolescent girls
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e) Providing quality family planning services to adolescent girls
This project will support UNICEF’s advocacy for measures to give children the
best start in life and for the attainment of MDG 4 (Reduce Child Mortality)
and MDG 5 (Improve Maternal Health). This project also will document
promising practices for the provision of essential sexual and reproductive
health for adolescents (including safe motherhood approaches) and to share
key learnings with Government and development partners for sustainability
and scale-up in the nominated geographic areas and for replication across
the Philippines.
2. Scope of the assessment: This assessment is the baseline assessment for the
Safe Motherhood Project having both quantitative (health facility assessment)
and qualitative (Key Informant Interview) parts. The health facility assessment
has captured data about the existing safe motherhood services being provided
to adolescent girls that includes the facility readiness and service provision
processes. The readiness includes assessing the space, number and skill of
staffing, supplies, medication, and youth friendliness of the facilities; while the
process includes how the antenatal care, delivery, postnatal care,
immunization, newborn care, family planning and documentation services are
being provided. Key Informant Interviews (KII) were also conducted separately
with key government officials (one provincial level and two municipality level
officials) and health providers at each health facility serving the adolescent
girls at both sites (Tacloban City and Balangiga Municipality) using different KII
tools for managers and providers.
3. Objective: The overall objective of this baseline assessment is to document
baseline data at both target sites on the magnitude of the problem and volume
and range of maternal and newborn health services provided to adolescent girls
and their newborns, health staff capacity to provide such services and
adolescent-friendliness (i.e., quality) of services. Specific objectives include:
a. Assessing the health facility readiness (youth friendliness, space adequacy, availability of trained staff, supplies, equipment and medications,…) for adolescent maternal and newborn health services
b. Assessing the magnitude of adolescence pregnancy and outcomes during the year 2014, a year before the project
c. Assessing the number and proportion of children born from adolescent girls (<19 yrs old) protected against tetanus at birth during the month of January 2015 as baseline
d. Assessing the number and proportion of adolescent girls (<19 yrs old) reached with family planning services during the month of January
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2015 as baseline e. Assessing the number and proportion of adolescent pregnant girls
( < 1 9 y r s o l d ) with at least 4 antenatal care visits during the month of January 2015 as baseline
f. Assessing the number and proportion of adolescent pregnant girls (<19 yrs old) who receive nutrition counseling during the month of January 2015 as baseline
g. Assessing the number and proportion of deliveries attended by skilled birth attendants during the month of January 2015 as baseline
h. Assessing the number and proportion of post-partum adolescent girls
with at least 2 post-partum visits during the month of January 2015 as baseline
i. Assessing the number and proportion of pregnancy by outcome (term, preterm, fetal death, abortion) during the month of January 2015 as baseline
j. Assessing the number proportion of live births by weight (>=2,500 g, <2,500, unknown) during the month of January 2015 as baseline
k. Assessing the magnitude of the problem and nature of existing interventions for adolescent maternal and new born health services (KII)
4. Methodology and Process
4.1. Assessment Team: International Medical Corps has conducted the baseline
assessment using the health team who are familiar with the local health system.
The assessment team is comprised of four staff; the Medical Coordinator who led
the overall assessment process, prepared tools, provided technical guidance and
compiled reports; the health program officer who led the field data collection
process; and the clinical nurse and data entry officer who have conducted the
facility based data collection.
4.2. Data sources: Secondary data from public health facilities registration
books and primary data from government health officials and adolescent health
service providers were collected during the assessment.
4.3. Study design: Descriptive study design was used and the assessment was
conducted using semi-structured health facility assessment checklists and key
informant interview guides.
4.4. Data Collection Process: The data collection process was completed in ten
days including half day orientation session, five days of data collection and on
spot data entry and four days of data compiling. A team of two members (clinical
nurse and data entry officer) were assigned to collect the quantitative data and
the medical coordinator and program officer have collected the qualitative data.
All the data collectors were oriented on how to conduct health facility assessment
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in the field and how to gather the required information during a half day
orientation workshop which was held at IMC Tacloban office. Every day, after
finalizing the daily data collection process, data was checked by the Medical
Coordinator, discussions with the team were held to make any adjustments to
the process or tools, and the ways forward were designed for the next day.
4.5. Assessment Tools: Semi-structured health facility assessment and
observation checklist was used for the quantitative data and KII guide was used
for the qualitative data. The quantitative tool had two components; one for the
baseline data and the other for the medical supplies, equipment and medication
needs assessment. For the qualitative data, two types of KII guides were used;
one for health managers and the other for health providers. The WHO RH
assessment checklist, IMC SRH rapid assessment tool and Pathfinder’s rapid
adolescent sexual reproductive health (ASRH) assessment tools were used to
adopt the tools.
4.6. Data Management and Analysis: The data collection team have entered the
data on spot to the data collection tool. The data has been then compiled together
by the Medical Coordinator. Key Informant Interview responses were submitted
to the Medical Coordinator and the results were manually analyzed and
documented by the Medical Coordinator. Then, the analysis of both quantitative
and qualitative data was completed and the draft report was drafted by the
Medical Coordinator.
5. Results and discussion
5.1. General Information – Balangiga is a municipality under Eastern Samar
north-east of Tacloban city with total population of 13,720. The municipality is
divided in to 13 Barangays and it has 3 basic health stations (BHSs) named Sta
Rosa, Bacjao and Guimayohan BHSs. The second pilot area of this project, the
main health center catchment of Tacloban City, is the most populous district of
the City with 45 Barangays. The catchment population for Tacloban is 21,579
which makes the total population for this project 35,299.
5.2. Health Facility Readiness; adolescent friendliness
During the assessment, both Tacloban City main health center and Balangiga
rural health unit (RHU) did not have separate rooms for adolescent SRH services,
such as consultation, counselling, family planning, ANC, PNC and vaccination
services, and the existing common rooms were not also comfortable for auditory
and visual privacy for sensitive issues like ASRH. Both the Tacloban City main
health center and Balangiga RHU use consultation and procedure rooms
together for all service users and data collectors have observed that discussions
between the service user and the service provider can be heard from outside as
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doors. Additionally, windows are usually open and people, aside from the patient
and doctors, occasionally will enter into the room during adolescent
consultations. Some windows are also covered with light curtains and one can
see what is happening in the room from the outside. Both target health facilities
have general waiting areas for all adult and adolescent users together.
The respondents from both facilities reported that the general staff has been
oriented to be friendly to adolescent service users, though it was not possible by
this cross-sectional assessment to know about the details of the orientations.
Adolescent users usually prefer morning and lunch times for consultation in
health facilities, though both health facilities do not have separate time
earmarked for teenager and young users.
Both health facilities have signs indicating services in the clinic, though the signs
lack details regarding working hours and exact room locations. Both health
facilities are not far from the majority of user adolescent communities, including
schools and places where they usually spend their free time, the average distance
being 1 km. However; there are still communities in Balangiga that are far from
the RHU, which they use as their main health facility.
Pregnancy tests for adolescent users is available in both facilities during the time
of this assessment. Both sites reported that there are not any active adolescent
and youth peer education or discussion services provided at health facility and
community levels. The only way health providers could get adolescents is when
they report to the health facilities. When adolescents visit facilities by
themselves, the registration, reception and consultation processes are not
private, enabling others to easily hear the reasons one attend the health facilities.
On average, adolescents have to wait 10-15 minutes for the service in Tacloban
and a bit more time (up to 20 minutes) in Balangiga. However; when there is a
client load in the facilities, they will wait for a longer period of time, as they are
treated mixed with the general client in the health facilities. Both facilities
reported that adolescents can be seen by a health provider without appointment
and alternative appointments may be given if needed.
Regarding payments, most ASRH services including ANC, normal delivery and
PNC consultation services are free in both assessed health facilities, though there
may be payments if laboratory investigation is needed and medication is
prescribed, which sometimes are not affordable by some adolescents.
In both facilities, there is no any job aid and information and communication
materials that can be used by service providers shared to adolescent service
users.
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5.3. Staffing; Technical staff readiness and referral pathway
Table 1 – Technical staff distribution
Category of Staff Balangiga Tacloban City Main Health
Center
Municipal Health Officer (MD) 1 1
Public Health Nurse 1 5
Midwife 4 15
TBA (in facility) 0 0
TBA (in community) 0 0
Medical Assistant 0 1
General Physician (MD) 0 1
Other (specify): NDP- Nurse 6 2
Total 12 24
As the above table indicates, there are 12 technical staff working in Balangiga
and 24 in the main health center of Tacloban city with one general practitioner
in Balangiga and two in Tacloban City main health D center.
During the assessment, it was revealed that in Balangiga there was not any
provider trained on adolescent friendly SRH service provision named in the
Philippines as Adolescent Job Aid (AJA) training and there were three providers
trained on AJA in Tacloban on December 2014. However; none of the AJA trained
health providers in Tacloban were implementing adolescent friendly SRH
services during the time of assessment. Regarding Basic Emergency Obstetric
and Newborn Care (BEmONC) trainings, three providers (a doctor, a nurse and
a midwife) were trained from both facilities in 2012 for Tacloban and in 2007 for
Balangiga. Trained providers in both facilities are implementing the skills they
have received from the trainings though refresher training should be considered.
Essential Intra-partum and Newborn Care (EINC) training was also provided in
Tacloban in 2013, while EINC training was not provided in Balangiga. No other
SRH trainings including family planning and abortion related trainings were
provided in either health facility.
During the assessment, it was indicated that the referral pathway for labor and
other pregnancy related issues was as follows: Home – BHS – RHU – Provincial
Hospital – Eastern Visayas Regional Medical Center (EVRMC). Both facilities
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have confirmed that they have ambulances to transport patients from BHS to
RHU and from RHU to hospitals. However, the Tacloban City main health center
reported that the ambulance is ready only Monday to Friday for eight working
hours. In Balangiga, the ambulance is ready for 24 hours and 7 days a week,
with exceptions of when there is a problem on the ambulance, such as fuel
shortage which sometimes happens.
5.4. Adolescent pregnancy during the year before the program (2014)
Table 2 – Adolescence (<19 years old) pregnancy and its outcomes during
2014
Balangiga Tacloban City
Main Health Center
Remark
Number of adolescents who were pregnant in
2014
63 48
Abortion 0 0
Still birth 0 0
Facility based
delivery
33 11
Home Based
Delivery
4 0
Unidentified
place of delivery
20 27 Problem of
recording and documentation in both target areas
Still pregnant during the time of
assessment
6 10
As the above table indicates, there were 63 and 48 adolescent girls who were
pregnant during the year 2014 in Balangiga and under the catchment area of
the main health center in Tacloban, respectively. International Medical Corps
has attempted to know the proportion of facility versus home delivery. However;
because of poor documentation and recording, International Medical Corps could
not identify the place of birth for 20 girls in Balangiga and 27 in Tacloban.
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5.5. Condition of the adolescent safe motherhood services a month before
the program (January 2015)
Table 3 – major adolescent safe motherhood conditions during January
2015
Adolescence
motherhood condition
Balangiga Tacloban main
health center
Remark
No % No %
Newborn Protected at
Birth from Tetanus
1 33.3% 2 50%
At least 4 ANC
coverage
2 66.7% N/A N/A Data in
Tacloban was not available
Nutrition counseling during pregnancy
1 33.3% 2 50%
Facility Based delivery 2 66.7% 4 100%
At least 2 PNC coverage 1 33.3% 2 50%
Pregnancy outcome – term/preterm
3/0 100%/0% N/A N/A Data in Tacloban
was not available
Birth weight – normal/under weight
2/1 67%/33% N/A N/A Data in Tacloban was not
available
As Table 3 above indicates, there were three adolescent deliveries registered in
Balangiga and four in Tacloban City under the catchment of the main health
center. Though the sample size (deliveries in the month) is small, International
Medical Corps believes that it is still representative of the monthly services in
these two health facilities, as situations and services are similar across the
recent months in these two sites. Thus, the proportion of children born from
adolescent girls protected at birth from tetanus is relatively better in Tacloban
(50%) than Balangiga (33%). The ANC coverage (at least 4 visits) for adolescent
pregnant ladies in Balangiga is also lower (66.7%) compared to regions plan of
>95% coverage. Nutrition counseling during ANC visits is also very low in
Balangiga (33%) and low in Tacloban (50%). PNC (at least 2 visits) was also very
low in Balangiga (33%) and low in Tacloban (50%). Tacloban City main health
center had problems in data recording and management and we couldn’t get data
about ANC visit, birth outcomes and weight of the newborn babies.
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5.6. Availability of medicines and medical supplies at the beginning of the
program
During the assessment, a facility audit was conducted to check the availability
and adequacy of basic SRH supplies, medicines and equipment at the primary
health care level. It was found that generally both health facilities had an optimal
level of supplies, including infection prevention supplies, basic equipment for
ANC, basic items for delivery, newborn supplies, vaccines, contraceptives,
antibiotics, antihypertensive, anti-consultants and other basic SRH supplies.
However; there was still a shortage of items including antibiotics, infection
prevention supplies, antihypertensive, anti-consultants and laboratory reagents.
Thus, IMC has started addressing the gaps by procuring and prepositioning
missed SRH supplies.
5.7. Opinions of health managers and providers about ASRH - KII
To triangulate the quantitative results, IMC also conducted Key Informant
Interviews (KII) with key government officials (one provincial level and two
municipality level officials) and two health providers at each health facility
serving the adolescent girls at both sites (Tacloban City and Balangiga
Municipality) using different KII tools for managers and providers.
According to the health managers interviewed, the major problems affecting
adolescents are shortage of youth friendly services and places, engagement of
adolescent in unhealthy activities, unprotected premarital sex leading them to
teenage pregnancy and STI/HIV infections, smoking, alcohol use, drug
addiction, joblessness and some moral and ethical problems. According to the
participants of the KIIs, premarital sex and teenage pregnancy are the major
SRH problems in their respective provinces and municipalities. Participants of
the KIIs suggested that both health facility and community level interventions
should be strengthened to minimize premarital sex and teenage pregnancy and
to keep adolescents in schools and colleges. Education and community
awareness activities should be implemented so that adolescents will be able to
avoid early sexual engagement and be able to be self-assertive and
knowledgeable to avoid unplanned and unprotected sexual engagement.
Interviewed managers have raised that a range of factors including maturity,
family, and religious and cultural challenges are hindering pregnant teenagers
from receiving timely antenatal care, health and nutrition counseling and
immunization services during their unplanned pregnancies. Pregnant
adolescents usually intend to hide their pregnancy even after they have learnt
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that they are pregnant, fearing the family and societal responses. Other barriers
participants of the KIIs mentioned are economic and level of awareness about
where these services are available free of charge.
All three interviewed managers have explained that the country has a fertile
policy in favor of adolescent SRH including the recently approved Reproductive
Health Bill, national ASRH strategies and Adolescent Job Aid (AJA) training
manuals in place to improve the ASRH situations in the country.
The interviewed public health nurse in Tacloban and the midwife in Balangiga
have also strengthened comments from the managers. They mentioned that
adolescents do not visit health facilities unless they are sick or getting pregnant.
They usually have limited knowledge and life practice about timing and
consequences of sexual intercourse. When adolescents visit health facilities,
they mentioned that they have learnt little about sexual bargaining,
consequences of unprotected and casual sex and problems associated with
teenage pregnancy.
Health providers have suggested that there should be peer education programs
at community level so that adolescents can share ideas and experience within
their peer groups. They also suggested that parents/guardians of pregnant
teenagers should also be counselled to support their girls and their male
partners/spouses should also be involved so that they will support the
adolescent pregnant girls to enable them psychologically stable, to seek health
services timely and to be well prepared for birth and newborn care.
Both managers and providers asked IMC to support health facilities in capacity
building trainings, provision of supplies and conducting mentoring and
couching supervisions. They also requested IMC support community level
adolescent adolescent/youth education activities by improving the capacity of
peer educators and community health team members and barangay health
workers.
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6. Conclusion
This rapid baseline assessment enabled IMC to understand the ASRH services in
general and adolescent safe motherhood services in particular both in Tacloban
City and the municipality of Balangiga. Points mentioned below are conclusions
from this assessment:
SRH services in both sites are not adolescent friendly with challenges
including shortage of space, lack of appropriate timing for adolescent
consultations, lack of services which ensure privacy and confidentiality of
adolescents and shortage of trained and skilled manpower.
However; there are some efforts to make SRH services reachable by
adolescents that includes efforts by the health system to avail training
materials, supplies and equipment and orienting the general health staff
about handling adolescents when they visit health facilities.
Teenage pregnancy and adolescent safe motherhood issues are the major
health problem in both sites and both health officials and health providers
have acknowledged the problems and are working with different partners
including IMC to address the problems.
Availability of adolescent safe motherhood services in both sites are limited
with low services coverages including ANC, PNC, health and nutrition
counseling and family planning services.
Supplies and medications necessary for adolescent safe motherhood
interventions are fairly available in both health facilities with some items
missing that can be provided by IMC for the project period and can easily
be taken over by government.
7. Recommendations
There should be adolescent friendly SRH services in both sites so that
adolescents will be attracted to services.
Midwives, nurses and doctors should be well training on adolescent friendly
SRH and safe motherhood service provision.
Adolescent safe motherhood data should be properly recorded and
maintained in health facilities
ASRH and safe motherhood medications, supplies and equipment should
be fulfilled in health facilities
There should be a strong community mobilization and peer education
interventions so that every pregnant adolescent can get timely and
necessary antenatal care, facility based delivery, postnatal care, health and
nutrition screening and counseling and immunization services.