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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.