[HEALTH]

Girl interrupted

by Carol Aloysius

With teenage pregnancies on the increase, young girls are forced into being mothers long before they are ready for motherhood:

An emerging trend that is fast spreading to all parts of the island, with a dangerous impact on young girls in particular, is the sharp rise in teenage pregnancies. Carried away by their new found liberation and the invasion of modern technology following the prolonged separatist war, youth are riding the crest of a wave. Discretion and responsible behaviour have given way to impulsive and irresponsible lifestyles which more often than not have shattered their youthful dreams more than a landmine could.

The increasing trend in teen pregnancies has become a matter of concern to parents teachers, sociologists and health officials. In Jaffna it was reported that parents blamed the flood of hi-tech gadgets, social media, internet and mobile phones which every teenager in the conservative North now has access, to the sudden spike in teenage pregnancies.

In the North Central Province, especially Anuradhapura where the number of teenage pregnancies has peaked, accusing fingers point to army deserters and the like who after vacating their posts, also left children whose mothers were forced into sexual relationships.

"The rape of minors in the past two decades has been on the rise cutting across religious and cultural barriers," authorities pointed out.

Nevertheless, rape remains one of the most under-reported crimes, in spite of several amendments to the existing law and stiffer penalties to offenders: fear, shame and social stigma being the most commonly given reasons for non reporting.

How do you define rape. What is the health impact of sexual violence on the victim, especially an under-aged girl, we asked Consultant Obstetrician and Gynaecologist, Dr Lakshman Senanayake. “Rape of a minor girl under 16 whether by consent or forced is statutory rape. Most under-aged girls are forced into these relationships with the opposite sex through fear, or bribed with gifts.

Under pressure and coercion

Whatever the method , there is some pressure exerted on her which is a form of rape,” he said. Dr Senanayake pointed out to another group of teenagers between 16 and18 who can consent to sexual relationships under the law. “Although not raped in a legal sense, still they too come under pressure and coercion of their male partners,” he said. “Like their younger counterparts, they more often than not, end up with unwanted pregnancies. We need to look beyond the superficial agreements, the aspect of pressure and coercion should be noted, since the consequence of this kind of violence is often unwanted pregnancies, among teenagers who are still not ready for motherhood.

"It is also mandatory for obstetricians to report all teenage pregnancies that come to their notice to the police. However, this seems to be in conflict with the 'Best interest' principle in the management of children on many occasions he noted. Many of these incidents lead to complicate the life of the teenager, he said.

The sad thing is, that under the provisions of Sri Lanka's law, there is no way the pregnancy could be terminated, except to save the life of the mother. “She has to go through the pregnancy and give birth to the child. It’s like a child having to give birth to another child, as the mother is ill-equipped to play the role of a mother,” he said.

"Worse still, due to social norms, access to family planning methods is also often beyond the reach of these young mothers. However, they could end up getting pregnant again and be forced to seek illegal abortions which can end tragically,” he pointed out.

“There are around 500-750 abortions in our back streets every day, according to reports, although abortion is illegal. Many mothers (whether under-aged or not) end up with the risk of bleeding and infection. Their tubes can get blocked and they can even die or become infertile. It is important that society recognises this aspect of pressure and coercion these teen mothers have to put up with rather than reject or ostracise them and empower them to deal with their problems," he said.

President, Sri Lanka College of Obstetricians and Gynaeclogists, Dr Gamini Perera agreed.

He too notes that these teen mothers are neither physically or mentally mature to be mothers. “They are also engaged in various other activities including achieving their educational goals and improving their career prospects. They don’t have a stable stand in society as a result," he said.

Teenage mothers range from 13 to 19 years. Of this group when asked who were the most vulnerable to negative health impacts brought about by pregnancy, he said it was the younger group – those below 15 years. “

“This is because they are less developed and emotionally still immature. Although they may be physically developed, they are still unable to make proper decisions. Motherhood is a lifetime commitment but all they can think of will be their own career and education. In the end the baby and mother will suffer.”

As their immature bodies are still growing, he said, they would experience problems while delivering the babies. “For one thing, they are unable to bear pain and they will not co-operate with the doctors at the time of childbirth. During delivery, doctors need to examine the mother carefully, internally and externally. For this, we need her fullest co-operation. If this is not forthcoming, it could be a problem to the doctors. The birth passage of a young mother may also not be big enough for the baby to come out.

That may need unnecessary intervention such as a caesarean section delivery. Again, post partum care could be a problem for these mothers if they refuse to attend our clinics, and this will prevent the mother and the infant from getting the care they need to keep them healthy during this critical period,” he said.

Psychological impact

He also drew attention to the fact that motherhood brought certain physical changes in the teenage girl which she may not like.

“Her face becomes more mature and her stomach will stretch after childbirth. There will be vaginal changes and the vulva and the birth passage will also stretch.

Childbirth also leads to weight gain and obesity in a teenage girl. This could have an emotional and psychological impact on the young mother.

One of the reasons for the escalation of teenage pregnancies, he feels is the fact that many young people today are unaware of the basic facts of life.

“Reproductive Health Education is almost non-existent in our schools. Most of our young people learn the facts of life from their peers or from the internet or television. Much of this information is wrong and could also lead to unwanted pregnancies,” he said. What are the schools doing about this gap in sex education, we asked

Head and Co-ordinator of the Schools Nutrition Program, Family Health Bureau, Dr Ayesha Lokubalasuriya, said that an under-aged girl giving birth to a child could be far more dangerous than a young woman in her twenties.

Studies conducted by the Family Health Bureau have shown that maternal deaths due to teen pregnancies was five times higher than maternal deaths in older women."This is because their bodies are still growing.

Due to nutritional problems which are common in the under 16 age group they could become anaemic as this is the age when their bodies experience a rapid growth and they need more iron, vitamins, minerals and proteins. Anaemia in a mother could lead to low weight babies.

They could have post partum haemorrhage due to obstructed labour resulting from a small birth passage,” she said. Since the the young mother was still a child, she was not ready to hug the baby which could lead to growth and mental retardation in the baby.

How does the Schools Nutrition Program hope to rectify these problems and will family planning be introduced into the curriculum, we asked

“As a routine we don’t teach family planning to schoolchildren, but try to empower them to take correct decisions such as saying ‘No’ to someone who may try to take them on the wrong path. We teach them about reproductive health and life skills in our programs.

We also encourage our midwives to refer any pregnant teenager they find in the homes they visit to our clinics. If they need further help we refer them to the Social Services Department,” she said.

Zika babies need support

by Hannah Kuper

Ana Beatriz, a baby girl with microcephaly,  celebrates her fourth month in Lagoa do Carro in Brazil

About 4,000 babies have now been born with microcephaly — abnormally small heads, often with underdeveloped brains — in Brazil alone. Evidence is mounting that this is because of infection during pregnancy by the mosquito-borne Zika virus.

Media attention on the epidemic has mainly focused on how to stop babies being born with microcephaly, whether by killing mosquitoes, finding a vaccine or easing abortion laws. Similarly, the WHO strategic response to Zika focuses on preventing outbreaks and controlling them when they occur. But what are the implications for the thousands of babies born with microcephaly? This is barely considered within the WHO response: disability is mentioned just twice. Microcephaly has many different causes, all with varying impacts. This means the implications for babies with what appears to be Zika-related microcephaly are not yet clear.

But, microcephaly can cause wide-ranging physical and mental disabilities, including learning difficulties, hearing problems and physical impairments. There is already evidence from Brazil that Zika-related microcephaly is linked to eye disease. So the support babies needs will vary, but some basic steps will be6nefit all of them.

Firstly, intervening within the first year of life will improve things for babies at risk of disabilities. Programs should target both the baby’s mother and cognitive skills, as these are intertwined and reinforce each other: Interventions such as physiotherapy or playing games will stimulate the child’s overall development.

These programs should take place within the community, rather than at central clinics, to minimise dropout rates. Information and communications technologies can help too: One program in India for children with disabilities uses community workers and mobile tech to deliver interventions — how to best feed the child, for example — informed by evidence. Despite Brazil’s strong primary healthcare service, support services for children with disabilities are limited. Philanthropic national organisations, fill some of the gaps. But essentially it will be parents, in particular mothers, who will be mainly responsible for caring for children with microcephaly. Interventions are needed to teach parents to better stimulate their child or pick up on cues from their children about what they need. The parents will also need emotional support, particularly as a lot of stigma and discrimination is reported around childhood disability. Evidence shows that parents of children with disabilities can suffer acute anxiety and may feel socially isolated. They may also face financial pressures.

Schools and teachers must adapt so they can give children with microcephaly an effective education. The Beyond Boundaries program in India does this by training teachers in inclusive methods and providing services — such as resource centres stocked with special equipment and adaptive devices. Governments and international health campaigners must act now to ensure these kids aren’t forgotten, so they and their families can have the best lives possible. Hannah Kuper is co-director of the International Centre for Evidence in Disability at the London School of Hygiene & Tropical Medicine, UK. - SciDevNet

Diabetes of tsunami proportions

South Asia is at high risk of Type 2 diabetes :

by Anu Anand

The nutritionist runs a white measuring tape around my waist. I defy the urge to suck in my stomach. I'm 42 years old, a mother of two and a journalist based in New Delhi, one of the world's most polluted cities. I eat organic food, rarely snack and consider myself slim and active.

"It's 87cm," says Chaya Ranasinghe, nutritionist at Sri Lanka's National Diabetes Centre. I'm here to find out why slim-looking Indians and Sri Lankans are increasingly falling victim to Type 2 diabetes – a disease we tend to associate with people who anyone could see were obese.

"It should be 80cm (31.5in) maximum," she replies. "You are 7 cm over."

Thick waists

Chaya is helping me assess my risk for diabetes and the waist measurement is key for people of Asian origin. That's because Asian genes dictate that fat is laid down in the abdominal area.

It's this "visceral" or belly fat – as well as fat inside the liver –that puts us at risk.

"Imaging technology that measures fat in humans has shown that Asians of a healthy BMI have more fat around organs and in the belly area than Europeans with the same BMI, thereby increasing risk," notes a 2009 report in the Journal of the American Medical Association.

Fat makes tissue resistant to insulin, the hormone that regulates blood sugar, so the glucose builds up, and can trigger Type 2 diabetes.

According to research, Asians, and especially South Asians, are more likely to have not only more abdominal fat, but also less muscle, which further increases insulin resistance.

In addition, Asian women are at greater risk of suffering from diabetes during pregnancy, which can put their children at risk of Type 2 diabetes in later life.

That's why the waist measurement - 80cm for Asian women and 90cm for men – is a good indicator of diabetes risk, along with five other factors: family history, smoking, drinking, exercise and stress levels.

My "lifestyle consultation" reveals that I'm at risk on five of those six factors – all except smoking. This is getting serious.

"Asians have what we call the "thrifty" phenotype which means our bodies are designed to conserve energy and lay down food in the form of fat," explains Prof. Chandrika Wijeyaratne, who runs NIROGI Lanka, a diabetes prevention task force.

"But when we conserve energy in today's environment of unhealthy food, we conserve way too much."

Wijeyaratne explains that body mass index (BMI) standards, which help classify people as "normal," "overweight" and "obese,"need to be adjusted for Asians.

For the average Westerner, it takes a BMI of 25 to 30 to be considered overweight, she says, but a person of Asian origin need only have a BMI of 23 to 25.

"It's a misconception that sugar alone causes diabetes."Starch is a big problem too."

Rice reality

Rice is a food I've always considered the epitome of healthy Asian cuisine. But it turns out that white rice, which is polished and processed, is not what my body – genetically speaking – is adapted to.

"You should be eating red or brown rice. White rice has had the husk – or fibre removed, so it's faster to digest. It means you eat more, it fills you up less and turns to sugar more quickly in the blood."

I'm stunned. I eat at least two bowls of rice each day. I've always thought of rice as my birthright –and a healthy one at that. Globally, the WHO says at least 350 million people live with Type 2 diabetes and the number is set to rise to half a billion in two decades' time.

"It's a frightening situation – diabetes is of tsunami proportions and South Asia is at the epicentre," says Wijeyaratne.

China is recognised as the world's diabetes capital with 109 million diabetics, or nearly 10% of the population.

According to the Diabetes Atlas –compiled by the International Diabetes Federation – India has 69 million diabetics (9% of the population.) However, there is insufficient screening in India and only the most rudimentary health system, so the numbers may be far higher. In Sri Lanka, 10% of the population already has diabetes and another 10% show early signs of it - that's a total of four million people.

WHO data indicates that over a quarter of Sri Lanka's population is overweight. Only 17% eat the recommended five or more servings of fresh fruit and vegetables daily and a whopping 88% have one-to-three raised risk factors for diabetes.

"A decade ago, we were talking about Type 2 diabetes in middle age. Now, increasingly, I'm seeing more and more young people, in their 20s, and more worryingly, school children between 12-18 years," says Dr. Manilka Sumanatilleke at the diabetes clinic in the Karapitiya Hospital.

More patients

The country's national health system is struggling to cope with the huge rise in patients with chronic illnesses such as diabetes. Infectious and other communicable diseases now account for only 10% of the demand on the country's health service. Non-infectious diseases – diabetes, cancer and asthma – swallow up the other 90%.At the Colombo National Hospital, Prof. Mandika Wijeyaratne witnesses the human cost of diabetes every day. A surgeon, he amputates the limbs of patients whose untreated diabetes has ravaged blood vessels, leading to loss of feeling and simple, but often catastrophic, injuries.

As I head back to Delhi, I consider my risk factors and plot what changes I can make immediately.

I no longer eat white rice. Instead and I've switched to red rice. I must do more exercise, but Delhi is a dense, chaotic urban jungle where pavements are broken, traffic omnipresent and clean parks few and far between. It's become the world's air pollution capital with levels of fine toxic particles twice as high on average as Beijing's.

In truth, most days the only exercise I get is walking the ten steps from my bedroom to my office, where I sit editing or writing on my computer. Even when I need to get out and about, it's by car, the fastest, safest option.

But I've seen my grandmother die from diabetes complications. And recently my father, who has stubbornly refused to confront his blood sugar levels, was diagnosed with retinopathy, where diabetes damages the fine blood vessels in the eye. Vision loss is irreversible.I may not escape the same fate unless I accept that my DNA is unforgiving and make drastic changes in my behaviour now.

For me, those changes include a decision to move somewhere less polluted, where physical exercise is easier.

For millions of South Asians, arresting the runaway growth of diabetes will have to wake up to the problem, making fundamental changes to the way people eat, work and play.

Anu Anand presents a new series The Truth About Diabetes on the BBC World Service. The series covers Sri Lanka, Mexico, Tonga and the United States, and asks how governments, healthcare and big business are responding to a crisis that is spiralling out of control.

-BBC