TRENDS AND POLICIES. Trends in child mortality. Trends in maternal mortality. Trends in maternal indicators

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1 Maternal and Newborn Health Country Profiles Cambodia Cambodia has achieved MDG 4 and is on track to achieve MDG 5. The annual rate of reduction in the under-5 mortality rate was 4.8 between 1990 and This impressive progress, unfortunately, has not benefitted all women and children equally eluding those living in rural areas, the poor and the very young (newborns in their first 28 days of life). Improving the quality of antenatal care and addressing the geographical and financial barriers to institutional delivery would make a massive difference in maternal and child health across all strata of the country. TRENDS AND POLICIES Deaths per 100,000 live births Under-5 mortality rate Trends in child mortality MDG target * 50 Infant mortality rate 38 Trends in maternal mortality MDG target Maternal mortality ratio *MDG target achieved in Neonatal mortality rate National health policies and services Availability Per capita expenditure on health 45 (US$), Out-of-pocket expenditure (% of private 64.3 expenditure on health), Specific notification of maternal deaths Midwifery personnel authorized to administer core set of lifesaving interventions Costed national implementation plans for maternal, newborn and child health available Number of basic emergency obstetric and newborn care facilities Sources: Confirmed by UNICEF Cambodia Country Office unless specified; 1 World Health Organization National Health Account database 2012 (retrieved from org); 2 As of November Yes 3,678 midwives deployed Yes 41 2 Facilities per 1,000 births 3 Community treatment of pneumonia with antibiotics Oral rehydration solution and zinc for management of diarrhoea No Yes Trends in maternal indicators DHS 2005 DHS 2010 Per cent (%) Contraceptive prevalence rate (met need) Unmet family planning need Women married before age Adolescent birth rate Sources for figures: Trends in child mortality: 1990 and 2010 child data from UN Inter-agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, 2011; 2015 targets from WHO/UNICEF Countdown to 2015 Cambodia Country Profile, 2012 and Cambodia MDG report, 2010 for IMR. Trends in maternal mortality: 1990 and 2010 from WHO/UNICEF/UNFPA/The World Bank, Trends in Maternal Mortality: 1990 to 2010, 2012; 2015 targets from WHO/UNICEF, Countdown to 2015 Cambodia Country Profile, 2012 Trends in maternal indicators: Cambodia DHS 2005 and Notes: Contraceptive prevalence rate proportion of currently married women age who were using some method of family planning at the time of the survey; unmet family planning need: % of women with an unmet need for family planning (spacing or limiting); adolescent birth rate: annual number of births among women aged per 1,000 women in the age group. Maternal and Newborn Health Country Profiles: Cambodia 1

2 Indicators of quality of care Antenatal care Intrapartum/delivery Postnatal care Per cent (%) ANC1+ ANC4+ BP measured* Blood sample* Urine sample* SBA Inst. delivery C-section BF (excl.) PNC within 2 days PNC within 4 days Birth reg. Source: Cambodia DHS Notes: ANC1+: % of women who received 1 ANC visit; ANC4+: at 4 ANC visits; *% of ANC visit that included measuring blood pressure (BP) and collecting blood and urine samples; SBA: % of births delivered by a skilled birth attendant (doctor, nurse, midwife); inst. delivery: % of births delivered at a health facility; C-section: % of births delivered by caesarean section; BF (excl.): % of children younger than 6 months who were exclusively breastfed; PNC within 2 days: % of women who received a postnatal check-up within 2 days of delivery (calculated by adding the sum of the % of women who received PNC within less than 4 hours, 4 23 hours and within 2 days of delivery and mentioned in the DHS); birth reg.: % of children younger than 5 years whose birth was registered with the State. Availability of national policies 1 for high-impact interventions shown to improve neonatal survival throughout the continuum of care 2 Preconception Antenatal Intrapartum Postnatal - Iron and Folic acid supplmentation - Tetanus toxoid immunization - Syphilis screening and treatment - Pre-eclampsia and eclampsia prevention and care - Presumptive malaria treatment - Detection and treatment of asymptomatic bacteriuria - Skilled maternal and neonatal care - Emergency obstetric care - Antibiotics for PROM - Steroids for preterm labour - C-section - PMTCT - Labour surveillance - Clean delivery practices - Resuscitation of newborn baby - Breastfeeding - Prevention and management of hypothermia - Kangaroo mother care - Community-based diarrhoea management - Emergency neonatal care Legend: green: national policies address these interventions; red: no clear national guidelines for these interventions. Sources: 1 The interventions were addressed in the Kingdom of Cambodia National Strategy for Reproductive and Sexual Health in Cambodia ; 2 Darmstadt et al., Notes: PROM: Premature rupture of membranes; emergency obstetric care: management of complications-obstructed labour, haemorrhage, hypertension, infection; C-section: caesarean section (detection and management of breech); PMTCT: prevention of mother-to-child transmission of human immunodeficiency virus (HIV); labour surveillance (including partograph) for early diagnosis of complications); kangaroo mother care (care for low birth weight infants in health facilities); emergency neonatal care: management of serious illness (infections, asphyxia, prematurity, jaundice). Reference: Darmstadt, G.L. et al., Evidence-Based, Cost-Effective Interventions: How many newborn babies can we save? The Lancet, 2005: 365 (9463). 2 Maternal and Newborn Health Country Profiles: Cambodia

3 READINESS FOR NATIONAL SCALING UP OF NEWBORN CARE Agenda setting - National needs assessment for newborn care conducted - Local evidence generated for newborn survival - Existence of a convening mechanism for newborn health issues - Focal person for newborn health in Ministry of Health - Maternal and newborn indicators included in national surveys (e.g. neonatal mortality rate) Policy formulation - National newborn policy endorsed - Newborn policy integrated into other health policies or strategies - Essential drug list includes injectable antibiotics for primary level care - Midwives authorized to perform neonatal resuscitation (at all levels) - Primary-level cadres authorized to perform neonatal resuscitation - Primary-level cadres authorized to administer injectable antibiotics for newborn infections - Maternal and newborn indicators included in national health information systems - Reproductive, maternal, newborn and child expenditure per child younger than 5 years and per woman aged National targets to track newborn health established Policy implementation - Cadre identified for home-based newborn care (Village Health Support Volunteers) - In-service newborn care training materials for community-based cadres - In-service newborn care training materials for facility-based cadres (part of integrated postpartum care training module) - Pre-service newborn care education for facility-based cadres - Pre-service newborn care education for community-based cadres - Resource requirement for primary health care level available for newborns - Resource requirement for secondarylevel health care available for newborns - Protocol or standard for district hospital care of sick newborns in place Agenda setting - Local evidence disseminated for newborn survival (partial) Policy formulation - National behaviour change communication strategy (partial; only covers newborn pneumonia) - Community-based cadres authorized to administer injectable antibiotics for newborn infections - Community-based cadres authorized to perform neonatal resuscitation - Costed implementation plan for maternal, newborn and child health (in process) Policy implementation - Supervision system for maternal, newborn and child health established at primary health centre level (partially functioning) - Integrated management of childhood illness algorithm adapted to include the first week of life - Resource requirement for scaling up home-based newborn care available (partial) - System for perinatal death audits exists - System for neonatal death audits exists (under development) Legend: green: benchmark met; red: benchmark not met/partially met. Source: Moran, A.C. et al., Availability of benchmarks as per the UNICEF Cambodia Country Office. Reference: Moran, A.C. et al., Benchmarks to Measure Readiness to Integrate and Scale Up Newborn Survival Interventions, Health Policy Planning, 2012: 27 (iii29-iii39). Maternal and Newborn Health Country Profiles: Cambodia 3

4 CONTINUING INEQUITIES: Indicators by residence, wealth quintiles and provinces Disparities by residence Disparities by residence U5MR IMR NMR Urine sample BP measured Blood sample Disparities by wealth quintiles PNC within 2 days Birth reg DPT Most and least affected provinces U5MR IMR NMR Poorest Wealthiest Poorest Wealthiest Per cent (%) Per cent (%) Per cent (%) Disparities by wealth quintiles SBA C-section Inst. delivery Most and least affected provinces Urine sample SBA Birth reg Poorest Wealthiest Poorest Wealthiest PV/ST PP PV/ST PP Kratie PP OMC PP Pursat PP MK/RK BMC Source: Cambodia DHS Notes: Comparison of data is by residence (rural versus urban versus country ), wealth quintiles (poorest versus richest versus country ) and by district (most affected versus least affected; urine sample (obtained during ANC visit); SBA: % of pregnancies delivered by skilled birth attendant; birth reg.: % of children younger than 5 years whose birth was registered with the State. Provinces: PV/ST: Preah Vihear/Steung Treng; PP: Phnom Penh; MK/RK: Mondol Kiri/Rattanak Kiri; OMC: Otdar Mean Chey; BMC: Banteay Mean Chey. 4 Maternal and Newborn Health Country Profiles: Cambodia

5 EQUITY FOCUS: Indicators by residence, wealth quintiles and provinces Indicator Residence Quintiles Rural Urban Poorest Wealthiest Most and least affected provinces U5MR (country avg: 51 per Levels & Trends 2011 report and 54 per the Cambodia DHS 2010) NMR (country avg: 22 per Levels & Trends 2011 report and 27 per the DHS 2010) IMR (country avg: 43 as per Levels & Trends 2011 report and 45 per DHS 2010) Pre-pregnancy Contraceptive prevalence (any method; country avg: 50.5%) Antenatal Informed pregnancy complication signs at ANC (country avg: 80.0%) M: Preah Vihear/Steung Treng (118); L: Phnom Penh (18) M: Kratie (47) L: Phnom Penh (8) M: Preah Vihear/Steung Treng (95); L: L: Phnom Penh (13) M: Preah Vihear/Steung Treng (37.3); Kandal (61.8) M: Otdar Mean Che (61.4); L: Pursat (98) ANC1 (country avg: 89.3%) ANC4 (country avg: 59.4%) Urine sample taken at ANC, % (country avg: 36.4%) Blood pressure taken at ANC (country avg: 90.6%) M: Kratie(5.1); L: Siem Reap (61.2) M: MK/RK (75); L: Siem Reap (98.8) Blood sample taken (44.5) M: Kratie (15.9); L: Phnom Penh (74.8) % of women whose last birth was protected against neonatal tetanus (country avg: 85.3%) M: MK/RK (62.1); Phnom Penh (97.4) Intrapartum Skilled birth attendant at delivery (country level: 71%) M: Preah Vihear/Steung Treng (28.2); L: Phnom Penh (98.8) Institutional delivery (country avg: 53.8%) M: Preah Vihear/Steung Treng (21.2); L: Phnom Penh (93.3) Percentage delivered by C-section (country level 3%) M: Takeo (0.8); L: Phnom Penh (9.9) Postpartum No postnatal check-up (country avg: 26%) M: Kratie (79.4); L: Kampong Speu (5.5) % PNC within 2 days of delivery (sum of <4h, 4-23h and 1 2 days after delivery; 70.4%) M: Otdar Mean Chey (45.1); L: Phnom Penh (96.8) Birth registration (country avg: 62.1%) M: Pursat (34.9); L: Phnom Penh (81.6) Median duration of exclusive breastfeeding for children born in the last 3 years (mean for all children: 4.9 months) Children younger than 5 years % who received ORS or RHF (country level: 52.6%) % continued feeding and given ORT and/or increased fluids (country avg: 48%) % of under-5 children with symptoms of ARI whom advice or treatment was sought from a health facility or provider (country avg: 64.2%) M:Kandal (2.2); L: Svay Rieng (5.5) M: Battambang/Pailin (38.4); L: Otdar Mean Chey (76.5) M: Preah Vihear/Steung Treng (28.7); L: Pursat M: Battambang/Pailin (48.9); L: Svay Rieng (83.4) % of under-5 children with symptoms of ARI prescribed antibiotics (country avg: 39.1%) M: Battambang/Pailin (13.4); L: Pursat (76.8) DPT3 (country level: 84.8%) M: Mondol Kiri/Rattanak Kiri (40); L: Banteay Mean Chey (95.6) Source: All data from the Cambodia DHS, 2010 unless specified; UN Inter-agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, Data for the following provinces is missing: Bantaey Mean Chey, Kampong Chnang, Kampong Speu, Kandal, Phnom Penh, Prey Veng, Siem Reap, Preah Vihear/Steung Treng. Note: In 2006, the Cambodian National Immunization Programme replaced the DPT vaccine with a tetravalent vaccine that includes DPT, Hib and Hepatitis B vaccine (HepB). Maternal and Newborn Health Country Profiles: Cambodia 5

6 Fairer public funding shortens both social and physical distances to health care Spotlight on UNICEF work Greater public investment in health programme coverage is paying high dividends in Cambodia. This combined with the innovative introduction of the Government s performance incentive scheme for midwives in 2008 and a steady expansion of Health Equity Funds to reduce financial barriers has led to clear progress. Achievements remain unevenly spread across the society, however; though closing in some areas, lower socio-economic groupings continue to have poorer health service access and poorer health outcomes. Poverty is a dominant cause of inequity in health outcomes and in coverage of health care interventions, but it is not the only cause. Other dimensions of poverty, vulnerability and exclusion are also important sources of inequity in access to health services: lack of maternal education, mobile communities, remote communities far from health facilities or lacking year-round road access, ethnic minority communities, local traditions and beliefs that dis-empower women, migrants and new unregistered settlements. These factors reduce demand for health services. They also operate on the supply side: such communities receive less frequent or no outreach, are likely to be in communes without a health centre or with a shortage of staff, particularly midwives. Children are at higher risk of missing out on immunization in communities, such as mobile, remote, ethnic minority, migrant, urban poor or unregistered villages. In Cambodia, approximately 30 per cent of the population has one or more of these higher-risk characteristics. According to the 2011 Reaching the Unreached for Health Care Services in Cambodia, distances are stretched by lack of capability, lack of money, lack of knowledge and the strong sense of isolation and exclusion that some of the poor families are experiencing. Thus, what is far cannot be measured objectively in health planning categories, such as distance from facility or walking time to facility. The research results made an imperative case for health planners to integrate social distance with geographic distance to arrive at a more realistic picture of access and how to improve it. By bolstering such innovative, specific and disaggregated data and evidence, UNICEF is engaging the Government in discussions on the bottlenecks that prevent disadvantaged children from fulfilling their rights. UNICEF advocacy led to a 60 per cent increase of resources from the Second Health Sector Support Programme, Cambodia s largest health partnership arrangement, allotted to outreach and other primary health care activities for the poorest and most remote areas. UNICEF provided advocacy and technical support to the Ministry of Health to revise its outreach guidelines (including the budget component) to ensure hard-to-reach communities are regularly reached (at least quarterly) with an integrated package of preventive health services, micro planning to ensure unregistered communities are covered and with higher budgets and allowances for hard-to-reach villages or communities. Background UNICEF research found that many mothers and children in abject-poverty pockets of villages had never seen a health centre or a health care worker. There were frequent expressions by women who were poor that they were afraid to attend health facilities or that they did not want to disturb village authorities for assistance. Of the health care providers, many of the poor people interviewed said they do not so much look at us or they ask for money first. distances are stretched by lack of capability, lack of money, lack of knowledge and the strong sense of isolation and exclusion that some of the poor families are experiencing Communes in 12 of Cambodia s 24 provinces have received resources, training and tools for prioritizing social spending with commune funds, which include providing transportation for pregnant women to health centres, community preschools and safe water and sanitation facilities. UNICEF is working at the national level towards equity-focused resource distribution within the decentralization and public finance management reforms to ensure sustainability of commune funds. In 2013, UNICEF is supporting a local fund in which communes receive US$1,000 per year that could be used for a range of activities to improve vulnerable population s access to social services including maternal and newborn health, such as awareness raising and covering expenses for expecting mothers in emergency medical situations. A mother with her newborn and post-natal care package (including iron folate, Vitamin A and mebendazole) in a referral hospital in Kratie CAMBODIA/August 2012/Vung 6 Maternal and Newborn Health Country Profiles: Cambodia

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