Lao People s Democratic Republic

Maternal and Newborn Health Profiles Lao People s Democratic Republic Lao PDR is among the top 10 countries achieving the highest reduction in under-5 mortality between 1990 and 2011, with an annual rate of reduction of 6. The country is on track to achieve MDG 4 but will require further investments in health care to impact its high neonatal mortality and to reach deep into the rural and remote populations, including among its many ethnic mirities. Lao PDR has achieved MDG 5, although the maternal mortality ratio is still among the highest in the East Asia region. Increasing coverage of skilled birth attendants in rural areas, investing in community health services and promoting nutrition are important. Reducing the cultural, geographical and financial barriers to skilled attendance at delivery and lifesaving emergency obstetric care services is critical to reduce the many preventable maternal and newborn deaths. The high rate of adolescent births merits attention, together with the expansion of quality services that promote optimal birth spacing. TRENDS AND POLICIES Deaths per 100,000 live births 145 Trends in child mortality 1990 2012 LSIS MDG target 2015 89 Under-5 mortality rate Infant mortality rate Neonatal mortality rate Trends in maternal mortality 1600 100 76 48 45 1990 2012 LSIS MDG target 2015 357* 400 Maternal mortality ratio 39 36 *MDG target achieved in 2011 National health policies and services Availability Per capita expenditure on health (US$), 46 2007 2011 1 Out-of-pocket expenditure (% of private 76.7 expenditure on health), 2007 2011 1 Specific tification of maternal deaths Partial Midwifery personnel authorized to Yes administer core set of lifesaving interventions Costed national implementation plans for Yes maternal, newborn and child health available Number of basic emergency obstetric and 150 newborn care facilities 2 Facilities per 1,000 births - Community treatment of pneumonia with Partial antibiotics Oral rehydration solution and zinc for Yes management of diarrhoea Sources: 1 World Health Organization National Health Account database 2012 (retrieved from www.data.worldbank.org); 2 United Nations Population Fund, The State of the World s Midwifery 2012. Trends in maternal indicators RHS 2005 NS 2007 LSIS 2012 Per cent (%) 38.4 49.8 Contraceptive prevalence rate (met need) 27.3 19.9 Unmet family planning need 37 Women 20-24 married before age 18 110 94 Adolescent birth rate Sources for figures: Trends in child mortality: 1990 child data from UN Inter-agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, 2011; 2012 data, Lao Social Indicator Survey (LSIS) 2012. Trends in maternal mortality: LSIS 2012. Trends in maternal indicators: 2005 Reproductive Health Survey (RHS), 2005 National Statistics (NS) and LSIS 2012. Notes: Contraceptive prevalence rate proportion of currently married women aged 15 49 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 15 19 per 1,000 women in the age group. Maternal and Newborn Health Profiles: Lao People s Democratic Republic 1

Indicators of quality of care Antenatal care Intrapartum/delivery Postnatal care 100 80 72 Per cent (%) 60 40 20 0 54.2 36.9 18.3 46.9 23.2 22.6 41.5 37.5 3.7 17 7.4 3.1 38.1 ANC1+ ANC4+ BP UA Bl BP measured Blood sample Urine sample SBA Inst. Delivery C-section BF (excl.) PNC within 2 days/ newborn PNC within 2 days/ mother PNC within 2 days/ newborn and mother Birth reg. Source: LSIS 2012. Notes: Lao PDR LSIS 2011-2012. 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/newborn: % of women who recieved a postnatal check-up within 2 days for newborn only; PNC within 2 days/mother: PNC within 2 days for mother only; PNC within 2 days/newborn and mother: PNC within 2 days for newborn and mother both; 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 - Folic acid supplmentation - Tetanus toxoid immunization - Syphilis screening - Pre-eclampsia and eclampsia prevention - 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 pneumonia management - Emergency neonatal care Legend: green: intervention addressed in the MNCH strategy; red: intervention has clear guideline/policy. Sources: 1 Lao PDR Ministry of Health, Strategy and Planning Framework for the Integrated Package of Maternal, Neonatal and Child Health Services 2009 2015; 2 Darmstadt et al., 2005. 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 immudeficiency virus (HIV); labour surveillance (including partograph) for early diagsis 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 Profiles: Lao People s Democratic Republic

READINESS FOR NATIONAL SCALING UP OF NEWBORN CARE Agenda setting - Local evidence generated for newborn survival - Existence of a convening mechanism for newborn health issues - Focal person for newborn health in the Ministry of Health - Maternal and newborn indicators included in national surveys (e.g. neonatal mortality rate) Policy formulation - 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 - Primary-level cadres authorized to perform neonatal resuscitation - Maternal and newborn indicators included in national health information systems - Community-based cadres authorized to administer injectable antibiotics for newborn infections (for community midwives) - Community-based cadres authorized to perform neonatal resuscitation (for community midwives) Policy implementation - Cadre identified for home-based newborn care - 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 - Supervision system for maternal, newborn and child health established at primary health centre level - Protocol or standard for district hospital care of sick newborns in place - Resource requirement for primary health care level available for newborns (t sufficient) - Resource requirement for secondarylevel health care available for newborns (t sufficient) - Resource requirement for scaling up home-based newborn care available (t sufficient) - Integrated management of childhood illness algorithm adapted to include the first week of life Agenda setting - National needs assessment for newborn care conducted - Local evidence disseminated for newborn survival Policy formulation - National behaviour change communication strategy - Community-based cadres authorized to administer injectable antibiotics for newborn infections (t for village volunteers) - Community-based cadres authorized to perform neonatal resuscitation (t for village volunteers) - Costed implementation plan for maternal, newborn and child health (in process) - Primary level cadres authorized to administer injectable antibiotics for newborn infections - National targets to track newborn health established - Reproductive, maternal, newborn and child expenditure per child younger than 5 and per woman aged 19-49 Policy implementation - System for perinatal death audits exists - System for neonatal death audits exists (under development) Legend: green: benchmark met; red: benchmark t met. Source: Moran, A.C. et al., 2012. Availability of benchmarks as per UNICEF Lao PDR 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 Profiles: Lao People s Democratic Republic 3

CONTINUING INEQUITIES: Indicators by residence, wealth quintiles and provinces Disparities by by residence U5MR IMR IMR NMR Disparities by by residence SBA SBA Inst. Inst. Delivery PNC PNC 2dNB PNC PNC 2dM 39 39 36 36 39 39 39 39 108 108 76 76 85 85 82 82 22 22 136 136 89 89 100 100 94 94 39 39 45 45 Disparities by by wealth quintiles 77.5 77.5 36.9 36.9 18.3 18.3 BP BP UA UA BI BI ANC4 Tet Tet Prot Prot 63.4 63.4 27.2 27.2 11.1 11.1 49.2 49.2 64.8 64.8 70.6 70.6 54.1 54.1 29.7 29.7 12.1 12.1 9.9 9.9 4 4 43.6 43.6 40 40 95 95 120 120 18 18 27 27 33 33 58.2 58.2 82.6 82.6 5.7 5.7 3.5 9.1 52 3.5 9.1 52 Most and least affected provinces U5MR IMR IMR NMR 160 160 131 131 74 74 58 58 62 62 27 27 Per cent (%) Per cent (%) Per cent (%) Per cent (%) Per cent (%) Per cent (%) 7.4 7.4 37.5 37.5 41.5 41.5 3.1 3.1 55.5 55.5 54.4 54.4 57.4 57.4 5.9 5.9 27 27 30.7 30.7 2.7 2.7 6.3 6.3 29.2 29.2 3.3 3.3 11.6 11.6 33.3 33.3 2.9 2.9 12.4 12.4 1.5 1.5 12.6 12.6 87.4 87.4 74.2 74.2 79.6 79.6 90.7 90.7 2.8 2.8 10.5 10.5 4.4 4.4 1.2 1.2 10.8 10.8 4.9 4.9 Disparities by by wealth quintiles ORT/CONT. Feed Tx Tx PNA DPT3 51.7 51.7 50.6 50.6 55.6 55.6 53.8 53.8 52.3 52.3 57.3 57.3 35.5 35.5 37.8 37.8 59.3 59.3 67.7 67.7 79 79 71.2 71.2 36.8 36.8 42.1 42.1 54.6 54.6 Most and least affected provinces 18.7 18.7 10.9 10.9 81.4 81.4 85.5 85.5 69.7 69.7 SBA SBA Inst. Inst. Delivery PNC PNC 2dNB 85.4 85.4 83.9 83.9 18.1 18.1 16.5 16.5 0 0 Phongsaly Phongsaly Vientiane Vientiane C C Phongsaly Phongsaly Vientiane Vientiane C C Attapeu Attapeu Borikhamxay Borikhamxay Source: LSIS 2012. Notes: Comparison of data is by residence (rural versus RR (rural with s) versus RW (rural without s) versus urban versus country ), wealth quintiles (poorest versus richest versus country ), eth-linguistic groups and provinces (most affected versus least affected); U5MR: mortality for children younger than 5 years; IMR: infant mortality rate; BP/blood/ urine: % of pregnant women who had their blood pressure (BP), blood and urine sample taken during an antenatal care (ANC) visit; ANC4: % of pregnant women receiving ANC 4 or more times during pregnancy (recommended # by WHO); SBA: % of pregnancies delivered by skilled birth attendant; birth registration: % of children younger than 5 years whose birth was registered with the State. Exclusively BF: % of children younger than 6 months who were exclusively breastfed; ORT/cont. feeding: % of children with diarrhoea who received oral rehydration therapy or increased intake and at the same time was continuously fed; Tet Prot: % of women aged 15-49 with a live birth in the last two years who are protected against tetanus; Tx PNA: % of children younger than 5 years with suspected pneumonia who were taken to any appropriate provider; DPT3: % of children age 12-23 months who received the recommended 3 doses of DPT by 12 months; PNC 2d NB: % of newborns who received a postnatal check-up within 2 days of delivery; Vientiane C: Vientiane capital. 4 Maternal and Newborn Health Profiles: Lao People s Democratic Republic

EQUITY FOCUS: Indicators by residence, wealth quintiles and provinces Indicator U5MR (country avg: 54 per Levels & Trends 2011 report; LSIS 2012: 89) NMR (country avg: 21 per Levels & Trends 2011 report and 36 per LSIS 2012) IMR (country avg: 42 per Levels & Trends 2011 report; LSIS 2012: 76) Pre-pregnancy Contraceptive prevalence rate/met need (country avg: 49.8%) Unmet need for family planning (% of women aged 15 49 currently married or in a union with an unmet family planning need) (country avg: 19.9%) Antenatal ANC1 (% of pregnant women receiving ANC 1 or more times from a skilled provider during pregnancy; country avg: 54.2%) ANC4 (% of pregnant women receiving ANC from any provider 36.9) % pregnant women who received BP check, urine test, blood test before delivery (18.3%) Blood pressure taken (country avg: 46.9%) Residence Quintiles Most and least affected by ethlinguistic group of household head (R): 100 w/ (RR): 94 w/o (RW): 136 R: 39 RR: 39 RW: 39 R: 85 RR: 82 RW: 108 R: 48.8 RR: 50.2 RW: 36.4 R: 20.2 RR: 19.3 RW: 27.6 R: 45.9 RR: 49.7 RW: 19 R: 27.2 RR: 29.7 RW: 9.9 R: 11.1 RR: 12.1 RW: 4.0 R: 38 RR: 41 RW: 17.4 45 120 33 M: Chinese- Tibetan (160); L: (74) 22 40 18 M: Chinese- Tibetan (62); L: (27) 39 95 27 M: Chinese- Tibetan (131); L: (58) 52.6 39.1 52.9 M: (31.7); L: Lao Tai (54.4) 19.2 25.6 19.2 M: (30.5); L: Lao Tai (17.9) 83.4 22.9 91.7 M: (30.5); L: Lao Tai (71.5) 70.6 9.1 82.6 M: Chinese- Tibetan (6.1); L: Lao Tai (55.0) 43.6 3.5 52 M: (2.7); L: Lao Tai (27.7) 77.9 18 87 M: (19.2); L: Lao Tai (62.4) Most and least affected provinces Region: M: North (104); L: Central (73) M:Phongsaly (151); Vientiane Capital (32**) Region: M: North (48); L: Central (26) M:Phongsaly, Huaphanh, and Khammuane (62); Vientiane (10) Region: M: South (88); L: Central (63) M: Khammuane (131); Vientiane Capital (27**) Region: M: South (88); L: Central (63) M: Khammuane (131); Vientiane Capital (27**) Region: M: South (24.1); L: North (16.7) M: Champasack (25.4); L: Xiengkhuang (10.4) Region: M: North (45); L: Central (63.3) M: Phongsaly (25.2); L: Vientiane (74.1) Region: M: South (28.3); L: Central 46.5 M: Phongsaly (9.4); L: Vientiane Capital (82) Region: M: South (12); L: Central 25.2 M: Huapanh (1.6); L: Vientiane Capital (62.6) Region: M: South (39.9); L: North (52.5) M: Phongsaly (24.9); L: Vientiane Capital (88.4) Maternal and Newborn Health Profiles: Lao People s Democratic Republic 5

Indicator Residence Quintiles Most and least affected by ethlinguistic group of household head Most and least affected provinces Blood sample (country avg: 23.2%) R: 14.4 RR: 15.8 RW: 4.7 54.1 4.2 65 M: (4.1); L: Lao Tai (35.1) Region: M: South (15.2); L: Central (29.4) M: Huapanh (3.6); L: Vientiane Capital (68.5) Urine sample taken at ANC, % (country level 22.6%) R: 14.9 RR: 16 RW: 7.6 49.2 5.7 58.2 M: (5.1); L: Lao Tai (32.6) Region: M: South (15.3); L: Central (32.1) M: Oudomxay (2.2); L: Vientiane Capital (72.8) % of women aged 15 49 with a live birth in the last two years who are protected against tetanus (country avg: 77.5%) R: 63.4 RR: 64.8 RW: 54.1 73.9 52.6 79.8 M: (53.4); L: Lao Tai (72.8) Region: M: South (62.7); L: North (71.8) M: Phongsaly (43.7); L: Borikhamxay (80.4) Intrapartum Birth attended by any skilled attendant (country level: 41.5%) 2 R: 30.7 RR: 33.3 RW: 12.4 79.6 10.8 90.7 M: (17.8); L: Lao Tai (58.5) Region: M: North (31); L: Central (52.8) M: Phongsaly (18.7); L: Vientiane Capital (85.4) Institutional delivery (37.5%) R: 27 RR: 29.2 RW: 11.6 74.2 10.5 87.4 M: (16.7); L: Lao Tai (51.8) Region: M: South (25.4); L: North (50.0) M: Phongsaly (18.1); L: Vientiane Capital (83.9) Caesarean section (country level: 3.7%) R: 1.9 RR: 2.1 RW: 0.0 10 0.1 13.1 M: Mon-Khmer (0.8); L: Lao Tai (5.8) Region: M: North (2.3); L: Central (5.1) M: Phongsaly (0.4); L: Vientiane Capital (15.4) Postpartum % PNC for newborn (country avg: 87.8%) R: 91.2 RR: 90.7 RW: 95.1 75.8 96.0 74.7 M: (97.8); L: Lao Tai (82.1) Region: M: North (90.7); L: Central (84.6) M: Attapeu (97); L: Vientiane Capital (75.7) PNC of the newborn within 2 days of delivery (country avg: 7.4%) R: 5.9 RR: 6.3 RW: 3.3 12.6 2.8 10.9 M: (1.7); L: Lao Tai (10.6) Region: M: South (4.5); L: Central (9.9) M: Attapeu (0.0); L: Borikhamxay (16.5) % of women 15 49 who gave birth within past 2 years who received a PNC visit w/in 2 days (country avg: 3.1%) R: 2.7 RR: 2.9 RW: 1.5 4.4 1.2 4.9 M: Chinese- Tibetan (0.8); L: Lao Tai (4.5) Region: M: South (2.0); L: Central (4.1) M: Oudomxay (0.0); L: Xayabury (6.0) % PNC for mothers (country avg: 92.8%) R: 94.7 RR: 94.4 RW: 96.5 86.4 97.9 84.3 M: (98.7); L: Lao Tai (89.2) Region: M: North (28.2); L: Central (46.6) M: Sekong and Oudomxay (99.7); L: Vientiane Capital (82.2) 6 Maternal and Newborn Health Profiles: Lao People s Democratic Republic

Indicator % women aged 15 49 who along with their newborn received PNC or a health check within 2 days of delivery (both mother and newborn; country avg: 38.1%) Birth registration (country avg: 76%) % of children aged 0 5 months who are exclusively breastfed (country %: 40.4) Children younger than 5 years % who received oral rehydration therapy (oral rehydration solution or recommended home fluids or increased fluids (country level %: 47.5) % continued feeding and given ORT (country avg: 57.4%) % of under-5 children with suspected pneumonia who were taken to any appropriate provider (country avg: 54.4%) Residence Quintiles Most and least affected by ethlinguistic group of household head R: 29.5 68.2 12.8 80.1 M: RR: 31.7 (15.5); L: Lao Tai (52.2) RW: 14.4 - - - - - - - R: 41 RR: 42.4 RW: 30.1 R: 44.7 RR: 46.3 RW: 37.6 R: 55.6 RR: 57.3 RW: 50.3 R: 50.6 RR: 52.3 RW: 37.8** 38.2 46.6 34.1 M: Lao Tai (33); L: (68.0) 69.4 39.7 76.1 M: (36.7); L: Lao Tai (51.5) 71.2 54.6 69.7 M: (46.4); L: Mon- Khmer (62) 79 42.1 85.5** M: Mon-Khmer (54.3); L: Lao-Tai (56.8) and other values *** Most and least affected provinces Region: M: North (28.2); L: Central (46.6) M: Huapanh (15.1); L: Vientiane Capital (78.7) Region: M: South (29.7); L: North (60.5) M: Champasack (20.1); L: Huaphanh (77.2) Region: M: South and Central (44.2); L: North (51) M: Xiengkhuang (27); L: Vientiane Capital (88.2**) Region: M: Central (53.4); L: North (61.4) M: Vientiane (33); L: Vientiane Capital (76.8**) Region: M: South (46.4); L: Central (59.5) M: Saravane (38.9); L: Sekong (54.9) and other values *** % of children aged 0 59 months with suspected pneumonia who received antibiotics in the last two weeks (57.4%) R: 54.8 RR: 56.9 RW: 39.1** 74.3 47.4 71.9** M: Mon-Khmer (54.3); L: Lao-Tai (60.1) and other values *** Region: M: South (45.6); L: Central (65.3) M: Saravane (35.8); L: Bokeo (64.1**) and other values *** DPT3 (country avg: 55.5%) with HepB-Hib R: 51.7 RR: 53.8 RW: 35.5 67.7 36.8 81.4 M: (26.6); L: Lao Tai (66.9) Region: M: Central (52.6); L: South (60.6) M: Phongsaly (23.8); L: Xayabury (91.8) Source: All data from LSIS 2012 unless specified; UN Inter-agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, 2011. ** Certain figures are based on 25 49 unweighted cases; *** Deminators of 24 unweighted cases and less, thus the information was suppressed. Maternal and Newborn Health Profiles: Lao People s Democratic Republic 7

Giving newborns a better chance Spotlight on UNICEF work In looking at why neonatal deaths remain high in prevalence in the country, the Lao Ministry of Health and UNICEF conducted a 2012 comprehensive assessment of the newborn care situation. A large proportion of home births without a skilled birth attendant, low coverage of early essential newborn care and postnatal services, and prevalent cultural practices of discarding the colostrum and early bathing are some of the challenges. Local beliefs and myths hinder access to care seeking from health facilities, even when a newborn is experiencing health problems. According to the assessment, poverty, geography, ethnicity and education level are important determinants of disparity t only for neonatal mortality but also for coverage of maternal and newborn health services along the continuum of care. The assessment s mapping of gaps showed that basic emergency obstetric and newborn care is available at district, provincial and central hospitals, while comprehensive care is largely limited to provincial and central hospitals. This has implications for out-ofpocket expenses required for transportation and the need for the mother to obtain permission from her husband. Background Dramatic increases over the past decade in child health services and outreach have been turning the negative trajectory of mortality rates of children younger than 5 years even in countries heavily hindered by poverty and a preponderance of remote communities. Lao PDR, for instance, has one of the fastest declines in under-5 mortality globally, from nearly 107 deaths per 100,000 live births in 2000 to only 75 in 2010. Although more children w live beyond their fifth birthday, a disproportionate number do t survive their first month of life. In Lao PDR, 39 per cent of all under-5 deaths occur in the first 28 days of life. The neonatal period has emerged as the most critical period for making a difference in child survival rates. Due to a lack of kwledge on having the assistance of a specially qualified health workers during childbirth, distrust in the competency of medical staff and facilities, preference for traditional healers, an inability to pay for transport to a facility or the services once there, or the inability to reach the services, more than 58 per cent of births in 2011 took place with skilled birth attendant; but that was significant improvement from 2005 when it was 82 per cent of births, according to government data. The Ministry of Health has been working with UNICEF and other agencies to improve health facilities and women s confidence in them. Basic health providers and midwives have been trained and given protocols and checklists to work with as well as newborn resuscitation equipment. Refresher courses on early essential newborn care are required. Perhaps the biggest stride in wooing women to facilities is the lure of free care, even for emergency obstetric surgeries the Government has been piloting free mother and child health services that will be scaled up across the country. To increase demand for facility care, UNICEF and partners are helping the Government revitalize village health committees and increase the number of midwives and village health volunteers who can encourage pregnant women and their husbands to seek out prenatal care and assisted births. The expanded cadre of midwives w make regular visits to communities to provide free contraceptives, vaccinations, antenatal care and, if need be, delivery assistance in remote villages. To break through the grip of myths and traditional beliefs, the Government and UNICEF, along with other partners, heavily promote outreach by the health centre staff to build villagers trust in them and in optimal care practices during pregnancy, at delivery and during the postnatal period. We hope that all maternal and child health issues will benefit with a greater attention to the quality of village volunteer training, improving community engagement and ensuring accessible basic health services in the under-served areas, says Viorica Berdaga, Chief, Child Survival and Development. Photo credit? Photo credit? 8 Maternal and Newborn Health Profiles: Lao People s Democratic Republic