World Vision’s Little Book of Maternal and Child Health in the Asia Pacific pdf

An introduction by Watt Santatiwat, Vice President, World Vision Asia Pacific region Maternal and child health and nutrition interventions are complex issues for the Asia Pacific region.

World Vision’s Little Book of Maternal and Child Health

in the Asia Pacific

Statistics and strategies to help bring Millennium Development Goals Four and Five within reach

© World Vision Asia-Pacific 2009

Stories researched and contributed by World Vision communicators, 2008/2009Editing and design: Katie Chalk

Review: Laurence Gray, Dr Sri Chander

To find out more about World Vision’s work with maternal and child health in Asia and the Pacific:

www.wvasiapacific.org

apro@wvi.org

Left: Doctor Goat

Thameesha has always suffered from wheezing

and breathing difficulties Since he started

drinking goat milk, he is stronger and his lungs

less prone to asthma or infections “A villager

told me that goat milk is good medicine,” says

Thameesha’s father “So with World Vision’s help I

went out and got a male and four female goats.”

While the “medicinal” properties of goat milk

are unconfirmed, its nutritional value for children

is very high Thameesha’s father says since the

goat’s milk was introduced to his children’s diets,

their wheezing has all but disappeared.

Photo: Hasanthi Jayamaha/World Vision Lanka

Contents:

terms and definitions

An introduction by Watt Santatiwat,

Vice President, World Vision Asia Pacific region

Maternal and child health and nutrition interventions

are complex issues for the Asia Pacific region

As statistical indicators they measure the health of a

nation and the level of its development But behind

those statistics are the shadows of many other urgent

development issues - gender inequality, massive wealth

discrepancies, inadequate education or public health

spending, and the tragedy of avoidable deaths through

under-prioritisation of women, children and the poor

The Asia Pacific region has made some progress in

changing the health of mothers and children for the

better But we still seriously lag behind in our efforts

The region still makes up 43% of the world’s total

maternal deaths, and well over 40% of our children are

malnourished

In our region, 18 of the 29 developing countries are

currently off-track to achieve Goal 4 – to reduce child

deaths by two-thirds, and 23 are off-track to achieve

Goal 5 – to reduce maternal deaths by three-quarters

In 2010, World Vision will commence advocacy efforts

across the region to encourage solutions at national

Why health, why now?

level on maternal and child health Each country faces

a different set of challenges, and no country can rest just yet

My home country of Thailand, for instance, has shown what can be possible with appropriate investment of government funds in its people Yet even here, in a country that is often held up as a development model for others, there is room for improvement We still see unacceptable levels of preventable illness and deaths in marginalised communities, and malnutrition still exists

in our children in both rural and urban areas

Fighting malnutrition needs to be a priority in all Asia Pacific countries, not just for children at different stages of their growth, but also for mothers Over 30%

of women are malnourished in this region, harming expectant mothers and reducing the chances of survival for their children before they are even born.Spending on health and nutrition needs to be increased and improved The Asia Pacific region spends well below the world average of 5.1% of GDP In South Asia only 1.9% is currently spent on health – and one

in every five children that dies worldwide is an Indian child

The ADB estimates that additional government

investment of only around $3 per person per year,

spent carefully to target specific healthcare gaps, could

bring the MDGs within reach

Private sector contribution to health coverage is

a vital component of strategies for meeting MDGs

Four and Five However, this should not detract

from or replace government responsibility for public

health care This region is calling out for private and

public collaboration on research, improvement and

promotion of healthier living, in tandem with facilities

and resources to improve the health of mothers

and children in the Asia Pacific’s most vulnerable

communities

I urge governments and donors in the Asia Pacific to

recognise the way forward on sustainable, equitable

health solutions to protect mothers and their children

It is at once a humanitarian duty and an investment in

the future resilience of every nation in the region

Watt Santatiwat

August 2009

This book is for anyone with an interest in maternal

and child health, but in particular for people who can

play a role in strengthening it

The Asia Pacific has some of the biggest health

challenges of any region Here, health is a complex

issue, at the heart of community development and

wellbeing and yet held back by resources, attitudes and

traditions These aspects come together as barriers

to deny fair access to health for more than half the

people living in the Asia Pacific

As an international NGO with a strong grassroots

approach, World Vision is ideally placed both to deliver

health strategies in under-resourced communities, and

to recognise gaps that cannot be filled without the

support and mobilisation of others

This book explores some of these gaps, as well as

potential solutions to fill them, by sharing stories

from World Vision’s field experiences A single story

may not constitute “evidence” but it can bring unique

insight into challenges, and how current health

practices are missing the mark when it comes to

pro-poor, child-focused protection of lives

Who is this book for?

Born in a remote village in the district of Xieng Nguen, Baby Anoi has had his weight and height measured since birth, and passes the test each time Despite its relative poverty, Lao PDR is one of the Asian countries on track

to achieve MDG Four The Laos government has announced its commitment

to opening community health centres, providing better delivery care, immunisations and micro-nutrient supplements for infants and mobilizing resources to improve mother and child health World Vision currently partners with the government in rural areas to monitor

child health through mobile clinics

Photo: Albert Yu/World Vision Lao PDR

On track: Bangladesh, China, Indonesia, Lao PDR,

Solomon Isl.,Timor-Leste, Nepal, Sri Lanka,

Thailand, Vietnam

Off track: Cambodia, India, Myanmar,

Papua New Guinea, Philippines, Vanuatu

On track: China, Philippines, Solomon Isl.,

Sri Lanka, Thailand,Vietnam

Off track: Bangladesh, Cambodia, India,

Indonesia, Lao PDR, Myanmar, Nepal, Papua New Guinea, Timor-Leste

MDG Four:

Reduce child deaths

(under five) by two

thirds by 2015

MDG Five:

Reduce maternal deaths by three quarters by 2015

Statistics and case studies in this book include only countries where World Vision is working in the Asia Pacific

The summary above is based on World Vision’s 2009 report “Strategies that Work”:

http://wvasiapacific.org/downloads/publications/StrategiesThatWork.pdf

Under five mortality rate

The probability (expressed as a rate per 1,000 live

births) of a child dying before reaching the age of

five

Infant mortality rate

The probability (expressed as a rate per 1,000 live

births) of a child dying before reaching the age of

one year

Maternal mortality ratio

The probability (expressed as a rate per 100,000

pregnancies) of a woman dying during pregnancy,

childbirth or the first 42 days after delivery

Low birth weight

A birth weight of under 2,500 grams Babies born

with a low birth rate are twenty times more likely to

die than babies born above the minimum weight of

2,500 grams

Stunting

Measures height against age: usually caused by

long-term insufficient nutrient intake or frequent

infections Stunting generally occurs before the age

of two; effects are largely irreversible

Wasting

Measures weight against height in all ages: usually an

indicator of acute food shortage and/or disease

A high prevalence of wasting usually correlates with

a high under-five mortality rate

Vaccination

Many childhood diseases including measles, polio, diptheria, tetanus and whooping cough are preventable through early vaccines However the measure of vaccination in statistical terms usually refers to immunisation against measles by the age of one year

Across Asia and the Pacific, World Vision’s focused programmes are partnering at house-hold, community and national level to:

child-• Improve standards and increase action around maternal and child health

to take good care of themselves and their children, including nutrition, vaccinations, first aid and family health responses, and birth spacing

• Encourage governments and international donors to find ways to provide affordable, equal access for all to healthcare, in particular services for mothers and children under five

World Vision is working

in nearly 90 countries worldwide with health interventions to support the achievement of Millennium Goals Four and Five.

Solomon IslandsSri LankaThailandTimor-LesteVanuatuVietnam

World Vision

Asia Pacific region

encompasses:

Bangladesh

Bangladesh’s poverty, and the constant setbacks of natural disasters, challenge its ability to remain food-secure In addition, gender inequality, including a lack of priority for girls’ education, means many mothers lack nutritional knowledge for themselves or their children

In Bangladesh today, 500,000 children are diagnosed with severe acute malnutrition The maternal mortality ratio

is also high, ranging from 320-380 per every 100,000 live births As only around 7% of births are registered, this figure

is an estimate and could easily be higher

Part 1:

Statistics

All statistics in this section are taken from UNICEF’s

State of the World’s Children 2009 unless otherwise

noted.

Cambodia

Despite many years of international aid and

involvement, Cambodia still has the second highest

level of child mortality in the region Out of every

1,000 children, 91 die before their fifth birthday

Cambodia’s family and community poverty, especially

outside Phnom Penh, prevents many children from

getting both macro- and micro-nutrients they need

to develop normally, while an under-resourced

healthcare system struggles to face up to water-borne

disease, malaria and dengue in children

Maternal mortality is one of the leading causes

of death for women aged 15-49, with around 470

maternal deaths per 100,000 live births Eight in

every ten women give birth at home Only around

40% have skilled help at hand during delivery2

Roughly three quarters of maternal deaths occur in

the immediate post partum period

China

China has made massive inroads to improve children’s health over the last fifteen years National statistics, however, do not necessarily reflect the geographical diversity of this massive country While government healthcare reaches most mothers and children in and around cities, rural communities, ethnic minorities, and urban migrants are still missing out

In China, World Vision administers over 30 health projects in areas of need, with a focus on global health indicators such as maternal and child health, malnutrition, tuberculosis, HIV and AIDS, and new and re-emerging infectious diseases, such as influenza

A school breakfast ensures at least one meal a day

has the right nutrition balance for these pre-schoolers

in Guangxi, China

Photo: World Vision China

2 Cambodia Department of Health (CDHS), 2005

Indonesia

Under 5 mortality (per 1000): 31

Living with improved sanitation: 52% Maternal mortality (per 100,000): 310

The diversity of living standards across Indonesia’s islands is not necessarily reflected in their national statistics In urban areas like Jakarta, micro-nutrient malnutrition affects the development of children even

in areas with improved healthcare facilities Isolated regions are more likely to suffer from famine or untreated illnesses, especially malaria which affects up to 20% of the population

Across the country, UNICEF estimates up to 70% of women and children are anemic

India

Under 5 mortality (per 1000): 72

Living with improved sanitation: 28%

Maternal mortality (per 100,000): 300

Despite its recent economic growth, India’s child health improvements are markedly behind the goals set by the MDGs

In India, the challenges start before birth Food shortages affect nearly

350 million Indians Nine out of ten pregnant women are undernourished, 20% of infant deaths can be

attributed to anaemia in mothers, and nearly one third of babies are born with low birth weight3 Only around 37% of babies are exclusively breastfed to six months

These early setbacks leave children extremely vulnerable to malnutrition, under-development and childhood illnesses One in five children who die globally before the age of five is Indian

DPRK

(North Korea)

(Govt estimates - independent

evaluation not possible)

Under 5 mortality (per 1000): 55

Living with improved water: 59%

Living with improved sanitation: 59%

Maternal mortality (per 100,000): 110

DPRK is known to have a massive

gap between need and supply of

basic health resources Government

clinics suffer a chronic shortage

of medicines and vaccinations that

are standard supplies elsewhere

- estimated at only half of what

is required to maintain a healthy

population

DPRK also faces regular food

shortages, but the situation became

dire in 2008 as floods devastated

harvests, China erected barriers to

food exports, and global food prices

skyrocketed The WFP projected a

doubling of prices for staples such as

rice, soybeans and maize

One third of pregnant women are

reportedly under-nourished or

anaemic

3 WFP statistic: http://www.wfp.org/countries/india

Laos PDR

Humanitarian development is a recent initiative

for Laos; while the current under-five mortality

rate is still unacceptably high, it is worth noting

that around 20 years ago it was a staggering

170 per 1000 live births In line with general

improvements in poverty indicators, child health

statistics are improving – but not quickly enough

to meet the goals of the MDGs Laos still sits at

50 on Unicef’s under-five mortality rate ranking

Every day three Lao women die due to maternal

health issues Only 19% of mothers give birth

with the assistance of a skilled birth attendant,

and less than one quarter (23%) of babies are

exclusively breastfed to six months

Mongolia

Living standards between country and city differ widely in Mongolia – while 87% of urban dwellers have access to improved water, only 30% of rural communities enjoy the same right For children living in poverty, access to

appropriate and varied food is also limited; deficiencies in iodine and Vitamin A make goiters and rickets common and dehabilitating conditions in Mongolia’s children

This family in urban Mongolia only eats one meal a day since rising food costs made basic staples unaffordable

They make do with tea to replace other meals.

Photo: Enkhbayar Purevjav/World Vision Mongolia

Myanmar is the most high risk country in Asia for

children In Myanmar, at least one in ten children

will die before the age of five – three quarters of

them before the age of one At the heart of these

statistics is malnutrition Only around 15% of children

are exclusively breastfed to the age of six months

Susceptibility to illness and infection as a result of this

is increased – water-borne diseases, left untreated,

claim many lives, and Myanmar’s malarial deaths

account for around half of those in South East Asia

Significant percentages of women suffer maternal

deaths – annually 320 women die per 100,000 live

births A total 43% of women deliver their child

without any skilled professionals attending

Nepal

Broad issues of poverty and isolation mean that the health and wellbeing of Nepal’s children is severely compromised A low level of education for many women means that many mothers do not have an understanding of good nutrition or the skills to recognise when their children are dangerously ill or malnourished

Malnutrition is considered the underlying cause of more than 60% of child deaths As well, the majority

of children do not practice good hygiene habits, like daily bathing or washing hands after going to the toilet Two-thirds of Nepalis do not use a toilet at all.Around one in 30 women die from pregnancy-related complications

Photo: Pamela Sitko/World Vision Myanmar

Papua New

Guinea

% children underweight: (no UNICEF

figure available)

Under 5 mortality (per 1000): 65

Living with improved sanitation: 45%

Maternal mortality (per 100,000): 370

Papua New Guinea’s capital of Port

Moresby has had much invested in its

infrastructure In theory healthcare,

clean water and toilets are available

to most, but residents in sprawling

settlements on the outskirts of town

struggle for access to these facilities

Outside the capital, infrastructure

quickly drops away, leaving

communities with huge challenges in

access to clean water, vaccinations,

improved sanitation or maternal and

child care The maternal death rate in

Papua New Guinea is approximately

370 in every 100,000 live births

Approximately 11% of infants born in

Papua New Guinea are underweight

In rural and highland areas, a priority

is to support communities to take responsibility for their own healthcare, by equipping them with basic knowledge on hygiene, nutrition and treatment of illnesses like malaria and diarrhoea

Philippines

Under 5 mortality (per 1000): 28

Living with improved sanitation: 78%

Maternal mortality (per 100,000): 160

The Philippines could be considered

a success story for Asia in prioritizing children, their health and their rights However, communities living

in poverty, both urban and rural, may not have the capacity to access the benefits that the government provides

Nutrition, especially micro-nutrition,

is still of concern, and tuberculosis

exists in epidemic proportions in many areas Community access to clean water, though at a respectable level of around 90%, has not changed markedly since 1990

Solomon Islands

Living with improved sanitation: 32% Maternal mortality (per 100,000):140

Despite its restive recent past, the Solomon Islands is on track to achieve both MDGs Four and Five Health interventions in the Solomons should now concentrate largely on preventable diseases, in particular malaria which is widespread and deadly The World Bank reports that maternal mortality rates appear to have increased slightly in recent years

Children at a Child-Friendly Space after Cyclone Nargis in Myanmar receive

a nutritious breakfast Good nutrition can be a lifesaver post-disaster, where

children suffering existing malnutrition or wasting are extremely vulnerable

to diseases like cholera, gastric infections and malaria.

Sri Lanka

Percentage children underweight: 23%

Under 5 mortality (per 1000): 21

Living with improved sanitation: 86%

Maternal mortality (per 100,000): 43

A concerted effort over 40 years

of public healthcare to improve the

standards of maternal health has paid

off, with Sri Lanka now able to report

a maternal death rate around 1/10th

of that of countries like Cambodia or

Papua New Guinea A total of 98% of

births take place in a medical facility

However, Sri Lanka’s children suffer

from a high level of malnutrition,

caused in part by a lack of knowledge

on the benefits of breastfeeding and

under-two nutrition requirements

Malnutrition is particularly prevalent

in the children of Sri Lanka’s

tea-planting regions, born into the

families that live and work on the

estates

The state of children’s health in Sri

Lanka is set to worsen as a result

of massive displacement, which has

disrupted health services in affected

areas, and rapidly rising food costs in

the country’s capital Colombo

Thailand

Living with improved sanitation: 96%

Maternal mortality (per 100,000):12

Overall, Thailand’s food security and child health needs have been met with committed determination from its government Maternal deaths are among the lowest in the region and the under-five mortality rate reflects

a high level of protective health interventions for this age group

Problems exist mainly in isolated, unrecognized or marginalized communities, especially in hill tribes along border areas and in large Burmese migrant populations Health and nutrition awareness programmes are vital to protect the children of these communities from avoidable malnutrition or infections, including tuberculosis

Dilsia, six and recovering from moderate malnutrition, has her arm measured for signs of wasting at a nutrition group in

Lequidoe, Timor-Leste

Photo: Katie Chalk/World Vision Timor-Leste

Timor-Leste remains extremely under-developed, and the

effects of this are seen in the health of its children Nearly

half of them are suffering from some form of malnutrition,

making them very susceptible to childhood illnesses Food

shortages in East Timor regularly impact more than one

third of the population In 82% of cases women do not

have skilled professionals attending the delivery of children

Timor-Leste’s birth rate of over seven children per family

contributes further to the problem; mothers are often

malnourished themselves and family incomes cannot meet

their children’s health needs

Vanuatu

Though a small country in population, Vanuatu is made

up of 83 different islands Around 20% of the population have no access to healthcare whatsoever Planning for support of Vanuatu’s maternal and child health should take into account the need for basic infrastructure as well as interventions specific to neonatal care

Vietnam

Percentage children underweight: 25%

Under 5 mortality (per 1000): 17

Living with improved sanitation: 61%

Maternal mortality (per 100,000) 160

Vietnam’s rapidly improving economy has allowed it to provide better health services to its people, but the gap between urban and rural living standards is vast Especially

at risk are ethnic minorities, who are still missing out on targeted public health interventions

While child mortality is comparatively low, one quarter

of children are underweight – a problem linked to malnourishment in their mothers and a low level (17%) of exclusive breastfeeding to the age of six months

There are a reported 160 maternal deaths per every 100,000 live births in Vietnam, and over 40% out of all pregnant women are anaemic.5.

4 AUSAid figures:

5 UNICEF statistic: http://www.unicef.org/vietnam/immunization.html

Part 2:

Strategies

maternal and child nutrition

• Strengthen communities to respond to preventable children’s diseases

• Strengthen childcare to reduce accidents and neglect

• Increase under-five focus of MDG Six to reduce malaria, TB and HIV and AIDS

• Improve access to quality ante-natal and natal services in remote areas

neo-• Increase community knowledge and commitment

• Inform and involve children

• Encourage mothers to recognise and share their child health achievements

Parbati cuddles her newest baby girl, Karuna, aged around three months.

Photo: Pratigya R Khaling/World Vision Nepal

The grief of Deepak’s loss was not healed properly for Parbati before she bore another child, a boy, Maila, who resembled Deepak but also passed away at the age of two

Parbati says, “Despite everything I tried, I couldn’t save him My mother in law tried her hand with all kinds of traditional healers They also failed and told us to take him to a hospital My husband worked more hours than ever before then and made some money but I guess it was too late Maila also died in front of my eyes.”

Parbati, now 35, has had three more children, a surviving son and two more daughters She is terrified of ill health, because until recently she has had no way to understand

it or address it

Parbati says, “I have such a big family We have no savings

If anyone falls sick in the family, we do not have extra money for treatment That is how we lost our two sons.”

Objective: Improve child survival

Growing up in a village in Nepal, Parbati never went

near a school She began doing the household chores

when she was around five or six; was working before

she was ten; married and pregnant before she was 20

Parbati’s first two children were daughters, both family

disappointments in a culture with such large gaps in

gender equality that female children, and sometimes

their mothers, are reportedly still murdered Parbati was

mistreated and often went without food, even when she

was breastfeeding

A little glimpse of hope in Parbati’s miserable life,

her third child was a son They named him Deepak

– meaning light But this happiness was short-lived

Deepak, at the age of three, passed away

Parbati recalls, “Deepak was a very small baby His legs

and arms were really thin He couldn’t breathe properly

One night his body became as hot as fire We had no

money to take him for treatment When we tried to

borrow money from neighbours, no one was willing to

lend us any It was very difficult for Deepak to breathe,

and all of a sudden he just stopped.”

In the tea plantation area of Ambagamuwa, Sri Lanka, World

Vision has helped the Ministry of Health go mobile By

providing transport to isolated areas and negotiating for

use of community or estate buildings, they have made it

possible for a monthly government clinic to provide pre-

and ante-natal checkups, monitoring of children’s weight

and health and general medical advice

Patients are checked by Dr Ragunath from Jaffna who has

been working in the estate sector for the past 20 years

Ministry of Health midwife, Kamala, says that many of these

women would find it too difficult to attend a clinic further

away, because they need to work or because they cannot

afford the bus fare to get there

“Anaemic conditions are very common in these young

mothers and their babies Almost all who visit this clinic are

estate labourers They have no knowledge about nutrition

They get through the day on plain tea and roti And now

through the clinic we have made them aware of their

conditions and taught them what could be done.”

Local women working as World Vision mobilisers are very

involved in the clinic arrangements every month They visit

every house in the area and inform them beforehand of

the clinic day They also come on the day in case language

becomes a barrier to accurate diagnosis or advice

Strategy: Strengthen communities to

respond to preventable children’s diseases

Kamala is pleased to report that the children are healthier “When the clinic was first started two years ago, we found a lot of children who had not received

a single vaccination since their birth So we had to start right from the beginning.”

“Since then, we have seen a positive increase in the interest of the mothers in their children’s health Every month the clinic is packed with over 50 mothers.”

Photo: Katie Chalk/World Vision Lanka

Child health is not always linked to clinics, vaccinations, medicines or diet Nearly 10% of child deaths in the Asia Pacific occur as a result of accidents.

Left alone at home while their labourer parents work all day, these girls and millions like them are extremely vulnerable to accidental injuries and limited in their knowledge or ability to seek treatment.

Photo: Alina Shrestha/World Vision Nepal

Strategy: Strengthen childcare

to reduce accidents and neglect

Malaria is one of the highest

causes of death for children

in Papua New Guinea,

misunderstood and

under-prioritised by communities At this

distribution of pyrethrum mosquito

nets, mothers also received clear

directions on their usage and

life-saving household health practices

to recognise and reduce the

symptoms of malaria.

Photo: Gary Fagan/

World Vision Pacific Development Group

Strategy: Increase under-five focus of MDG Six

to reduce malaria, TB and HIV and AIDS