ED695_Cao_Tiffany_PolBrief_27April2017

“The Good Laotian Woman Gives Birth to Four Children”
Introducing Laos PDR-Specific Maternal Education to Ensure that
Each of Those Four Children Survives and Thrives

Executive Summary Table of Contents

Lao People’s Democratic Republic (PDR) is a country plagued Introduction 1
with high rates of maternal and child mortality. For the most
part, the diseases causing the high mortality rates are prevent- Background 1
able, the results of non-vaccination and undernutrition. Present
Ministry of Health solutions address health provision, leaving Infrastructure and Health 2
opportunity wide open for creative community solutions to
push mothers to adopt proper nutrition practices and seek Maternal and Child
healthcare. Maternal education is not a novel concept, but a
community and family-centered, culturally-perceptive educa- Health by the Numbers 3
tion program catering to the least educated and least wealthy
is and needs to cater to the Laotian expectant mother. Learn Other Barriers 4
to Live’s experience in Mok Mai primes the NGO to successfully
implement a Lao PDR-specific maternal education program Lao PDR Ministry of Health 5
will drive progress towards the Learn to Live missions.
A Snapshot of Child Mortality

in Lao PDR 6

Stunting, Undernutrition, 7
Wasting

Beriberi: A Case Study 8

Recommendation 9

References 12

27 April 2017

Introduction

The Newborn embodies the hope and fears of a lifetime yet edge passed on from family members and cultural precedents.
unrealized. The blessing of it all is the chance that the infant The aim of the program proposed in this policy brief is to
may grow up through childhood and tumultuous adolescence address the community’s role in disseminating birthing and
to become a full-fledged adult who has lived a long and caretaking practices through the delivery of a community-wide
meaningful life. The tragedy is the possibility that, instead maternal education program. The aim is to ensure that each
of holding promise, the Newborn’s future may be marred by child is supported by all family members, not just the moth-
sickness and closed doors with the wrong decisions and mis- er, to grow up unfettered by health ailments preventable with
informations. knowledge and education.

In Lao PDR, an average of 500 children are born each day, Learn to Live’s prior experience and contacts in the Mok Mai
approximated from 2014 data. Not all of the families taking region of rural Northern Lao PDR makes Learn to Live an
a child home will be equipped to rear a healthy infant. Lao invaluable vehicle to pilot a new community maternal edu-
PDR’s Under-Five population is plagued by high mortality and cation initiative. The maternal education initiative outlined not
disease rates, stunting (disrupted growth and development), only directly aligns with Learn to Live’s mission to reduce
and the transmission of communicable diseases for which the infant mortality rate in Lao PDR but also serves as a
there exist vaccinations. framework which, after curricular adjustments, can be a model
to address Learn to Live’s secondary mission in Lao PDR: to
The Laotian mother is an agentive caretaker who makes deci- educate young men and women about reproductive health.
sions based upon her best judgment. She internalizes knowl-

Background

Lao PDR is located in Southeast Asia, landlocked by Vietnam, The population density of Lao PDR varies immensely from
Thailand, Malaysia, Myanmar, and China. There are close to region to region. One-third of Laotians (approximately 2.3
7 million people living in Lao PDR. 51% of the population is million people) lives in the cities with most Laotians in
female. 51% of the population has the potential to experience Vientiane, the Laotian capital. Two-thirds (approximately 4.6
motherhood. By Laotian government standards of poverty, 2 million people) reside in the rural areas. Lao PDR is diverse
million of its population lives in poverty. in elevation, spanning across low hills and highly mountainous
. areas. Generally, the Northern-central area around Louang-
prabang (See: Map A) is mountainous, Vientiane and the
Southwest border of Lao PDR are flattest, and the North and
Southeast are comprised of low hills.

Object A: Population density map of Lao Access to health services varies widely between urban resi-
PDR. Source: Encyclopedia Brittanica, 2011. dents and rural residents. The rate of antenatal care (ANC),
or during-pregnancy health check-ups, is 71% for pregnant
urban women compared to 29% for rural pregnant women.
The average amount of time for a rural resident to reach a
healthcare facility is 3 hours compared to urban residents’
travel time of 19 minutes. The disparity between those living
in the highlands and those in the lowlands is equally wide:
3 hours compared to 48 minutes, respectively. Road infra-
structure in Lao PDR greatly impacts an expectant mother’s
decision to seek professional and skilled care.

1

Background

Infrastructure + Health Outcomes

Though economic arguments have been made for the improvement of Lao PDR Health Infrastructure
Laotian road infrastructure, little has been said for the positive health
outcomes from adequate coverage of well-maintained paved roads. 4 central general hospitals in Vientiane
The economic and human costs of losing children because mothers 3 specialist hospitals in Vientiane
are unable to give birth in hospitals and health centers raise the 16 regional and provincial hospitals
urgency for the Laotian state and district governments to build paved 130 district hospitals
roads impervious to weather. 860 health centers
.8 hospital beds per 1,000 people
Lao PDR formal healthcare is comprised of public and private pro- 14.2% of villages >16 km from a healthcare
viders, though the latter is still nascent. Public hospitals and health- facility
care centers are under-utilized across the board. Long distances on 21% of the population without road access
dirt roads, in addition to inconsistent fee waiver structures and the
poor’s lack of knowledge about waivers, prevent many from seeking
care from formal health facilities. Mothers who do not seek formal
health care miss out on a host of benefits, as formal health settings
serve as invaluable touch points for vaccinations, health education,
and blood tests.

Emergency Obstetric and Newborn Care Centers (EmONC)

Object B: Map of Emergency Obstetric and New- Basic EMonC centers are equipped to deliver antibiotics,
born Care centers, both Comprehensive and Basic oxytopics, and anticonvulsants, resuscitate infants, manually
(CEmONC and EmONC, respectively), per prov- remove the placenta and pregnancy tissue, and perform vaginal
ince. Blank Map: D-Maps; Source: UNFPA, 2008. delivery. CEmONC centers perform basic EmONC functions, in
addition to Cesarian sections and blood transfusions. Num-
bers in red (Object B, at left) represent the provinces with
more than one EMonC center. As the map indicates, 12 of
Lao PDR’s 17 provinces do not have more than one CE-
mONC or EmONC. Interestingly, Lao PDR meets the WHO
criteria of having 1 CEmONC per 500,000 residents. Due to
the geographic difficulties of reaching health centers and the
impact of winter weather on dirt roads, however, 1 CEmONC
per 500,000 residents is still not enough to be considered
accessible to an expectant mother in the most remote areas of
Lao PDR.

Money and distance are two primary reasons why
75% of pregnant women choose to give birth at home.

2

Background

Infrastructure + Health Outcomes

At present, the Laotian mother’s only option when she lives Road infrastructure also impacts the number of women opting
far from a health center is to birth at home. For the 75% of into ANC. The value of ANC is that it informs families of
pregnant women who give birth at home, 63% are assist- the health of the child and educates them about risk fac-
ed by relatives while 12% are assisted by traditional birth tors and potential complications during pregnancy. ANC visits
attendants. Only 58% of births benefit from the presence improve the likelihood that a child will be vaccinated and that
of a skilled birth attendant (in contrast to a traditional birth the mother will give birth in a medical facility. Though 25% of
attendant who adheres to historical and cultural practices). expectant mothers already seek ANC, many still believe that
The risks of at-home birthing without a skilled birth attendant ANC is not necessary or that the distance to a health facility
include tangled umbilical cords and maternal hemorrhaging, is too far.
making it all the more imperative that hospitals become more
readily accessible, mothers are convinced of the necessity of
in-hospital birthing, or those attending at-home births become
more skilled.

Lao PDR Maternal Child Health by the numbers

Lao PDR falls short of its Southeast Asian peers on a number of child and maternal health indicators. The following graphs
compare the Lao PDR Infant Mortality and Maternal Mortality Rates within Southeast Asia. U.S. statistics have been included
to compare Lao PDR rates to one developed country case.

Object C: Lao’s 2015 Millennium Development Goal for Infant Object D: The Laos Millennium Development Goal for Maternal
Mortality was 45 infant deaths per 1,000 births. As the graph Mortality Rates was 260 maternal deaths per 100,000 births. As the
shows, as taken from World Bank data, Lao PDR has not yet graph shows, Laos has achieved it 2015 MMR goals. The country is

reached that goal as of 2016. Source: World Bank. still highest in the Southeast Asian region, however.
Source: World Bank.

3

Background

Other barriers to improving child and maternal health stem from
the Lao PDR education system, economy, and cultural practices.

Numerous studies have pinpointed lower levels of C Laotian maternal practices are influenced by a host of
U traditions and cultural dictates. “To be a good Laotian
E maternal education and literacy as risk factors of low would be to have a good family and at least four chil-
D maternal and child health. For women, the literacy rate dren,” one health worker notes. In addition to its effect
is high in urban areas (96% are literate) while in rural on family planning, traditions impact maternal practic-
es of discarding of the colostrum (breast milk) and
U Lareas, 72% of women are able to read. The intersec- adherence to strict food avoidance postpartum. Some
tion of a rural woman’s low literacy ability coupled with pregnant women have also confessed that they feared
that preparation in advance of the birth might lead to
C Tgeographic remoteness and farming livelihood puts her the death of the baby. Superstitious women, such as
children at greater risk for being undernourished, devel- those who adhere to the belief that advance prepara-
tion increases the likelihood of infant mortality, are less
A Uoping diseases such as beriberi*, and not completing likely to use ANC, get vaccinated for tetanus, and have
T immunizations. R a skilled birth attendant present at their births. Despite
I ELao PDR, for reasons including cultural beliefs, consis- the negative impact of superstitious beliefs on maternal
O tently has had the highest fertility rates in the South- decisions in these three areas, ANC is still growing in
east Asian region: 2.99 births per women in 2014. popularity.
N Education has had an impact on fertility rates in Lao
PDR, however. Attending primary school and completing
primary, secondary, and tertiary education reduces the

number of births in a woman’s lifetime by .23, .41,

.49, and .53 births, respectively. Lao PDR has certain-

ly made great strides reducing its fertility rate from 4.6

births per woman in 2005, but women still give birth

young with short spacing between successive children.

Short spacing risks a child being born preterm.

*See Beriberi: A Case Study on the importance of
maternal nutrition and the impact of cultural postpartum
practices (Page 9).

Object E: Source: David Sanger Photography

Lao PDR’s economy is one of the fastest growing in There are 49 ethnicities in Lao PDR, comprising 160

E its region - at a rate of 7% each year since 2006. S ethnic groups and 82 distinct languages. Ethnic and
C The economy is based on resource extraction: of for- O linguistic diversity, as rich as it is, poses the challenge
O ests, agriculture, hydropower, and minerals. The Laotian C of increasing the communication barriers between patients

human economy is heavily skewed towards agriculture, and healthcare providers.

N however, with 70% of working Laotians working in the I
agriculture industry. Of land used for farming, 72% is E
T
O used for rice. The other 18% is used for other crops, Y
such as coffee, sugarcane, cassava, and sweet potato.

M Lao PDR’s high production of rice plays an important
Y part in the country’s food insecurity. As food pric-

es have increased, household consumption has relied
increasingly on food produced by the family. The result,

diets made up of an increasing proportion of carbohy-
drates (about 60%). High levels of carbohydrates and
low percentages of protein and vegetables in the cur-

rent-day Laotian diet have made the population particu- Object F: Source: David Sanger Photography
larly vulnerable to undernutrition.

4

Background

What is the Lao PDR Ministry of Health doing now?

In a 2009 speech, Dr. Somchith Akkavong, Deputy Director of the Lao PDR Ministry of Health’s Department of Hygiene and
Prevention, unveiled the country’s strategy to improve Lao PDR’s high infant and maternal mortality. Dr. Akkavong’s frame-
work for action captures those on the provision-side and the mothers and families involved:

Object G: Lao PDR Ministry of Health Framework for Ma- Ministry of Health Maternal and Child Health
ternal and Child Health Care. Source: Akkhavong, 2009. Improvement Strategy:

A good majority of the activities in the strategy are to be un- 1. Establish a standard of a good quality routine
dertaken by the hospitals, healthcare providers, and the Minis- services for mother and child
try of Health. The Ministry of Health’s strategy affects little on
the right side of its framework: community and family action. 2. Capacity building
In fact, the only three activities which encourage mothers and 3. Early detection of common causes of
communities to act are Activities 10 (Develop IEC materials),
11 (Providing information and health education on MCH), obstetrical complications
12 (Promote well-child clinic checking), and 13 (Inform free 4. Early emergency triage, assessment, and
of charge services on ANC, normal delivery, and well-child
check-up). treatment for children
5. Renovation for facilities
6. Provide the necessary supply & equipment
7. Strengthen referral system
8. Extend implementation of PMCT (Prevention of

Mother to Child Transmission) programme
9. Introduce MCH (maternal-child health)

regulation
10. Develop IEC (information, education, and

communication) materials
11. Provide MCH information and health

education
12. Promote well-child clinic checking
13. Inform free of charge services on ANC,

normal delivery, and well-child check-up
14. Training (especially at the grassroots level)
15. Regular monitoring, supervision, and

evaluation
16. Make a comprehensive team using uniform

services
17. Integration of services and collaboration with

other sectors

In 2005, the Lao PDR Ministry of Health passed a health care law giving all citizens the right to receive health services.
Granting the right to health care did not guarantee that citizens would go to facilities, however. Particularly in periphery
areas, the public health system was underutilized. A reason for this was the out-of-pocket payments still being charged at
public and private facilities. The burden of payment fell significantly on the poor. To address underutilization resulting from
high costs, the Lao PDR Ministry of Health, in conjunction with the World Health Organization, is rolling out a program which
will provide vouchers to offer free ANC and postnatal maternal and child care. The program is set to cover 83 districts in
13 provinces.

5

A Snapshot of child
mortality in Lao PDR

Based on 2009 data presented by Dr. Somchith Akkavong, Deputy Director
of the Lao PDR Ministry of Health’s Department of Hygiene and Prevention:

HIV / AIDS Diarrhoeal Diseases Hepatitis B
* 34.4%: the % of Laos * 11% of children under 5 years die from diarrhoea. * Is endemic to Lao
children with HIV, transmitted * Children aged 1 to 5 years are most prone to E. PDR, affecting rural ar-
from mothers. Coli and rotavirus, both of which cause diarrhoea. eas more than urban or
* Prevention: * For diarrhea induced by rotavirus, breastfeeding for semi-urban areas.
up to two years after birth is highly recommended. * High rate of mother-to-
1. Giving HIV-positive child transmission of HBV
pregnant women medicines + poor routine vaccination
during pregnancy and child program, the result of
birth. untrained staff and vaccine
2. Birth by C-section. shortages
3. Giving HIV medicines to * High efficacy in Hepa-
babies 4-6 weeks after birth. titis B vaccine birth dose
4. Instructing HIV-positive (70-95% effective against
mothers not to breastfeed. mother-to-child transmis-
sion)
ARI * Recommendation: Focus
* Pneumonia, which leads on newborns in health
to ARI, is responsible for facilities, adequate stock
19% of Under 5 deaths of vaccines & funding at-
with 70% of those deaths home vaccinations.
in Sub-Saharan Africa and
Southeast Asia. Neonatal Tetanus
* 57% of pneumonia in * A 2015 WHO survey
Lao PDR affects children revealed a low incidence
under 5 years old. rate of neonatal tetanus
in Lao PDR.
Complications * The low incidence rate
During Birth is a result of increased
efforts to immunize
* 30.9 per 100,000 chil- women before and during
dren die of preterm birth pregnancy, promote
complications, resulting in a hygienic birth practices,
loss of 2,752 DALYS.1 and encourage postnatal
* Birth asphyxia: the depriva- umbilical cord care.
tion of oxygen to a newborn, * Despite the low inci-
leading to encephalopathy dence rate, steps need
(brain damage). to be taken to reach
* 14.2 per 100,000 chil- rural regions and women
dren die of encephalopathy who give birth at home.
induced by birth asphyxia,
resulting in the loss of 1,257
DALYS

1DALY: a disability-adjusted life year i.e. the years lost from not being at full health as a result of a particular disease

6

A Snapshot of Child Mortality in Lao PDR

Stunting, Undernutrition, & Wasting

The undernourished child has already lost. When Risk factors pinpointed in malnutrition in children under 5 include:
children do not receive adequate nutrition and 1. Low maternal education
intake in the long-term, their earnings over a 2. Poor knowledge about maternal nutrition and feeding practices
lifetime are diminished. They suffer from a de- for sick children
creased ability to learn in school. They have a
higher risk of developing diabetes, obesity, and Stunted versus Underweight versus Wasted:
hypertension. For the Lao PDR national econ- What is the difference? (from UNICEF)
omy, the cost of undernutrition totals between
$113 million and $200 million (USD) per A stunted child is at least two standard deviations below the medi-
annum, counting the losses from mortality, lost an height given his age.
productivity and work, and depressed cogni- The underweight infant is at least two standard deviations below
tive development. Anemia alone reduces future median weight given her age.
wages by 2.5%. A child who is wasting is at least two standard deviations from the
median weight given his height.
*Medians are based upon WHO Child Growth Standards

45% of all deaths of Laotian children under 5 years of age is caused by undernutrition.

Object H: Stunting Rates in SE Asia and USA.
Source: UNICEF, 2012.

7

A Snapshot of Child Mortality in Lao PDR

Beriberi: a case study on the impact of
cultural postpartum practices on
maternal nutrition
In recent years, doctors have increasingly begun diagnosing infants Characteristics of Laotian mothers
and attributing causes of infant deaths post-mortem to beriberi, whose infants contracted beriberi:
particularly in remote rural villages in Northern Laos. Beriberi is a
disease whose symptoms include shortness of breath, numbness in Less diet diversity
the limbs, and paralysis. At its most deadly, beriberi induces sudden Oversoaked rice
onset cardiac failure. The disease is caused by deficiencies in thia- Fewer years of schooling
mine, or Vitamin B1. Seeds, cereals (including rice), legumes, and Family income inadequate for basic
meats contain Vitamin B1. Particularly in the Northern region among needs
ethnic minorities (pinned on the map, Object I), food preparation Performed hard physical labour
practices and dietetic composition leave the child population vulnera-
ble to beriberi.

In villages reporting incidences of thiamine deficiency, the infant
mortality rate is 106 per 1,000 births. Compare that to the national
average of 51 deaths per 1,000 births. Thiamine-deficient villages
have infant mortality rates over twice as high as those that are not.
Infant mortality trends in thiamine deficient populations are character-
ized by high neonatal mortality rates which remain steady and high
before another mortality peak before 6 months of age.

In the Lao PDR context, a few practices and food production de- Object I: This map shows Luang Namtha Hospital,
velopments have contributed to population thiamine deficiency. In where Barennes et al. (2015) researched the impacts
Barennes et al.’s study (2015) of pregnant women whose infants and causes of beriberi. Their conclusion, that mothers’
were diagnosed with beriberi, 98.4% of the women practiced strict
food avoidance for cultural reasons. Their diets consisted primarily postpartum nutrition practices of strict food avoidance
of milled glutinous rice soaked in a tea or water mixture containing and the introduction of electric rice mills had a signif-
enzymes that deactivated thiamine. Thus, the infants were not getting icant impact on infants being thiamine deficient. Blank
enough thiamine through their mothers’ breast milk.
map: Google Maps.
The installation of electric rice milling machines in Barennes et al’s File no 117. Origin: Denkang Village, Long Village
study was also characteristic of villages experiencing high rates of
thiamine deficiency and beriberi. 81% of villages studied had recently Mother: 28 years old, Hmong ethnic group, farmer,
installed an electric rice milling machine. Though convenient and a illiterate, 7 children, 5 deaths
mark of economic progress, rice polished by electric mills loses more
Vitamin B and nutrition than rice polished by foot. Post partum: strict food avoidance after delivery: she ate
only polished rice, and salt during one month
Beriberi and thiamine deficiency reduction strategies range from the
preventative to the curative. Preventative measures for pregnant and Symptoms: edema of legs and arms; paresthesias,
breastfeeding mothers include preparing rice in a way that the rice is dyspnea
not unnecessarily soaked for too long, avoiding fermented fish paste
and betel nuts, and adjusting postpartum diets so that the mothers Infant: In the age of 1 month and in good health, he
no longer adhere to strict food avoidance. Curative measures include died suddenly after a day with silent screams, cyanosis
an initiative in Xayaboury in Northwestern Laos which provided of the body, and inability to breastfeed. The child was
community-wide thiamine supplementation in a prenatal education anuric, no liquid stools, no fever, no cough.
program.

8

A Snapshot of Child Mortality in Lao PDR

In summary,

Lao PDR’s high child and maternal mortality rates can be attributed to a number of diseas-
es and health outcomes that are the result of a lack of (1) immunization (2) skilled workers
or access to healthcare facilities and (3) knowledge in the areas of postnatal nutrition and
antenatal care.

The Ministry of Health’s maternal child health strategy (see: page 6) focuses extensively on the role of the providers. The
Ministry of Health strategy includes Ministry oversight and cross-sector collaboration (Activities 9, 15, 16, 17), skill building for
health workers (Activities 1, 2, 3, 4, 7, 8, 14), and facility and equipment updates (Activities 5, 6). To ensure utilization,
however, women, children, and families need equal prioritization. In fact, many cultural and access barriers prevent more pregnant
Laotian women from seeking antenatal care, giving birth in equipped facilities, and choosing into vaccination and best caretaking
and health practices for their children. Some of the greatest causes of maternal and infant mortality, undernutrition and vitamin
deficiency, and preterm births, are more likely to occur when there is not a skilled birth attendant present, when a woman does
not give birth in a health facility, and when she is poor or uneducated There is opportunity and space to improve maternal child
health in Laos on the community and family side that is not addressed by the Lao PDR Ministry of Health.

Policy Recommendation

Maternal education encouraging mothers to vaccinate their children,
seek antenatal and postnatal care, and provide adequate nutrition is
an economical and sustainable intervention to address the Ministry of
Education’s strategy gap. A maternal education program in the Lao-
tian context, however, needs to pay particular attention to the role
that culture and tradition play in birthing and health practices and the
demographics of Laotian mothers, often poor and uneducated. A ma-
ternal education program to most effectively address Laotian mothers is
outlined at the end of this section.

Taking the impact on improved infant feeding and nutrition alone, the

Object J: Source: World Health Organization, approximated return on investment (ROI) to maternal education in
Michael Bainbridge, 2014 this area has been calculated to be 1400%. The ROI for Vitamin A
supplementation is 1700%. Though the latter is not directly addressed

The approximate by maternal education, informing mothers of the benefits of giving birth
in a health facility encourages them to give birth in centers, which can
offer regulated and consistent Vitamin A supplementation to those who

r e t u r n o n i nv e s t m e nt enter. If women do not give birth in a health center, they and their
newborns may go unrecorded and undetected by the Laotian health

t o m at e r n a l e d u c at i o n system. Undernutrition costs the Lao PDR economy between $113
and $200 million per year in productivity. 1400% and 1700% ROI,
respectively, can be huge for the intellectual and economic vitality of

on i n f ant fe e d i ng and the growing state.
Maternal education in the areas of nutrition, health center care, and in-
nutrition is fant mortality risk factors would be able to address 63% of the causes
1400%. of neonatal mortality (see: A Snapshot of Child Mortality in Lao PDR,
page 6) as well as undernutrition.

9

Policy Recommendation
Nutrition Education

On the topic of maternal and child diets, mothers are more likely to change their breastfeeding and nutrition prac-
tices based upon maternal nutrition counseling. This change in their feeding in turn increases children’s height and
weight from 6 months to 24 months, thereby reducing malnourishment and the number of children underweight,
stunted, or wasted. Healthy breastfeeding practices were most prevalent with mothers who had higher education,
received ANC, delivered their babies in a healthcare facility. Women in Lao PDR with knowledge of the benefits of
breastfeeding were not likely to implement the practice unless they had been given clear instructions from a health
care provider. Knowledge of, it turns out, is different from knowledge how. Effective Laotian maternal education
needs to encourage the how.

Giving Birth in Health Facilities

Health facilities provide a range of functions: antenatal care, postnatal check-ups, and vaccinations, among other
routine services. The scope of solutions to poor ANC and public hospital attendance is broad, encompassing road
infrastructure, health financing, and cultural barriers. Though maternal education cannot tackle all of the solutions, it
can address the pregnant women who refuse ANC because they believe that they are healthy and not at risk. Ma-
ternal education can also educate women about their financial options. In Lao PDR, user fees have been charged at
public hospitals since 1995. A 2005 health law set user fee exemptions for the poor in theory but in practice was
sporadically implemented. The success of a 2009 pilot of user fee eliminations in two regions of Laos has led the
government to push for expansion of the free delivery scheme in 2017. By equipping women with the knowledge
that their nearest health facility offers free deliveries, a maternal education program can eliminate one barrier at least
to the low rates of birth in hospitals.

By encouraging women to give birth in public hospitals, their risk of giving birth unhygienically and taking improper
care of the umbilical cord post-birth is decreased, lowering the newborn’s chances of contracting neonatal tetanus.
Getting women into hospitals and health facilities also gives providers the chance to offer vaccinations, which are
important to reducing Hepatitis B and neonatal tetanus.

Understanding Preterm Birth Complications

An effective maternal education program to address premature births and birth asphyxia already developed and im-
plemented is Weiner et al.’s 10 minute educational program on basic neonatal care for expectant mothers in the
Laotian capital. Their program taught umbilical cord care and ways to detect neonatal illness. The mothers retained
the information from the short session through early information. Like the recommendations from the breastfeeding
intervention, the educational program’s success was dependent in part upon the presence of a skilled health worker
who could teach and answer questions.

10

Policy Recommendation

How? To offer maternal education is to empower mothers to make decisions. The choice is the mother’s
on how she will give birth and take care of her child. Other maternal education programs have found
themselves faced with the constraints of time and chose to address the what and the straightforward
facts of motherhood. Though fact-provision is still empowering, teaching the how of breastfeeding and

proper nutrition and childcare is key to affecting behavior.

Laotian health practices differ from Western medicine, so it is important to take tradition into consideration rather than neglect-
ing it altogether. One belief is that the child will develop jaundice if the mother sleeps during the day during her pregnancy.
Herbal medicines and eggs are placed on the abdomen to ensure easy delivery. Objects, clothing, and herbal medicines are
prepared. Maternal education programs should discourage practices such as discarding the colostrum, but others practices that
are important to the community though not necessarily common in Western practice should not immediately discarded without
consulting communities and leaders.

The family is important to the birthing process with husbands often as main decision makers and female family members being
influential. Grandmothers in particular hold great influence. The rest of the family and the community should be included in the
education process, because they have a large say in the mother’s decisions. The value of the family being an important part
of the decision-making process is that the informed mother can pass her maternal education to other family members and
generations.

Children born from mothers who have low levels of education and who are illiterate are at higher risk of certain diseases and
malnutrition. Ohnishi et al’s study (2015) of a Paraguayan maternal health literacy program targeting women who did not
complete compulsory education notes the importance of educating the women in the language in which they are functionally
fluent. High quality health providers and educators also have a significant impact on women’s health knowledge. In Lao PDR,
traditional birth attendants, present at a 12% of births, are also transmitters of information to women at all levels of education
about risks related to abortion, vaginal hemorrhage, and premature delivery. They can encourage women to get ANC and go
to medical facilities if a birth is deemed too high risk. Pictorial representations and face-to-face communication with a health
provider, essential to Weiner et al’s (2015) education program on premature birth risks, are two other means of educating
women with low levels of education.

The Role of Learn to Live

Learn to Live will be an important agency in the battle to reduce infant and maternal mortality. Maternal education is cru-
cial to advancing Learn to Live’s mission of reducing the high incidence of infant mortality in the Mok Mai region. Learn to
Live already has the health network in Mok Mai established through its ultrasound delivery and education program to find the
providers and educators needed for the maternal education program. The health network also has the knowledge to point the
program to areas of highest need.

The value of piloting a maternal education program in Mok Mai is the impact of reaching one of the most impoverished and
isolated districts in Lao PDR. Piloting in the hardest to reach regions and communities can set the maternal education program
up for success in other regions having already catered to the most isolated and impoverished in the population.

A successful maternal education pilot program in Mok Mai also has the potential to be a vehicle for Learn to Live’s secondary
mission: “educating women & men about their reproductive health.” The maternal education program, through targeting women
who are least educated and least accessible, can provide a framework to target women and men who are hardest to reach
for a reproductive health education program. Results and strategies from the maternal education pilot can be adapted for other
education programs.

Learn to Live does not need to start a maternal education program from scratch. The Lao PDR Ministry of Health, in union
with UNICEF, released the report “Infant and Young Child Feeding Guidelines” in 2012. With Learn to Live’s connections
in Mok Mai and the UNICEF-MoH guidelines, a foundation is already in place to jumpstart a maternal education program to
effect positive and meaningful changes to the futures of Laotian newborns.

11

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