Grant No.

08－084

Research Report
Name : Outavong Phathammavong
Organization (at the time of the grant):
Department of Health Policy and Planning, The University of Tokyo
Title of Research:

Antenatal care enhancing hospital delivery and child immunization among minor ethnic populationsin Louang Namtha province, Lao PDR
Purpose of Research:

Numerous studies in developing countries indicated factors affecting the ANC. In their systematicreview, Simkhada et al. showed that socio-demographic factors, availability and accessibility,
affordability, health insurance, women’s status in the household, and women’s knowledge, attitude,
belief and culture affected the ANC utilization in developing countries.
The contribution of ANC to the reduction of maternal mortality was found to be limited insome studies because the prediction of complications threatening the mother’s life was low. It might
be true in countries with low MMR and high ANC coverage. A study in Surabaya, Indonesia showed
the association between maternal mortality and number and onset of ANC visits. Many studies,moreover, demonstrated the benefits of the ANC visits on birth weight of newborn baby (Fujita etal., 2005), hospital delivery and delivery attended by skill personal, postpartum care, TT vaccine ofwomen, child immunization and breast-feeding practices.
Although there is a low ANC utilization rate and low proportion of delivery at healthcare
facilities in Laos, there are no studies to explore associated determinants and no study on beneficial
effects of ANC on MCH services utilization such as hospital delivery and child immunization inLaos. This study aimed to fill this gap, specifically to assess ANC utilization rates among mothers
who live in the rural area of Laos, to investigate the determinants of ANC utilization and to explore
whether ANC utilization enhances the mother’s decision-making regarding the place of delivery andimmunization status of the children under five.

Content/Methodology of Research:Methods
Study design and study site
A community based, cross-sectional survey was carried out in Viengphukha district, Louang
Namtha province in January 2008. Louang Namtha, a mountainous province located in north ofLaos, was identified as one of poverty-stricken provinces, consisting of five districts of which threewere classified as poor. Viengphukha was one of the poor districts, notable for its lack of electricity.
There were 46 villages and 11 minor ethnic groups. Total population was 19,996 people.
There are 9 health centers in Viengphukha district; of these, 5 health centers covering 21
catchment villages were randomly selected by simple random sampling method. Five villages wereexcluded due to inaccessibility, and the remaining 16 villages were targeted for our field survey. The
entire 1,213 households were recruited in this study and visited by research assistants; however,1007 (83%) were available for interview. Two households were excluded because household
representatives refused to participate. Of the participating 1005 households, 620 had at least a childaged less than five years. Among households with children under five, parents of children under fivewere interviewed.
Data collection
Door-to-door technique was used in this study to ensure that all households were visited trained
research assistants. Face-to-face interview using semi-structured questionnaire was conducted tohousehold representative for households without children aged under five and parents of children
aged under five for households which children aged under five were identified. The questionnaire
was developed to investigate the socio-demographic and characteristic of the participants and theirhouseholds, experiences of MCH care service utilization among mothers during the most recent
pregnancy, and the immunization status of their youngest child. The immunization status wasconfirmed by checking the vaccination card (yellow card).
Ethical considerations
This study was approved by the National Ethics Committee For Health Research, Ministry of Healthin Laos before we conducted field survey. Verbal informed consent was obtained from eachparticipant before an interview.
Data analysis
Data analysis was done using the SPSS statistic program version 13.0 for Windows. Chi-square test
was performed to explore the determinants of ANC visits, delivery at healthcare facility and fullimmunization of children under five. The statistically significant factors for the chi-square test wereincluded in the binary logistic regression analysis. A p-value of less than 0.05 was considered asstatistical significance in our study.
Results
Utilization of health facility
One hundred forty five (23.4%) of 620 mothers with children under five had at least one ANC visit,of which 4.5% had at least four ANC visits during the most recent pregnancy (Table2). 558 (90%)
of deliveries took place at home, of which 4.8% were assisted by skill birth attendant and 24.7%
were assisted by traditional birth attendant (TBA). Among children under five, 25.2% were received
full immunization.

Determinants of ANC visits
In Table 3, the results of chi-square test showed that the education level of fathers and mothers weredirectly associated with ANC visits (OR=2.3; p<0.001 & OR=2.9; p<0.001, respectively). ANC
visits among mothers whose household income were more than 5 US$ were 1.5 times higher thanthe others (p<0.05). Furthermore, ANC visits among lowland and midland mothers were 19.7 and6.0 times higher than highland mothers, respectively (p<0.001). Mothers living in a village withhealth center were more likely to visit ANC at least one time than mothers in a village without
health center (OR=2.5; p<0.001).
Logistic regression analysis showed that ethnicity is a statistically significant predictor for
ANC: ANC visits among lowland and midland mothers were 3.9 and 7.2 times, respectively, higher
than highland mothers (p<0.01 & p<0.01, respectively). Mothers who had attended school weremore likely to have had at least one ANC visits (adjusted OR=1.6; p<0.05).
ANC enhancing hospital delivery and child immunization
Bivariate analysis showed that, home deliveries were less likely when mothers and fathers had
higher education. Mothers living in the village without the health center and having no ANC visits
during the most recent pregnancy were more likely to do home delivery (Table 4). Home delivery
was higher among highland (OR=30.6; p<0.001) and midland (OR=6.9; p<0.001) than lowland
mothers. In a logistic regression analysis only ANC visits remains a strong association with homedelivery (adjusted OR=20.1; p<0.001).
Children of the parents who have higher educational level and have more than 5
US$ monthly income were less likely to have incomplete immunization (Table 4). Incomplete
immunization was 4.5 times higher among highland children than lowland. Furthermore, children
living in the village without a health center and whose mother had no ANC visit during the mostrecent pregnancy were more likely to get incomplete immunization than the others. In a logistic
regression analysis, however, an association was found only between mothers who had no ANC
visit and incomplete of routine immunization of children under five (adjusted OR=1.9; p<0.01).
Conclusion/Observation

Discussion
We found that 23% of mothers received at least one ANC visit, which was consistent with the WHO
report (23%) in 2003. This rate (23%) was much lower than in our previous study of semi-urban
areas of Xiengkhuang province (63%), suggesting a gap in ANC utilization between women inurban and rural areas of Laos. Our study confirms the lowest rate of ANC visits rate in the Southeast
Asia region. WHO recommended four ANC visits for each pregnancy to eliminate risks ofpregnancy-related maternal death. Data of four ANC visits, however, had not been available inLaos. We showed that only 4.5% of at least four ANC visits among minor ethnic mothers.

Our study shows even with the low levels of education for both parents there is a positive
association between education level among women and their husbands and ANC utilization for themost recent pregnancy. The association between ANC visits and education was much stronger instudies in Vietnam, India and Kenya. Simkhada et al. showed that findings from many studies in
Asia and Africa supported this association.
The significant factor influencing ANC visits was ethnicity. Not surprisingly, ANC visitswere less common among highland and midland mothers than lowland mothers. Among highlandand midland people, utilization of MCH might stick to the belief, culture and lifestyle. Studies fromEthiopia, India, Nigeria and Viet Nam pointed out a consistent finding.
The availability of healthcare facility seems to be another determinant of ANC visits.
Mothers needed to walk for one or two hours to reach the nearest healthcare facility, which would
discourage them to attend an ANC. This finding is consistent with studies from Kenya and Tamil
Nadu, South India.
Having received no ANC visits were directly associated with home delivery regardless ofthe socio-demographic characteristics of targeted people and availability of healthcare facility.
Studies from Bangladesh and Cambodia consistently showed the direct association between regular
ANC visits and delivery taking place at healthcare facility among mothers in rural community.
Children whose mothers had ANC visits were more likely to get fully immunized thanchildren whose mothers had no ANC visit regardless of the socio-demography, ethnicity andavailability of healthcare facility. Moreover, in the study area, vaccines are provided free of charge
through outreach team at village four rounds a year; therefore, all children have an equal
opportunity to receive full immunization. A study in North India showed that children were more
likely to receive immunization if mothers received ANC. A study from Ghana showed that children
whose mothers received ANC provided by doctors and/or nurses were more likely to receive fullimmunization than those whose mothers received ANC provided by traditional birth attendant andwhose mothers received no ANC.
Conclusion
Notwithstanding the antenatal care was prioritized as one of strategies to tackle the high maternal
death in Laos, this study revealed the low ANC utilization rate (23%) among ethnic minority
mothers, who were less educated. Although the cause-effect relationship was not able to establish
due to the nature of cross-sectional study design, we confidently demonstrate the possibility of ANC
visits enhancing the decision-making of the mothers toward hospital delivery and immunization of
their children.
The ministry of health in collaboration with the United Nations Children’s Fund (UNICEF)
has been implementing the community-based ANC aiming at increasing its utilization rate among
women in remote, rural area. However, the quality and benefits of the community-based ANC on
MCH services utilization remain questions. Further researches are needed to prove these issues.