62956 RePRODuctive HealtH at a GLANce April 2011 LAO PDR country context Lao PDR: MDG 5 Status Lao PDR has made notable progress towards achieving MDG 5A indicators some of its MDG goals thanks to a remarkable growth rate Maternal Mortality Ratio (maternal deaths per 100,000 live 580 that averaged 7 percent during the past decade. However, births) UN estimatea most of this recent growth has benefited disproportionally Births attended by skilled health personnel (percent) 18.5 people living in urban areas, which as a result, have wid- MDG 5B indicators ened the disparity between the rich and the poor. Further, 44 percent of the population still subsists on less than US Contraceptive Prevalence Rate (percent) 38.4 $1.25 per day.1 Adolescent Fertility Rate (births per 1,000 women ages 15–19) 76 Antenatal care with health personnel (percent) 30.3 Lao PDR’s large share of youth population (38 percent of the country population is younger than 15 years old) pro- Unmet need for family planning (percent) 27.3 vides a window of opportunity for high growth and poverty Source: Table compiled from multiple sources reduction—the demographic dividend. For this opportu- a DHS estimate not available. nity to result in accelerated growth, the government needs to invest more in the human capital formation of its youth. MDG target 5A: Reduce by three-quarters, between Gender equality and women’s empowerment are im- 1990 and 2015, the Maternal Mortality Ratio portant for improving reproductive health. Higher levels Lao PDR has been making progress over the past two decades on of women’s autonomy, education, wages, and labor mar- maternal health but it is not yet on track to achieve its 2015 targets.5 ket participation are associated with improved reproduc- tive health outcomes.2 In Lao PDR, the literacy rate among Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target females ages 15 and above is 63 percent. Fewer girls are 1400 enrolled in secondary schools compared to boys with 81 1200 1200 percent ratio of female to male secondary enrollment.1 81 1000 970 790 percent of adult women participate in the labor force that 800 650 MDG 580 mostly involves work in agriculture. Gender based violence 600 Target has only recently been addressed, and the National Assem- 400 300 bly is making strides towards quantifying the problem. It is 200 estimated that almost half of women in the country have 0 1990 1995 2000 2005 2008 2015 been victims of domestic violence by a husband or intimate partner.3 Gender inequalities are reflected in the country’s Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report human development ranking; Lao PDR ranks 115 of 157 countries in the Gender-related Development Index.4 World Bank Support for Health in Lao PDR Greater human capital for women will not translate into The Bank’s current Country Assistance Strategy is for fiscal years 2005 to 2011. greater reproductive choice if women lack access to repro- The Bank’s new Country Assistance Strategy under preparation (P120311) is scheduled to be approved by the Bank’s Executive Board on May 19, 2011. ductive health services. It is thus important to ensure that current Project: health systems provide a basic package of reproductive P074027 LA-Health Services Improvement Project ($15m) health services, including family planning.2 P114863 LA-Community Nutrition Project ($4m) Pipeline Project: Additional Financing for Health Services Improvement Project—it has been proposed that this will focus MNCH, including capacity building, increasing access to routine preventive MCH services, and reducing financial barriers to MCH services, including delivery. Previous health project: THE WORLD BANK P100081 LA-Avian and Human Influenza Control n Key challenges traception (25.6 percent) than their urban counterparts (44.7 percent) (Figure 3). High Fertility Figure 3 n use of contraceptives among married women by residence Fertility has been declining over time but still remains high in 50 44.7 rural areas. Total fertility rate (TFR) has been declining steadily 40 38 % Overall 36.0 from an estimated 6.0 births per woman in 1990 to 4.1 in 2005.6 30 25.6 20 Figure 2 n total fertility rate by residence 10 5 4.7 0 4.1 Overall Urban Rural with road Rural without road 4 3.7 3 Source: PDR Reproductive Health Survey, Lao PDR 2005. 2.0 2 Unmet need for contraception is high at 27 percent indicat- 1 ing that women may not be achieving their desired family size. 0 Urban Rural with road Rural without road This is especially the case for women in hard-to-reach rural areas for which unmet need reaches 32 percent compared to 22 percent Source: PDR Reproductive Health Survey, Lao PDR 2005. among urban women.6 Despite this positive trend, Lao continues to have one of the Wanting more children and health concerns about modern highest TFR in the East Asia and the Pacific region. Further, wide contraceptive methods are the predominant reasons women urban-rural disparities exist with women living in rural areas do not intend to use contraception in the future. Twenty-sev- without a road having more than twice the TFR of women living en percent of women not intending to use contraception indi- in urban areas. Similarly, TFR among women with no education cated that they wanted another child while another 23 percent is more than double that of women with upper secondary educa- cited health concerns.6 Husband’s disapproval (19 percent) and tion (5.4 and 2.0, respectively). lack of knowledge (15 percent) were also frequent reasons for Adolescent fertility rate is high (47 births per 1,000 births not intending to use contraception in the future. Cost and access women aged 15–19 years) affecting not only young women and are lesser concerns, indicating further need to strengthen family their children’s health but their long-term education and em- planning services. ployment prospects. Births to women aged 15–19 years old have the highest risk of infant and child mortality as well as a higher Poor Pregnancy Outcomes risk of morbidity and mortality for the young mother.2 Less than a third of pregnant women receive antenatal care Early childbearing is more frequent among women who from skilled health personnel (doctor, midwife, nurse, or live in rural areas without a road and among women without health worker).6 Further, 61 percent of the pregnant women who education. While about one third of women age 15 to 19 with received antenatal care had the recommended four or more ante- no education have begun childbearing, only 2.4 percent of those natal visits. Still, 56 percent of pregnant women are anaemic (de- with upper secondary education did. Furthermore, the data sug- fined as haemoglobin < 110g/L) increasing their risk of preterm gest that early childbearing seem to have become more common delivery, low birth weight babies, stillbirth and newborn death, a over time.6 figure that suggest that there is scope to strengthen the quality of the antenatal services being offered.7 Large increase observed in the contraceptive prevalence rate irrespective of women’s background characteristics About two- Figure 4 n Birth assisted by skilled health personnel (percentage) fifths of married women use contraception. Modern contracep- by residence tive methods are more widely used among married women than 60 traditional methods (35.0 and 3.4 percent, respectively).6 The pill 53.2 is the most commonly used modern method among married 40 women (15.9 percent), followed by the injectables and female 18.5 % Overall sterilization. Use of long-term methods such as the IUD and im- 20 15.3 plants are negligible. 5.3 0 Accessibility is an important issue. Married women in hard- Urban Rural with road Rural without road to-reach rural areas are much less likely to use any form of con- Source: PDR Reproductive Health Survey, Lao PDR 2005. Only 18 percent of women deliver with the assistance of skilled technical Notes health personnel. Wide urban-rural disparities exist: while 53 Improving Reproductive Health (RH) outcomes, as outlined in the percent of women in urban areas delivered with the assistance RHAP, includes addressing high fertility, reducing unmet demand for of skilled health personnel, only 5 percent of women in hard-to- contraception, improving pregnancy outcomes, and reducing STIs. reach rural areas obtained such assistance (Figure 4). The RHAP has identified 57 focus countries based on poor Most of the women who delivered at home believed it was not reproductive health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high necessary to delivery in a health facility. One third of them cited priority countries as those where the MMR is higher than 220/100,000 long distance to a health facility as the main reason (Table 1).6 live births and TFR is greater than 3. These countries are also a sub- group of the Countdown to 2015 countries. Details of the RHAP are table 1. Reasons for not delivery in a health facility (women age available at www.worldbank.org/population. 15–49) Reason % The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the Not necessary 75.7 same dimensions as the HDI while adjusting for gender inequality. Its Distance to health facility 33.7 coverage is limited to 157 countries and areas for which the HDI rank Other 6.5 was recalculated. Cost 5.5 Health services 1.3 Source: PDR Reproductive Health Survey, Lao PDR 2005 Human resources for maternal health are limited with only 0.35 physicians per 1,000 population; nurses and midwives are slightly more common, at 0.97 per 1,000 population.1 Development partners support for reproductive health The high maternal mortality ratio at 580 maternal deaths per in Lao 100,000 live births indicates that access to and quality of emer- WHO: Safe motherhood, support in the implementation gency obstetric and neonatal care (EmONC) remains a challenge. of the MNCH strategy. uNFPA: Reproductive health and rights, access to RH Stis/Hiv/AiDS prevalence is low but knowledge of commodities, training of midwives and health needs to be strengthened workers in EmOC; HIV prevalence is low (0.2 percent) and HIV/AIDS aware- uNiceF: child protection; under-5 mortality ness is not widespread. Overall, just 70 percent of women have GAvi: Support immunization services and introduction ever heard of HIV/AIDS. Further, only 46 percent of women liv- of new vaccines for children. ing in hard-to-reach rural areas have ever heard of HIV/AIDS.6 JicA: Planning, Management and Coordination for the Knowledge of HIV/AIDS increases with level of education of MNCH strategy; women. ADB: Health system capacity strengthening, support in the implementation of the MNCH strategy. Knowledge of mother-to-child prevention methods is low. Among women who have ever heard of HIV/AIDS, knowledge Luxembourg Support in the implementation of MNCH that HIV can be transmitted from mother to child is just 19 Development: strategy percent. n Key Actions to improve RH Outcomes Strengthen gender equality personnel (especially in rural settings) to ensure the promotion • Support women and girls’ empowerment by working in close and correct use of all modern contraceptive methods. cooperation with the Lao Women’s Union, which is active in all villages in the country, especially to educate and raise aware- Reducing maternal mortality ness on the impact of early marriage, child-bearing, and the family planning services available. • Promote institutional delivery through provider incentives and by generating demand for services. Community mobilization • Build on advocacy and community participation, and involve around maternal, neonatal and child care is key to increase men in supporting women’s health and wellbeing; work with knowledge and action on the importance of delivery with a both men and the village elders to ensure local engagement and skilled health personnel and ANC and PNC care. commitments. • Continue the ongoing efforts in training more midwives and pilot innovative approaches to increase their retention in rural Reducing high fertility areas. Invest in training and provision of basic emergency ob- • Increase family planning awareness and utilization by ex- stetric care (EmOC) which is still limited in rural areas. panding Community Based Distribution of FP commodities, • Address the perception that it not necessary to deliver at a especially targeting rural and remote communities; also po- health facility, both through increased community mobiliza- tentially consider the role of FP in village drug kits and ex- tion and through investments in infrastructure to ensure that pand engagement with the private sector for the provision of health centers are not only easily accessible, but also safe and FP services. acceptable for ANC, delivery, and PNC. • Provide quality family planning services that reflect local needs: in rural areas the focus should be on delaying the first pregnan- Reducing Stis/Hiv/AiDS cy for younger married women and on birth spacing for older women, and increase contraception education and awareness; • Despite the low prevalence, efforts should focus in integrating in urban areas, broader campaigns targeting youths and vul- HIV/AIDS/STIs and family planning services in routine ante- nerable populations, highlighting the effectiveness of modern natal and postnatal care to ensure that HIV positive mothers contraceptive methods, and properly educating women on the are identified and their babies are born HIV-free. health risks and benefits of such methods. • Focus on increasing HIV/AIDS knowledge and awareness • Focus on improving the capacity of the health system through amongst all populations through community outreach in both extensive and systematic training of health and family planning urban and rural areas. References: 7. Worldwide prevalence of anaemia 1993–2005 : WHO global da- tabase on anaemia / Edited by Bruno de Benoist, Erin McLean, 1. World Bank. 2010. World Development Indicators. Washington DC. Ines Egli and Mary Cogswell. http://whqlibdoc.who.int/publica- 2. World Bank, Engendering Development: Through Gender Equality tions/2008/9789241596657_eng.pdf. Accessed March 9, 2011 in Rights, Resources, and Voice. 2001. 3. UNHCR. Report on Rural Domestic Violence and Gender Research: Lao PDR. Available at http://www.un.org/womenwatch/daw/vaw/ ngocontribute/CUSO.pdf. Accessed March 9, 2011 correspondence Details 4. Gender-related development index. Available at http://hdr.undp. org/en/media/HDR_20072008_GDI.pdf. Accessed March 1, 2011 This profile was prepared by the World Bank (HDNHE, PRMGE, and 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by EASHH). For more information contact, Samuel Mills, Tel: 202 473 WHO, UNICEF, UNFPA, and the World Bank 9100, email: smills@worldbank.org. This report is available on the 6. Lao PDR National Statistics Center and UNFPA. Lao PDR following website: www.worldbank.org/population. Reproductive Health Survey 2005. LAO PDR RePRODuctive HeALtH ActiON PLAN iNDicAtORS indicator Year Level indicator Year Level Total fertility rate (births/woman ages 15–49) 2005 4.1 Population, total (million) 2008 6.2 Adolescent fertility rate (births/1,000 women ages 15–19) 2008 76 Population growth (annual %) 2008 1.8 Contraceptive prevalence (% of married women ages 15–49) 2005 38.4 Population ages 0–14 (% of total) 2008 38.2 Unmet need for contraceptives (%) 2005 27.3 Population ages 15–64 (% of total) 2008 58.2 Median age at first birth (years) from DHS 2005 19 Population ages 65 and above (% of total) 2008 3.6 Median age at marriage (years) 2005 18 Age dependency ratio (% of working-age population) 2008 72 Mean ideal number of children for all women 2005 3.5 Urban population (% of total) 2008 30.9 Antenatal care with health /sonnel (%) 2005 30.3 Mean size of households 2005 5.6 Births attended by skilled health /sonnel (%) 2005 18.5 GNI/capita, Atlas method (current US$) 2008 760 Proportion of pregnant women with hemoglobin <110 g/L) 2008 56.4 GDP/capita (current US$) 2008 893 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 1200 GDP growth (annual %) 2008 7.5 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 970 Population living below US$1.25/day 2002 44 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 790 Labor force participation rate, female (% of female population ages 15–64) 2008 81.4 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 650 Literacy rate, adult female (% of females ages 15 and above) 2005 63.2 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 580 Total enrollment, primary (% net) 2008 82.4 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 300 Ratio of female to male primary enrollment (%) 2008 90.6 Infant mortality rate (per 1,000 live births) 2008 48 Ratio of female to male secondary enrollment (%) 2008 80.6 Newborns protected against tetanus (%) 2008 47 Gender Development Index (GDI) 2008 115 DPT3 immunization coverage (% by age 1) 2008 61 Health expenditure, total (% of GDP) 2007 4.0 Pregnant women living with HIV who received antiretroviral drugs 2005 0 Health expenditure, public (% of GDP) 2007 0.8 (%) Prevalence of HIV (% of population ages 15–49) 2007 0.2 Health expenditure/capita (current US$) 2007 26.9 Female adults with HIV ( % of population ages 15+ with HIV) 2007 24.1 Physicians (per 1,000 population) 2004 0.35 Prevalence of HIV, female (% ages 15–24) 2007 0.1 Nurses and midwives (per 1,000 population) 2004 0.97 Poorest-Richest Poorest/Richest indicator Survey Year Poorest Second Middle Fourth Richest total Difference Ratio Total fertility rate — — — — — — — 4.1 — — Current use of contraception (Modern method) — — — — — — — — — — Current use of contraception (Any method) — — — — — — — 38.4 — — Unmet need for family planning (Total) — — — — — — — 27.3 — — Births attended by skilled health personnel MICS 2006 2.9 8.6 14.3 32.8 81.2 20.3 –78.3 0.04 (percent) National Policies and Strategies that Have influenced Reproductive Health 2005 National Reproductive Health (RH) Policy was adopted 2006 Revised National Population and Development Policy (NPDP) 2008 Skilled Birth Attendant Development Plan 2008–2015 2009 Strategy and Planning Framework for the Integrated Package of Maternal, Neonatal and Child Health Services 2009–2015; the strategy advo- cates primary health care approaches for delivering public health services and promote community participation. 2010 Free Maternal and Child Health Policy