SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH MATERNAL AND CHILD HEALTH IN A MARGINALIZED COMMUNITY ALONG THE THAI-MYANMAR BORDER Wit Wichaidit1, Jaranit Kaewkungwal1, Chukiat Sirivichayakul2, Pimsurang Taechaboonsermsak3 and Visut Suvithayasiri4 1Department of Tropical Hygiene; 2Department of Tropical Pediatrics, Faculty of Tropical Medicine; 3Department of Family Health, Faculty of Public Health, Mahidol University, Bangkok; 4Department of Obstetrics, Bangkok Metropolitan Administration Medical College, Bangkok, Thailand Abstract. The objective of this study was to conduct a cross-sectional evaluation of pregnancy indicators, child growth failure, and the effect of antenatal care on birth outcomes in a marginalized community under the care of a health center in Suan Phung District, Ratchaburi Province. Health and socioeconomic data about children born in 2007 and their parents were obtained from the sub-district health center and district hospital were collected and analyzed by univariate and multi- variate methods. Most of the residents in the study were Karen ethnic origin. Data was available for 152 children, of which 136 met study inclusion criteria. Health outcomes of the study population significantly different from the general Thai population included higher average parity (2.53 ± 1.99 vs 1.735; p<0.001), lower average birth weight (2,876.05 ± 399.48 grams vs 3,200 grams, p<0.001), and lower average height-for-age and weight-for-age (p<0.001). The prevalences of stunting, underweight and wasting were higher than the general Thai population (p<0.001). Having fewer than 4 antenatal care (ANC) visits was associated with low birth weight (unadjusted OR 4.88, 95% CI 1.13-21.05; adjusted OR 5.77, 95% CI 1.27- 26.30). Keywords: maternal and child health, birth outcomes, marginalization, Karen people, Thailand INTRODUCTION sion when additional targets were added. Health outcomes and utilization of Maternal and child health (MCH) is a various MCH services are used as indica- domain of public health which has impli- tors of the achievement of these revised cations for at least 3 of the 8 Millennium MDGs. The proportion of births attended Development Goals (MDGs) of the United by skilled health personnel is an indicator Nations, particularly after the 2005 revi- of Goal 5, Target 5.A (reduction in mater- nal mortality), while adolescent birth rate Correspondence: Jaranit Kaewkungwal, De- partment of Tropical Hygiene, Faculty of Tropi- and antenatal care coverage (at least 4 vis- cal Medicine, Mahidol University, 420/6 its) are indicators of the revised Goal 5, Ratchawithi Road, Ratchathewi District, Target 5.B (achieve by 2015 universal ac- Bangkok 10400, Thailand. cess to reproductive health). The propor- Tel: +66 (0) 2354 9100 ext 9188 tion of 1 year old children immunized E-mail: [email protected] against measles is used as an indicator of 152 Vol 42 No. 1 January 2011 MATERNAL AND CHILD HEALTH IN A MARGINALIZED COMMUNITY the revised Goal 4 (reduction in childhood Health Office, the District Hospital, and the mortality). The proportion of underweight Provincial Public Health Office. Other data children aged < 5 years is an indicator of sources for MCH data were the sub-district Goal 1 (eradicate extreme poverty and health center and the district hospital. hunger) (United Nations, 2008). Socioeconomic data at the sub-district Despite Thailand’s success in many health center are normally collected and MCH factors, such as infant mortality maintained in recording system known as comparable to that of Western countries, Family Folders and also in its electronic 97% institutional deliveries, and 96% database called the Health Center Infor- measles immunization rate by 1 year of mation System (HCIS). age (UNICEF, 2009), MCH along the Thai- Data regarding maternal health out- Myanmar border remains problematic comes, number of antenatal care visits, and (WCRWC, 2002), particularly in mar- birth outcomes were collected from ante- ginalized ethnic communities. No compre- natal care records and birth certificates of hensive research regarding MCH out- the sub-district health center and the HCIS, comes has been carried out among the eth- and from obstetrics records and birth cer- nic, marginalized, non-refugee population tificates of the district hospital. along the Thai-Myanmar border in Data regarding childhood immuniza- Ratchaburi Province, Thailand. Although tion were collected from the sub-district the debate about the effects and benefits health center’s records and the HCIS. A of antenatal care is still on-going among considerable number of childhood immu- public health scholars, there has yet to be nization records in paper format were miss- a study of the effect of antenatal care on ing and data in the HCIS were incomplete; birth outcomes in such a population. therefore, immunization information was We carried out a cross-sectional study not included in the analysis of this study. of MCH pregnancy outcomes and birth During each immunization visit, the com- outcomes (ie, parity, birth weight, gesta- munity public health officers measured the tional age, preterm birth, birth attendant, weight and height of the children; thus data institutional delivery, 1-minute Apgar regarding childhood growth were also score, and referral or complications dur- available from child immunization records. ing delivery), the prevalence of growth On average, each child received immuni- failure in 2007-born children (stunting or zation more than once, thus their weight very low height-for-age, underweight or and height were recorded on more than one very low weight-for-age, and wasting or separate occasion. very low weight-for-height), and the effect Child anthropometry Z-scores (Height- of antenatal care on birth outcomes, in an for-Age Z-Score or HAZ, Weight-for-Age area under the care of the sub-district Z-Score or WAZ, and Weight-for-Height health center in Suan Phung District, Z-Score) were calculated and compared to Ratchaburi Province, located at the Thai- the national data (Nutritional Division, Myanmar border. 1999). However, the average height-for- age Z-score (HAZ), weight-for-age Z-score MATERIALS AND METHODS (WAZ), and weight-for-height Z-score (WHZ) of each child were calculated and Data collection and management used instead of treating the z-score from Data were extracted from the District each measurement as separate units, in Vol 42 No. 1 January 2011 153 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH HCIS Birth Birth to be elaborated further later. (Health Center certificates records Database) (Health Center) (Distric Hospital) Statistical analyses For comparison of health out- comes of the study population to All children with available data (n = 152) the general Thai population, in- dependent one-sample t-tests Excluded were applied to continuous data, (n = 16) while one-sample tests of propor- tion were used in order to com- Available for analysis pare the prevalence of health out- (n = 136) comes in the area with those of the general Thai population. The Family folders and HCIS health outcome data of the gen- Child growth records from eral Thai population were from ANC records health center official sources and relevant inter- from health center national organizations (Nutri- Dataset for tional Division, 1999; Health In- analysis formation Group 2006 a, b; UNICEF, 2009). For comparison Fig 1–Flow of information in the study. of the prevalence of preterm births, no national data were order to comply with the assumption of available. The author used a figure re- independence on the Student’s t-test. ported by the Faculty of Nursing at Chiang Growth failure was defined as being either Mai University (Faculty of Nursing, 2007) stunted, underweight, or wasted at any for comparison purposes only; the men- measurement session. Stunting was de- tioned figure did not represent the na- fined as a child having his or her HAZ tional-level data in any way. For determi- below -2, being underweight was defined nation of the association between ANC as a child having his or her WAZ below -2 usage and birth outcomes, logistic regres- and wasting was defined as a child hav- sion was performed. ing his or her WHZ below -2. RESULTS This study included all children who were born in 2007, according to informa- One hundred fifty-two records of chil- tion from birth certificates or a record of dren born in 2007 were available, of whom the child in the HCIS. Children who were 136 met inclusion criteria. Socioeconomic identified as being “from outside the area” status and demographic status of the moth- and children whose parents were not ers in the study are shown in Table 1. The linkable were excluded from the study, as education level of the study participants, records of either parent of the child must particularly women, were lower than be linkable (by the HCIS) in order to make among the Thai population. Approxi- adjustments in the determination of the mately 60% of mothers in the area lacked effect of ANC on birth outcomes. The data Thai citizenship based on birth certificates used in this study consisted entirely of sec- and the HCIS. Among children with birth ondary data, which has several limitations, certificates, 6.58% of the certificates were 154 Vol 42 No. 1 January 2011 MATERNAL AND CHILD HEALTH IN A MARGINALIZED COMMUNITY Table 1 Maternal and paternal socioeconomic and demographic indicator in the study population. Variable Study area (n, %) National dataa p-value Maternal education 65 No formal education 40 (61.5%) 3.2% <0.001b Primary