The Impacts of a Community-Based Health Education and Nutritional Support Program on Birth Outcomes Among Migrant Workers in Maesot, Thailand: A Retrospective Review.

• Author: Blue, Wayland J.
• Position: Article 3

Infant and maternal mortality remain significant problems throughout the developing world. The United Nations' third sustainable development goal (good health and wellbeing) includes the reduction of the global maternal mortality ratio to less than 70 per 100,000 live births, and ending preventable deaths of newborns and children under five years of age. (1) These objectives are often challenged by structural problems, including prolonged conflict, a lack of infrastructure, and social instability caused by factors such as migration or lack of state capacity. Myanmar faces significant challenges in meeting these goals. At the time of this study, it ranked 148 of 189 on the United Nations Human Development Index. (2) Regarding infant and maternal mortality specifically, the maternal mortality rate is estimated at 250 in 100,000 (number 42 globally), while the infant mortality rate is 31.7 in 1,000 (number 50 globally). (3)

This underperformance is due to numerous historical and structural factors, such as longrunning internal conflicts, a history of isolationism resulting in underdevelopment, and political and social instability, which poses challenges to greater investment in economic and social development. Expenditure on healthcare alone is estimated at 4.7 percent of Myanmar's GDP as of 2017. (4)

Due to relatively higher levels of development and economic opportunity, a significant number of people migrate to neighboring countries in search of employment. Myanmar is the largest regional source of migrants with the majority (as many as three million) living in Thailand. (5) The city of Maesot, located in Tak Province of Thailand, is a major port of entry for migrant workers from Myanmar. It is also a major destination due to investment in the Maesot Special Economic Zone, which provides numerous employment opportunities. (6)

The migrant population in Maesot, however, faces several challenges to stability and human security, including linguistic barriers, lack of access to the Thai legal system, systemic prejudice, and poverty. This population is also difficult to study because many migrant workers cross between Thailand and Myanmar or migrate farther into Thailand depending on changing economic opportunities. While accounting for the difficulty in defining and analyzing the migrant population, family stability is inferred to be a major concern due to the prevalence of orphanages in the area. (7) Estimates based on interviews conducted with children housed in seventeen orphanage-type institutions in Thailand's Songkhlaburi district, which also shares a border crossing with Myanmar, indicate approximately 90 percent of these children had at least one living parent. (8) More widely generalizable estimates for the larger migrant population at the national level are confounded by a lack of further research. However, the existing analysis indicates at least a majority of institutionalized migrant children are likely not true orphans meaning the death of both parents. Rather, institutionalization is more likely due to poverty, abuse, and other factors negatively impacting family stability. Institutionalization of children may provide critical protection in the absence of other competent family members to serve as guardians or in cases of abuse. However, beyond such extreme circumstances, institutionalization fails to address the deeper factors of human insecurity that influence the decisions of at-risk families to place children in such institutions.

A primary goal of the Charis Project, a US registered 501(c)(3) charity, is the protection of children in the Myanmar migrant community of Maesot by strengthening at-risk families. In 2017, The Charis Project established Shade Tree Foundation, which is registered under the Thai Department of Social Development and Welfare and serves as The Charis Project's implementing partner managing all Thailand-based programs. Since 2014, The Charis Project and later Shade Tree Foundation have been conducting community-based interventions focusing on nutritional support and education for pregnant and nursing mothers to alleviate immediate human security threats and encourage family stability. The purpose of this paper is to analyze the effectiveness of the first iteration of interventions from 2014 to 2017 in meeting the objectives of increased human security and family stability.

Research Question

What were the impacts of the Charis Project's community-based interventions on promoting family stability as measured by positive birth outcomes? This study answers this question by analyzing the communities supported, types of support provided, and comparing our outcomes to available statistics for similar populations in Myanmar.

The answer to this question is important for developing a community-based family stability centric model of development and human security. Strong positive results from community-based interventions of the type conducted by the Charis Project have significant potential both in the context of the migrant community, and more broadly, as a low cost and potentially high reward intervention in other development contexts.

A review of the literature must begin with analyzing the key threats to positive birth outcomes in the developing world, and the effectiveness of community-based interventions broadly, as well as a review of the available literature covering the threats and interventions in the context of the Myanmar migrant community.

Literature Review

The World Health Organization estimates 75 percent of infant and maternal deaths during childbirth are due to preventable causes, which include severe bleeding, infection, high blood pressure, complications from delivery, and unsafe abortions. (9) These causes of morbidity during delivery are most often due to a lack of adequate health care. (10) However, prenatal, delivery, and postnatal health are impacted by several additional factors that can be more readily mitigated at the community level.

Low birth weight in particular is a major contributing factor to infant mortality and present in as much as 80 percent of cases. (11) Preterm birth, as well as constraints in utero, were identified as the main direct causes of low birth weight. (12) Other studies have identified multidimensional factors associated with low birth weight, such as the age of the mother, exposure to passive smoking, and educational level, depending on the specific context. (13) However, the most significant and widespread indirect contributing factor to low birth weight and later antenatal underdevelopment remains maternal malnutrition. (14)

An additional factor impacting birth and early childhood development is trauma due to intimate partner violence. (15) However, the precise impact and causal mechanism remains case-specific and appears to interact with cultural and environmental variables. (16) In the case of Myanmar, 21 percent of ever-married women have experienced domestic or sexual violence based on recent surveys. (17) This reporting was based on randomly selected households throughout the country, and found higher rates of domestic violence in less stable areas such as Rakhine and Kayin State, which are both the sites of ongoing conflict between armed ethnic groups and the central government. Additionally, this study found reported heavy alcohol use on the part of the husband as well as low levels of education on the part of the wife to correlate with reported violence. (18) Although these statistics are not directly representative of the migrant population, they are reviewed here as a baseline for the social background of the Myanmar migrant community.

The potential psychological and physiological stress inducers of poverty, malnutrition, and violence are also associated with some birth defects. (19) Additionally, economic stress and instability have been associated with a higher prevalence of child trafficking. (20) These factors not only impact immediate birth outcomes, but long-term family stability and child development. (21)

Malnutrition has been targeted by several low-cost community-based interventions focused on key nutritional support and education throughout the developing world with significant positive effects. (22) In particular, exclusive breastfeeding for the first six months has been shown to strongly support early childhood development and mitigate several causes of morbidity. (23) Additionally, studies have demonstrated the benefits of community-based groups for providing psychological support for pregnant women and young mothers in several contexts. (24)

In the case of the Myanmar migrant community, population instability renders this group difficult to analyze. However, recent analysis of refugee camp residents and some migrant communities...