A reproductive health needs assessment in Myanmar

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A Reproductive Health Needs Assessment in Myanmar water and leaves, then covered with a blanket. Some woman also applies saffranin paste all over the body and takes saffranin pellets orally. The traditional birth attendants interviewed had delivered both normal and breech presentations (“folded babies”). One TBA reported that if the labour were prolonged, they would give the woman water in which her husband had washed his hands. The belief is that the woman has had the upper hand in the family and this was causing the labour to be prolonged, and that drinking this water would undo it. One TBA had conducted a labour in which bleeding occurred just before delivery. She sent for the midwife but the woman delivered shortly after. They had come across women with retained placenta, and reported calling the midwife if it could not be delivered within a half to one hour. One traditional birth attendant recounted a case that she and the midwife had delivered where the placenta was retained. They sent for the lady health visitor but in the end they had to take the woman to a nearby township hospital for removal. Another TBA referred to a patient who had postpartum haemorrhage who was referred to the station hospital and later to the township hospital. There were a number of instances reported to the assessment team in which the TBA failed to recognise complications during delivery and delayed the call for help. Such actions can sometimes lead to life threatening complications in the women and the baby. This is illustrated by following cases. A 21 year old woman in her second pregnancy had had a very unfortunate obstetric history. In her first pregnancy, she had no antenatal care and went into labour at term. She was attended by a TBA. She went into labour and after her membranes ruptured the traditional birth attendant waited for two days. After that she noticed that the baby stopped moving and then called a doctor. The doctor gave an injection and the woman delivered a stillborn baby. During her current pregnancy, she also did not take any antenatal care. When she went into labour, a midwife was called. The midwife was not in the village, however, since she was travelling to Yangon. The TBA of that village (they had now moved to another village) attended the birth and reassured her that all was well. Again, the baby had not been born two days after her membranes ruptured. At this point the husband called the auxiliary midwife from another village. The auxiliary midwife said that the baby was transverse and sent them to the township hospital (at 7:00 am) six miles from the village. They arrived at the hospital at 9:40 am. The baby had stopped moving on the way to the hospital. Emergency caesarean section was performed for transverse lie with prolapsed hand. A stillborn baby was delivered at 12:40 am. She had postoperative fever that had subsided by the fourth postoperative day. The estimated cost during her stay in the hospital is about 5,000 kyats. A 23 years old woman went into labour at term. A traditional birth attendant was called for help, but she failed to diagnose a twin pregnancy and continued to provide assistance. The first baby was delivered normally. After waiting for six hours, she referred the woman to the township hospital for delivery of the second twin. The doctor in the hospital noted that the baby was already dead and that the uterus had contracted and that there were no labour pains. The doctor performed a caesarean section to deliver the dead second twin. The woman remained in the hospital for about ten days at considerable social and financial cost. 20
A Reproductive Health Needs Assessment in Myanmar The midwives were generally found to provide adequate quality of assistance at normal deliveries. Many of the midwives’ clinical practices have not been updated, however, and are not based on current international best practices for obstetric management. For instance, ergometrine was found to be widely used instead of oxytocin, which is the drug of choice internationally for prevention of postpartum haemorrhage. On probing, it transpired that while some midwives recommend and administer ergometrine injection, others advise ergometrine tablets for prevention of postpartum haemorrhage. The practice varies by preference of the midwife and the family’s ability to pay. Labour is not monitored using the partograph. Midwives are not formally trained to perform and suture episiotomies. They do perform these procedures, however, including the repair of lacerations (without anaesthesia, especially in deliveries conducted at home). Although the training of midwives includes instructions for referrals, there are no formal guidelines and no monitoring mechanisms to ensure the appropriateness of their decision-making. Most midwives generally recognise complications and refer the labouring woman to hospital. Some patients, however, are reluctant to deliver in hospital and continue to labour at home. Only when labour becomes prolonged or obstructed do they decide to go to a referral centre. If patients have postpartum haemorrhage, midwives usually give intramuscular ergometrine. A few would put up an intravenous infusion. Patients can be more easily persuaded to go to hospital for haemorrhage than for obstructed labour. The midwives interviewed had not seen many cases of elampsia during their years of service. Oedema is regarded with nonchalance by both pregnant mothers and midwives. There is a common Myanmar belief that “a woman gets oedema three times before she delivers” Oedema is therefore considered to be a natural phenomenon. Most normal deliveries in hospitals are conducted by midwives. Doctors are usually only contacted when labours become complicated. They perform forceps deliveries, attend the labour of women with heart disease or hypertension and manage women with ante- and postpartum haemorrhage. POST-DELIVERY CARE Post-delivery care is provided by the midwives and auxiliary midwives at the woman’s home. National guidelines require the midwife to visit the woman each day during the first week after delivery, and then again at six weeks. According to the information provided to the team, however, while the usual care does involve daily visits for the first seven days, a follow-up visit is conducted only if the woman is experiencing problems. The content of care concentrates on care of the neonate. On probing regarding services for the women, service providers, including the traditional birth attendants, mentioned advice on breastfeeding, breast and cord care, and sometimes counselling for birth spacing. Administration of vitamin injections, sometimes for up to seven days, for which the woman or her family pays, is also a common practice. CAUSES OF MATERNAL MORBIDITY AND MORTALITY The assessment team observed that the number of maternal deaths continues to remain high. Preliminary data from the ongoing UNFPA-supported study of maternal mortality indicates that 57.4 per cent of maternal deaths take place at home and 3.7 per cent on way to the hospital. Even though a substantial percentage of women die before reaching the hospital, it 21
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ANNEX I Summary of Reproductive Hea
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Agency UNHCR Programme Local Reinte
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ANNEX III Summary Reproductive Heal
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Assuming that: (1) TFR in 1990 was
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A reproductive health needs assessment in Myanmar

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