A reproductive health needs assessment in Myanmar

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A Reproductive Health Needs Assessment in Myanmar is noteworthy that 37 per cent of deaths take place in government hospitals. Limiting identification of maternal deaths to the examination of hospital statistics provides a different picture since we know that the proportion of deaths that take place in hospitals is relatively small. The assessment team observed that one of the reasons for such a situation is that there is a tendency for relatives to sign-out women who are in a serious condition who are likely to die, so as to prevent them from dying in hospital. Typically, the maternal mortality is higher in remote and economically poor areas. An analysis based on verbal autopsies in the ongoing UNFPA-supported maternal mortality study shows that the major causes of maternal deaths are complications of induced abortion, hemorrhage, eclampsia and prolonged labour. This pattern is similar to the observations made by the team in various hospitals and communities, although regional variations in relative magnitude were noted. Service providers and community members in most places visited by the team identified postpartum haemorrhage as a relatively common complication of delivery. Postpartum haemorrhage, however, was often not the main cause of maternal death reported in the hospitals visited during the assessment. Septic induced abortion emerged as the most common cause of maternal death in many of the hospitals visited, followed in a number of cases by prolonged labour. Malaria during pregnancy was also reported to be a common cause of maternal death in the Mon State, an area with a high rate of endemic malaria. Although difficult to assess, the burden of maternal morbidity is considerable. The most common complications of pregnancy include pre-eclampsia, eclampsia, prolonged/obstructed labour, antepartum haemorrhge, and malpresentation. Among older women, grand-multipara women are more likely to have serious complications related to pregnancy. Discussions with specialists at the hospitals showed that grand multiparity is also a factor in maternal mortality. With an increasing prevalence of birth spacing, however, both community members and providers reported that the number of grand-multipara women is decreasing. THE PROBLEM OF ABORTION The team observed that abortion and its related complications continued to be a major reproductive health problem. Most community members mentioned that many women in their community seek abortion for unwanted pregnancy. Although the incidence of abortions is difficult to estimate, the proportion of admissions for abortion-related complications to the total obstetrical and gynaecological admissions in the hospitals visited by the team vary from 1.1 to 58.6 per cent. There is also a variation in the proportion of these who are under 20 years of age (see Table 4). Reports from previous studies indicate that approximately 50 per cent of maternal deaths are due to abortion related complications (Tun Yee 1990, Than Than Yin 1992, Central Women’s Hospital 1997). Opinions among the providers differed on whether abortion and its related complications are increasing or decreasing. Many felt that they were decreasing because: (a) birth spacing was becoming more widely known, available and practised; (b) people are more conscious of the dangers of abortion; and (c) availability of antibiotics has reduced the dangers of postabortion sepsis. On the other hand, in some areas, the incidence of abortions and its complications was reported to be on the rise. 22
A Reproductive Health Needs Assessment in Myanmar Table 4. Abortion related admissions in the hospitals visited by the assessment team Hospital Htanaungdaing Mawlamyaing Mudon Myingyan Myitthar Tachileik Taunggyi Thaton Theinzeik Per cent of OG admissions which are abortion related 1995 1996 1997 17.2 25.0 36.1 14.2 12.6 12.0 27.6 20.4 21.2 20.7 21.4 7.3 9.2 8.4 14.6 9.0 1.1 27.0 16.7 32.0 47.5 46.4 58.6 Per cent of abortion admissions who are under 20 Years old (1997) 0.0 8.7 23.9 26.1 1.3 0.0 2.2 2.0 It is difficult to estimate the number of abortions in Myanmar as induced abortions are illegal. It may be possible to comment, however, on trends in abortions based on data from the PCFS and provisional results of the FRHS data using Bongaarts proximate determinants of fertility method (see Annex IV). Using figures for total fertility rate in 1990 and 1996 as 2.90 and 2.72 respectively, we calculate that abortions have declined. There is some concern, however, that both these estimates are too low. If we accept the more conservative estimates implying a drop in total fertility rate of 0.3 per cent, the calculation still shows that the proportion of pregnancies that end in abortion has declined between 1990 and 1996, although with a smaller magnitude. What is particularly important about these calculations is that in neither case was abortion seen to be on the increase. A variety of methods are used to terminate an unwanted pregnancy. Commonly used methods are massage, insertion of a foreign body (bicycle spokes, twigs, herbal medicine), oral traditional medicines for menses induction such as Kay Thi Pan and Kya Nga Gaung (Five Tigers). A previous assessment (MOH 1997) found that the usual sequence of events are that a woman takes Kay Thi Pan, if this has no effect they visit a provider to get a menstrogen injection, and if this still does not induce bleeding they will seek the services of an abortionist. Massage is the most commonly reported method used, but most abortion complications resulting in hospital admission are due to the insertion of a foreign body into the uterus. Instances were also reported to the team of the use of anti-malarial drugs, and a combination of Kay Thi Pan and alcohol. The team found that most people seem to know where to get an abortion, but sometimes were reluctant to share this information with interviewers. Many community members mentioned that the cost of getting an abortion varies by the duration of pregnancy, and the cost seemed to vary by region. One woman told the team that the cost was 1,000 kyats per month. Another study of abortion found that the cost varies from 100 to 500 kyats for early pregnancies (less than three months gestation), and from 300 to 1,000 kyats for late pregnancies (Ba Thike et al. 1996). Management of abortion-related complications Many midwives reported that women consult them for problems related to spontaneous abortions and when they experience a complication following an induced abortion. The help of lady health visitors, midwives and auxiliary midwives is generally not sought before the procedure. When a woman consults for bleeding, fever, incomplete abortion or other complications of induced abortion, the provider will generally refer the women to hospital. 23
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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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