A reproductive health needs assessment in Myanmar

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A Reproductive Health Needs Assessment in Myanmar They also report counselling them about birth spacing, advising them to use pills, injections or female sterilisation. Contraceptive supplies are generally not provided post-abortion in the hospitals visited by the team, however. Most of the patients admitted for abortion-related complications are older women (35 or more), but complications among younger women (16 to 18) are not rare. Many community members believe that abortion among unmarried women is rare, because when an unwanted pregnancy is experienced the woman would be expected to marry and carry the pregnancy to term. There are, however, reports of unmarried women having an abortion to avoid the stigma of childbirth out of wedlock. There is also a social stigma associated with complications of abortion in unmarried women so they may not be taken to the hospital for treatment. Older women generally seek induced abortion because they do not want a large family and the associated economic burden. Most providers reported that once the patient is admitted to hospital with abortion related complications, the chances of survival are good even though in terms of numbers, many women do die in the hospital. Some complications may be quite serious, however, as is evident from this provider’s experience. If women have abortion-related complications and a foul smelling vaginal discharge, fever or pain in suprapubic area, she will generally go to the general practitioner in the hospital to obtain a referral note for the hospital. In the past year and a half, the hospital had treated two very ill abortion patients. One had generalised peritonitis and was referred to a tertiary hospital but did not go. She signed herself out and left the hospital. Another, who was also referred to tertiary hospital had septicaemia and survived the experience. However, her total expenses came to 45,000 kyats. This girl was unmarried, about 28 years of age. If a woman is admitted with her cervical os open, an evacuation is done. If the os is closed, the state of the pregnancy is determined and a dilatation and curettage is performed in the operating theatre if it is an incomplete abortion. Women may have to stay up to 10 days in the hospital if there is sepsis. Post-abortion contraception is generally not provided and therefore it was common for the team to hear that repeat abortion is quite prevalent, with one case report of as many as six induced abortions experienced by a woman. CONSTRAINTS TO BASIC OBSTETRIC CARE Access and referral One of the reasons women die even after arriving at the hospital is the extensive delay they may experience in reaching the hospital. This is a major factor determining the seriousness of the condition of the woman at arrival. There are many factors contributing to such delays, including failure to recognise the seriousness of the problem, physical access to a relevant facility, an ill-defined referral chain, and cost considerations. It was observed during discussions with community members, as well as with health care providers, that the woman herself, as well as her family and the person attending the birth (traditional birth attendant, auxiliary midwife or midwife), do not always recognise that complications have occurred and that the woman needs to be referred to a higher level of care. Many midwives and auxiliary midwives do not recognise that early rupture of the 24
A Reproductive Health Needs Assessment in Myanmar membranes is a problem, and therefore often do not take prompt action to prevent complications arising. Many times when the traditional birth attendant or auxiliary midwife is assisting the woman during labour, if in need she calls for the services of a midwife. It was reported that in such situations the midwife is not always available. When the midwife is available, however, she reassesses the condition, and in most instances refers the woman to the station or township hospital. The need to include the midwife in the referral chain results in delays in making the decision to go to the nearest health facility. The midwives interviewed generally thought that the auxiliary midwives were capable of doing the referral herself. Transportation is not usually readily available, and thus, once the decision to refer has been made, such transportation has to be arranged, resulting in another delay. Other factors such as distance and the state of the road, particularly during the rainy season, were also mentioned as factors limiting access to referral facilities, Other factors influence the timeliness of the decision to refer a woman. Many women would prefer to stay at home to minimise the disruption caused to their family, and therefore put off the decision to go to the hospital in the hope that everything will resolve itself at home. The knowledge that the cost of transportation and hospitalization are high also delays the decision to go to the hospital. Costs The cost of transportation to hospital was reported to be often rather high, which, as mentioned above, was a major deterrent to seeking care at a hospital facility. This figure is often significantly higher at nights. The story of delays and the cost factor does not end after a woman reaches a hospital. It was clear that most families are expected to pay for supplies once the woman reaches the hospital. This includes the cost of medicines, IV sets, laboratory tests, gloves and needles. There are, however, no formal charges for the service provider, especially for the care provided for management of complications in women who seek care for obstetric emergencies. Costs were reported to be a major barrier to timely referral and appropriate treatment. As one community member in Mon State stated “unless you have reasonable amount of money” you don’t think about going to the hospital”. This seems to be a general perception based on previous experiences of the family and other community members. Cost sharing in health is a relatively new concept for Myanmar. It appears that there is no clear policy describing the cost sharing mechanisms and guidelines for fixing costs for specific service components are not well defined. The team found that the practice of cost sharing varied widely and that policies were not clearly understood by the community or the providers. Between different health care facilities charges for products, laboratory tests and other procedures vary significantly. For example, policy states that hospital charges should not be made for routine laboratory tests, but in a number of facilities the team found that patients are paying for such services. The implementation of cost sharing is not uniform even within the same facility and varies between doctors. Doctors generally make the decisions regarding the required interventions and treatments, and it was reported that if the woman is being treated with hospital resources she will not necessarily receive the first choice drugs. Women also know that the poor are supposed to be treated for free, and many service providers claim that women will say that they cannot afford to pay so that they get this free treatment. Hospital staff do not have a mechanism for identifying those women and families 25
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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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