A reproductive health needs assessment in Myanmar

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A Reproductive Health Needs Assessment in Myanmar the quality of antenatal care varies greatly. Consequently, while antenatal services exist almost everywhere, many women do not reliably receive important interventions (such as effective antenatal syphilis screening) because of inadequate quality of care. Similarly, some of the delivery practices of untrained traditional birth attendants may be harmful and, consequently, require change. In many locales the clinical management of obstetrical complications needs to be updated urgently to be in consonance with the currently known best international practices. The referral of obstetrical clients should be more timely, however, ensuring that women transported for emergency care receive quality services is equally important. Maternal morbidity and mortality could also be dramatically reduced through the introduction of vacuum aspiration techniques for the management of incomplete abortions. The quality of post-abortion counselling was an area where the quality of service was consistently poor. The need for improvements in service quality extended beyond maternal health services. In the area of birth spacing, contraceptive commodities with questionable efficacy continue to be used and there is considerable switching between the once-monthly Chinese injectable and three-monthly injectables, such as DMPA, due to sporadic supplies, cost factors, and inadequate provider knowledge. The counselling provided in relation to side effects also needs to be improved. RTI case management desperately needs to be standardised, with greater attention to partner referrals and more proactive counselling for condom use, as current practice presently focuses solely on antibiotic provision (often with the wrong antibiotics). Adolescents currently face serious barriers in accessing reproductive health services and often receive incomplete and inaccurate information. The importance of improving the quality of current reproductive health care services has been highlighted by the assessment team. Considerable efforts will be required to improve this quality of care. At a minimum, however, standards for services and protocols for treatment should be established where they do not currently exist and be made known widely. Role of private sector The distinction between public and private sector providers is somewhat blurred in Myanmar. The service providers in the public sector also often have their own private practice. In addition, persons retired from government service, as well as traditional birth attendants, private general practitioners, pharmacists, and drug shop personnel also provide a variety of health services. Several NGOs carry out a range of IEC activities related to reproductive health issues. Recently, the social marketing of condoms was introduced in a number of programme townships, however, evidence suggests that even larger areas are being reached through significant diffusion. As a consequence, a considerable proportion of Myanmar’s reproductive health services are currently provided in the private sector. Except for few clients seeking STD services from the STD teams, most clients go to private general practitioners for symptoms of RTI. In townships without a formal birth spacing programme, only female sterilization services are offered in public sector. In birth spacing programme townships (117 out of a total of 324 townships), contraceptive commodities (injectables, pills, condoms and IUCDs), as well as sterilization services are provided in the public sector. Even in programme townships, however, the majority of contraceptive supplies are provided by private sector sources. 58
A Reproductive Health Needs Assessment in Myanmar A larger proportion of maternal health services are provided by the public sector. Almost all antenatal care, many deliveries, and most treatment of obstetrical and abortion-related complications are provided by the public sector. Even here, however, the role of the private sector is expanding. The assessment team found that among those who can afford to pay, some women prefer general practitioners for antenatal care. In large cities, some private facilities now even have maternity beds and an instance of gynaecological surgeries being performed in the private sector was reported. Traditional birth attendants continue to provide assistance at a significant proportion of deliveries. It was reported that even when services were delivered in the public sector, providers often receive gifts for their services. Any reproductive health care programme therefore must build an effective partnership with the private sector. UNICEF, for instance, has involved private general practitioners, through the Myanmar Medical Association, in the development of its user-friendly STD clinics. Partnership with the private sector needs to go beyond these initial attempts, however. International experience shows that the private sector can significantly expand access and availability, as it has already done in Myanmar. As with the public sector, however, there is a need to ensure a better quality of services. As mentioned previously, quality of care is a serious issue throughout the health sector in Myanmar. GPs are currently perceived as offering a better quality of care than the public sector, however, we observed numerous instances of poor quality services - particularly in regard to infection prevention and client counselling. Innovative ways need to be found to involve private sector in efforts to ensure the quality of care. These could include training, skills development and quality audits through peers. Ideally, a partnership between public and private sectors should be forged for improving the reproductive health status of men, women and young persons. Cost as a barrier to improved reproductive health care Community members repeatedly mentioned to the team that the cost of commodities and services was a major consideration in whether to seek services, what services to seek, where and from whom. In many cases concerns about cost were described as determining the accessibility, availability and quality of care. For example, often women are reluctant to go to hospital for delivery complications even when referred because they wish to avoid having to spend money for transport and hospital costs. Delays in seeking emergency obstetrical care result in avoidable morbidity and mortality. Other women reported switching to the once-monthly injectable made in China because they did not have money to pay for DMPA. Similarly, service providers often mentioned that they may not prescribe their first choice of treatment if they felt that the client would not be able to afford it. To compensate, doctors themselves often donate money for tests and drugs for very poor patients. Gender issues Although the situation of women has not been fully documented, the gender distinctions in Myanmar are remarkably muted. Marital patterns also attest to a high degree of autonomy. The challenge is to ensure that gender gaps do not arise as a consequence of rapid economic and social change. Consequently, gender considerations need to be included in all aspects of development activities. While health care services include several services specifically for women, a full understanding of women’s reproductive health risks is yet to develop both among the community and the health system. Access to birth spacing still remains constrained and most 59
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