A reproductive health needs assessment in Myanmar

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A Reproductive Health Needs Assessment in Myanmar of the men are not aware of birth spacing methods; viewing contraceptive use as primarily a responsibility of women. Women are also at considerable risk of acquiring STD/HIV from their spouses because men are more likely to have multiple sex partners and use of condoms is very low. Thus, there is a need for community education activities on women’s overall reproductive health risks and special IEC materials need to be developed to enhance men’s role in birth spacing and responsible sexual behaviour. The assessment team found that violence against women is not common. But some specific instances were reported, usually in the context of alcohol use. The team was not able, however, either to assess domestic violence or violence against women in the society. Therefore, a fuller programmatic response will have to await the results of research studies currently in progress. SPECIFIC RECOMMENDATIONS Improving maternal health Through its fieldwork, the assessment team observed evidence of significant maternal morbidity and mortality. Our observations revealed many missed opportunities to prevent maternal illness and serious deficiencies in the system for providing essential and comprehensive obstetrical care. Consequently, improvement of maternal health care in Myanmar requires a broad range of interventions. To date, considerable emphasis has been placed on antenatal care and the establishment of an infrastructure for basic obstetrical care for the management of pregnancy. While there is certainly scope for improving ANC, particularly in regard to screening efforts for antenatal syphilis detection, the most significant benefits would derive from strengthening the obstetrical care system. It is essential that the interventions recommended below be considered as a package since isolated action will not be sufficient for improving maternal health status. Improving technical skills of maternal health providers Technical skills are essential for delivery of quality maternal health care. Any woman can develop complications during pregnancy, labour, and/or the postpartum period and it is not possible to accurately identify all woman who will develop a complication based on risk profiling. Many complications can be prevented, however, through provision of quality antenatal, delivery, and postnatal care. Unfortunately, at present the training of maternal health providers in Myanmar is not yet adequate to ensure that all pregnant women receive pregnancy related care from a well-trained provider. There is an urgent need to update the curriculum for training midwives, auxiliary midwives, and traditional birth attendants to develop competency in the provision of routine maternity care, as well as the recognition of complications and referral. Appropriate decision-making by primary maternal health care providers is the foundation of essential and comprehensive obstetrical care. This curriculum should be used in a co-ordinated effort to train and periodically retrain basic health staff. Training of township-level trainers should be given the highest priority in implementation of this training. The development of a competency-based curriculum will serve to set a national standard for high quality maternal health care. In developing this standard important decisions need to be 60
A Reproductive Health Needs Assessment in Myanmar made regarding the optimal management of obstetrical complications based on a review of current international best practice (for example, routine administration of oxytocin versus ergotamine for prevention of post-partum hemorrhage and the use of magnesium sulfate versus diazepam for the management of eclampsia). Ensuring that this standard is met throughout the maternal health system in Myanmar will require diligent efforts in regard to management and supervision. Supervisors must certify that maternal health care at all levels of the service system meets national standards. In line with the revised maternal health care curriculum, a set of technical guidelines should be prepared which describe this standard of care. These guidelines should be periodically updated as new scientific data becomes available. These technical guidelines should be used by supervisory and management personnel through the health delivery system to certify an appropriate level of quality in maternal health services. Doctors and other health personnel at hospitals almost always reported to the assessment team that patients with serious delivery complications come too late. Some of these delays appear to be due to delayed referral from primary maternal health providers (e.g. midwives referring the women after extremely prolonged labour or auxiliary midwives calling midwives first when it should have been clear the woman needed referral to the hospital.) A critical element of the maternal health training curriculum should focus on prompt identification of those conditions requiring immediate referral to a medical facility. A clear set of referral guidelines adapted to the local transport, resource, and facility setting should be clearly articulated by township-level supervisors. Supervisors should also be alerted to those instances when referral has been delayed and subsequently review such cases with the responsible maternal care providers. The use of a partograph (with adaptation for use by midwives or auxiliary midwives) could be one effective tool for monitoring of labour. Prior experience with the use of the partograph in Myanmar, however, has been mixed and opinions regarding its utility differ widely among obstetricians and gynaecologists. Consequently, a pilot trial of a tool adapted specifically for use in Myanmar is recommended. In some places, the township medical officers or other doctors at station hospitals do not carry out Caesarean Sections. In these instances the referral chain for essential obstetric care becomes even longer, with negative consequences for maternal health. Efforts should be made to train (or provide refresher training) in the emergency care of obstetrical complications, including the performance of caesarean section, for medical staff at all township hospitals, and where appropriate station hospitals. In those situations where this proves to be impossible, primary maternal health care providers must be instructed to refer women with obstetrical complications to alternative health facilities capable of providing such essential care, without delay. The team observed that there were numerous vacancies in basic health staff positions responsible for maternal health (i.e. vacant midwife positions and some communities without auxiliary midwives). Simultaneously, traditional birth attendants are performing a substantial proportion of deliveries and many of them are untrained. Obstetrics and gynaecology specialists also reported that they had seen women with obstructed labour where traditional 61
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A reproductive health needs assessment in Myanmar

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