A reproductive health needs assessment in Myanmar

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A Reproductive Health Needs Assessment in Myanmar birth attendants had pushed with hands or sticks in attempts to facilitate delivery or used other potentially harmful practices. Priority should be given to filling vacant staff positions within the basic health services responsible for maternal health care. In the meantime, training of traditional birth attendants should be pursued as a means to bridge the gap until all women have access to trained midwifery care. TBA training should focus on the content of maternal care, including the avoidance of harmful practices, the observance of aseptic measures during delivery, and the need for early recognition and referral of complicated obstetrical cases. Linkages between the traditional birth attendants, auxiliary midwives and midwives should be strengthened. The role of the TBA in postpartum care, including birth spacing counselling, should be better defined. Post-delivery care Although current national guidelines stipulate that the midwife should visit the woman for up to a week post-partum and then see her again at six weeks post-partum, midwives in most townships reported that, while they routinely visit the woman every day for the first week, they only see her again if she experiences problems. As a result, an important opportunity to provide post-partum birth spacing counselling is missed. Maternal health providers should be encouraged to follow national guidelines regarding the schedule of post-partum visits, with special attention to follow-up at five to six weeks. Training concerning the provision of post-partum birth spacing counselling, including the use of progestin-only pills (where available) among lactating women, should be provided to all maternal health providers. Essential equipment for health providers and facilities Adequately equipped health facilities are a pre-requisite to provision of quality maternity care. Skilled service providers will be successful only if necessary equipment and supplies are available at referral facilities as well as at the primary care level. For midwives, auxiliary midwives, and traditional birth attendants, having an appropriate delivery kit and other instruments for delivery care are as important as essential surgical equipment for the hospitals. Since sepsis is one of the major causes of maternal mortality in Myanmar, interventions to reduce the risk of sepsis are essential. Given that most deliveries take place at home, the feasibility of providing a disposable, clean delivery kit should be considered. Since most women currently pay for all medical supplies used during their delivery anyway, women could be encouraged to purchase such a kit in advance of their labour. Public sector services could subsidise the provision of such delivery kits for women who could not afford to purchase them. A checklist of essential equipment and supplies should be developed for the first referral level, including surgical instruments for Caesarean section, fluid volume expanders, forceps, examination lamp, labour room table, suction machine, steriliser, oxygen cylinder, refrigerator for essential drugs, etc. This checklist could be used to strengthen logistic and supply systems to ensure that all referral facilities were equipped to provide essential and comprehensive obstetrical care. 62
A Reproductive Health Needs Assessment in Myanmar Management of maternal health services The team noted that O/G specialists had recently have been placed in 50 district hospitals across Myanmar, and commended this policy as it has the potential to contribute substantially to improved technical quality throughout the country. Currently many of O/G specialists, however, perceive their tasks as limited to hospital care. The linkage between the O/G specialists and the TMOs is also unclear at present. An expanded role for the district O/G specialists should be explored. These specialists have the potential to provide a much broader range of technical support for maternal health care services in the district through. • Establishing referral mechanisms and strengthening the referral chain for management of obstetrical complications; • Developing and utilizing the checklists for essential equipment and supplies at different levels of basic health services; • Orienting TMOs and other practitioners to the national standards of care; • Training all levels of maternal health care providers; and • Periodically reviewing the maternal health situation in the district, including maternal deaths, and identifying appropriate actions. Increasing Community Awareness Most community leaders in the areas the team visited were neither adequately informed nor concerned about maternal health. The exception was in very remote areas where maternal mortality was reported to be very high and community leaders identified this as a major health concern. Advocacy to raise awareness among community leaders regarding the magnitude of maternal morbidity and mortality in Myanmar is needed as a means of mobilizing community commitment for interventions to improve safe motherhood. Township medical officers should be encouraged to organise meetings with local community leaders to describe the extent of maternal morbidity and mortality, as well as other reproductive health problems as a means of increasing their awareness and commitment to address these problems. Health education can play an important role in raising awareness among communities, spouses and other family members, and pregnant women concerning the risk of serious morbidity and possible mortality associated with pregnancy complications. Health information should stress that most complications can be prevented and lives saved through timely and appropriate action. IEC programmes should include information concerning the prevention and early detection of maternal complications. Messages should include information on healthy behavioural practices (e.g. related to diet, food, and physical rest), as well as recognition of danger signs associated with pregnancy (such as bleeding, symptoms of pre-eclampsia, and severe anaemia), child birth (premature labour, early rupture of the membranes, prolonged labour, and haemorrhage), and the post-partum period (e.g. fever, abdominal pain, etc.). Direction on where to seek care for serious problems should be included as part of the health education package. 63
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A reproductive health needs assessment in Myanmar

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