an analysis of policy options for maternal mortality reduction in myanmar
DESCRIPTION
An Analysis of Policy Options for Maternal Mortality Reduction in MyanmarHLA MYAT TUNMasters in Public Affairs (Institute of Strategic Planning and Policy Studies)MARCH 2010An Analysis of Policy Options for Maternal Mortality Reduction in MyanmarHLA MYAT TUNA Field Study Submitted to the Institute of Strategic Planning and Policy Studies University of the Philippines Los Baños, Los Baños, Laguna, In partial fulfillment of the requirement for the degree of Masters in Public AffairsTRANSCRIPT
An Analysis of Policy Options for
Maternal Mortality Reduction in Myanmar
HLA MYAT TUN
Masters in Public Affairs (Institute of Strategic Planning and Policy Studies)
MARCH 2010
An Analysis of Policy Options for Maternal Mortalit y Reduction in Myanmar
HLA MYAT TUN
A Field Study Submitted to the Institute of Strategic Planning and Policy Studies University of the Philippines Los Baños, Los Baños, Laguna,
In partial fulfillment of the requirement for the d egree of Masters in Public Affairs
MARCH 2010
ii
This field study entitled “AN ANALYSIS OF POLICY OPTIONS FOR MATERNAL MORTALITY REDUCTION IN MYANMAR ” prepared by HLA MYAT TUN in partial fulfillment of the requirement for graduation with the degree of MASTERS IN PUBLIC AFFAIRS major in STRATEGIC PLANNING AND PUBLIC POLICY is hereby accepted.
ADVISORY COMMITTEE
Dr. Merlyne M. Paunlagui Dr. Dulce D. Elazegui Member Member
Guidance Committee Guidance Committee
______________________ __________________ Date Signed Date Signed
Dr. Rogelio N. Tagarino Chairman
Guidance Committee _____________________
Date Signed
Dr. Rogelio N. Tagarino Director
Institute of Strategic Planning and Policy Studies
____________________ Date Signed
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ACKNOWLEDGEMENT
The author wishes to express his sincerest gratitude to the following persons who have helped make this field study possible: U Nyo Tun and Daw Yi Yi Cho, his parents, for giving him a precious life, love, supports and wisdom they provide. This study is dedicated to you May May. Dr. Rogelio N. Tagarino, Dr. Merlyne M. Paunlagui and Dr. Dulce D. Elazegui, his Adivser and Members of Guidance Committee, for their inspiration, patience, encouragement, precious advices, constructive comments and recommendations; Asia Pacific Scholarship Consortium, his scholarship organization, for the financial support and everything he needed for his master degree; Daw Khin May Aung, his beloved Aunty, for her strong support for his study and assistance for important data for his field study. This study is dedicated to you also May May Aung. Daw Khin Ma Ma Aye, Daw Pansy Tun Thein and Dr. Ne Win, his former supervisors in United Nations Population Fund (UNFPA) Myanmar and professional mentors, for their supports, guidance, concepts and opportunities they provided; His Professors in the College of Public Affairs, for giving him ideas, concepts and knowledge; His beloved Titas as well as his Filipino mothers especially from Institute of Strategic Planning and Policy Studies, Graduate School and all the staff members of College of Public Affairs, for their love, warmth, kindness and support during his stay in the Philippines; Hla Myat Moore and Isidra B. Bagaras, for their support, guidance and being part of his achievement; His PuPuChit for the caring, understanding, supporting, making his study to be more meaningful and being part of his achievement; His country mates in Los Baños and Manila, classmates and friends for the Myanmar foods, and great and memorable moments they shared together. Those people whom he failed to mention.
Hla Myat Tun
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ABBREVIATIONS AND ACRONYMS
AIDS Acquire Immune Deficiency Syndrome
CEDAW Committee on the Elimination of Discrimination against Women
FRHS Family and Reproductive Health Survey
HIV Human Immunodeficiency Virus
ICPD International Conference on Population Development
INGOs International Non-Government Organizations
IEC Information, Education and Communication
IUD Intra Uterine Device
LA Legalized Abortion
MDGs Millennium Development Goals
MMR Maternal Mortality Ratio
MOH Ministry of Health
MS Male Sterilization
NGOs Non-Government Organizations
NHC National Health Committee
PFCS Population Changes and Family Health Survey
RH Reproductive Health
RTIs Reproductive Tract Infections
STIs Sexually Transmitted Infections
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
WHO World Health Organization
WS Women Sterilization
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EXECUTIVE SUMMARY
Maternal health plays important role in health sector of every developing country
around the world. Maternal Mortality Ratio (MMR) shows the status of health of the
countries and quality of life of people in the country. In Myanmar, target MMR in 2015 is
56 per 100,000 live births but MMR in 2005 is 316 per 100,000 live births. MMR is high
especially among married population due to inadequate access to permanent
contraceptive methods. This study focuses on enhancing male participation particularly in
contraception, analysis of existing policy and programmes, and determines policy
strategies that will enhance male participation to reduce MMR. This study primarily
made of policy content analysis, descriptive analysis, trend analysis of various policies
and programmes. Valuative and normative approaches were used for the policy options.
Comparative analysis of benefits cost ranking for policy alternatives are also included.
There are several alternatives the National Health Committee (NHC), highest
policy making body for health matters in the country, could consider including existing
birth spacing policies. One option is putting the policy that allows women for abortion
with specific criteria. Another option is to allow and promote male sterilization and the
last option is to remove strict policies for women sterilization. Among these options,
male sterilizing policy comes out as the best option. It has the least cost with high
benefits for government and the community.
Based on the experiences of Asian countries, male sterilization policy can be
effectively implemented in Myanmar with the existing government system. Myanmar has
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no religious barriers for the recommended policy option. The government will not need
much public expenditure to implement the policy since it can be put into existing
programme and activities.
This study addresses to National Health Committee (NHC) to legislate and
include male sterilization in existing birth spacing policy. NHC should consider removing
barriers for male sterilization and providing supportive programmes for men
contraception. As results, pregnancy related death among married population will be
reduced and it contributes achieving targeted MMR goal by 2015.
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An Analysis of Policy Options for Maternal Mortalit y Reduction in Myanmar
Table of Contents Pages Title page ……………………………………………………………………… i Approval Sheet ………………………………………………………………... ii Acknowledgment ……………………………………………………………… iii Abbreviation and Acronyms …………………………………………………... iv Executive Summary..……………………………………………………….….. v Table of Contents ……………………………………………………………… vii List of Tables ……………………………………………………….................. ix List of Figures …………………………………………………………………. x Chapter 1. INTRODUCTION
1. 1. Rationale …………………………………………………………… 1 1. 2. Statement of Problem ……………………………………………… 4 1. 3. Objectives of the Study ……………………………………………. 5 Chapter 2. METHODOLOGY 2. 1. Conceptual Framework …………………………………………….. 6
2. 2. Data and Sources …………………………………………………… 7 2. 3. Methods of Data Analysis..…………………………………………. 7 Chapter 3. RESULTS AND DISCUSSION
3. 1. Incidence of Abortion and Maternal Mortality …………………….. 8 3. 2. Analysis of Contraceptive Use …………………………………....... 10
3. 2. 1. Methods and Extent of Contraceptives ……………………… 10 3. 2. 2. Trends in Contraceptive Use ………………………………… 12 3. 2. 3. Contraceptive use of Married Women by Age Groups and Number of living Children ...…………………………... 14 3. 2. 4. Uses and Limitations of Condom …………………………… 16 3. 3. Existing Policies and Programmes on Birth Spacing ……………… 17 3. 4. Policy Alternatives to Reduce Maternal Mortality ……………….... 22
3. 4. 1. Advantages and Disadvantages of the Policy Alternatives....... 23 3. 4. 2. Ranking Costs and Benefits of Policy Alternatives …….…… 26 3. 4. 2. 1. Ranking Costs for the Policy Alternatives ……………. 26 3. 4. 2. 2. Ranking Benefits for Policy Alternatives ………….…. 30
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3. 5. Recommended Policy Alternative to Reduce Maternal Mortality …. 34 3. 6. Male Sterilization in the Developing World……………….………... 34
3. 6. 1. Experiences of Contraceptive Programmes and Male Sterilization Programmes in Asian Countries..………..……… 35
3. 6. 2. Possibilities of Male Sterilization in Myanmar ……………… 38 Chapter 4. CONCLUSION AND RECOMMENDATIONS 4. 1. Conclusions ………………………………………………………… 41 4. 2. Recommendations ………………………………………………….. 42 LITERATURE CITED ………………………………………..……………….. 44 ANNEX I ………………………………………………………………………... 51 ANNEX II ……………………………………………………………………..... 53
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List of Tables
1. Percent of Abortion by Age Group (2007) ……………………………… 8 2. Maternal Mortality Ratio (MMR) by Age (2004-2005) ………………… 9 3. Maternal Mortality Ratio (MMR) by Year (1988 to 2006) ……………… 10 4. Trends in Contraceptive Methods Used by Married Population in
Myanmar ………………………………………………………………… 13 5. Contraceptive use of Married Population by Specific Age Groups and
Number of living Children (%) in Myanmar, 2007 ………………....….. 15 6. Summary of Contraceptive Policies and Programmes in Myanmar ……. 18 7. Summary of Contraceptive Programmes for Married Population ……… 21 8. Advantages and Disadvantages of Policy Alternatives ………………… 25 9. Ranking Costs for the Policy Alternatives ……………………………… 29 10. Ranking Benefits of Policy Alternatives ……………………………….. 33 11. Use of Male Sterilization in Asian Developing Countries ……………… 36
x
List of Figures
1. Map of Myanmar……………………………………………………….. 3 2. Conceptual Framework…………………………………………………. 6 3. Contraceptive Prevalence Rate of Married Population by Specific
Methods in Myanmar…………………………………………………… 11 4. Contraceptive Programme Covered Townships by MOH and UNFPA… 19
1
CHAPTER 1
INTRODUCTION
1.1. Rationale
Maternal mortality is defined as the death of a woman while pregnant or within 42
days after termination of pregnancy from any cause related to or aggravated by the
pregnancy or its management. This includes death as a complication of abortion at any
stage of pregnancy (United Nations Population Fund (UNFPA)). Maternal health plays an
important role in health sector of every developing country. Maternal Mortality Ratio
(MMR) shows the status of health of the countries and quality of life of people in the
country. Women died due to lack of family planning, skilled birth attendance or
emergency obstetric care (UNFPA). Ms. Thoraya Ahmed Obaid, Executive Director of
UNFPA, indicated during The Partnership Launch at United Nations, New York that
“Globally, estimates show that ensuring the access of women and couples to voluntary
family planning could reduce maternal deaths by 20 to 35 per cent, and child deaths by as
much as 20 per cent” on 12 September 2005 (www.unfpa.org/safemotherhood/ , Feb 12,
2008).
The study was done in the Union of Myanmar, United Nations member country,
which is bounded by India and Bangladesh in the North-West, China in the North-East
and Laos and Thailand in the South-East (Figure 1). Myanmar’s population is estimated
at 56.515 million with annual growth rate of 2.02 percent in 2006-2007 (Myanmar
Ministry of Health & WHO, 2008). Majority of the people in Myanmar are Buddhist with
predominantly Theravada tradition, practiced by 89.20% of the country's population
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(http://asiarecipe.com/burreligion.html, Date access: July 9, 2009). The average
population density for the whole country is 77 persons per square kilometers. It ranges
from 14 persons per square kilometers in Chin State, the western part of the country to
595 person per square kilometers in Yangon Division, where the city of Yangon is
located.
In 1994, the United Nations (UN) coordinated International Conference on
Population and Development (ICPD). At the conference, they set four goals, and the
reduction of maternal mortality is one of the goals (http://www.un.org/popin/icpd2.htm,
December 15, 2009). In 2000, UN member countries set eight Millennium Development
Goals (MGDs). Among these MDGs, the fifth goal is to improve maternal health by
reducing maternal mortality to 75 per cent below 1990 levels by 2015 and providing
universal access to reproductive health which include contraceptive prevalence rate and
need for family planning (http://www.undp.org/mdg/basics.shtml, December 7, 2009). In
Myanmar target MMR is 56 per 100,000 live births in 2015 but MMR in 2005 is 361 per
100,000 live births (UNFPA).
MMR remains high because of inadequate programmes for birth spacing. In the
public health sector, birth spacing services have long been offered mostly through the
existing programmes of maternal and child health centers but these centers were only
visited by women and mothers. Target can not be achieved without the effective men’s
participation in birth spacing programme. Public policy decision makers, development,
population and health agencies have largely ignored men’s participation in birth spacing,
even if there are no significant barriers regarding culture and religion in the country.
3
Figure. 1. Map of Myanmar
The government has been providing birth spacing services in health centers since
1991. However, male’s access to contraception and their participation has not been
stipulated in existing policies. The general perception and knowledge among men on the
need for reproductive health is primarily for the prevention of HIV/AIDS and Sexually
Transmitted Infections (STIs). There is a very low appreciation of the role of men and the
importance of birth spacing purpose is yet to be appreciated. Generally, men have yet to
be informed and educated on the use of contraceptive. Political commitment, supportive
policy and programmes are needed to enhance male participation in birth spacing
programmes. Supportive men’s role in reproductive health and birth spacing programmes
must be emphasized to meet the target
.
4
1.2. Statement of the Problem
Maternal Mortality can be reduced if all women who want no more additional
children were able to stop child bearing (WHO, 1995). Limited access to permanent
contraceptive service is one of the factors of having unwanted pregnancies which is the
root cause of high incidence of maternal mortality among married women. The problems
which married population confront are;
1) Abortion, large part the result of unmet contraceptive need among women, is illegal
but the rate of occurrence of this practice is significant among women. At least 54 per
cent of maternal death and 20 per cent of all hospital admission have resulted from
complication of abortion (UNFPA, 2004). Thus, abortion tends to be the leading
cause of maternal mortality.
2) Fear of perceived side effects, hormonal affects, inconvenience and poverty are the
main reasons for not using contraceptives such as pills, injectables and intra uterine
devices (IUDs).
3) Female sterilization is only available after approval by a sterilization board. The use
of female sterilization is low due to a lengthy and difficult approval process.
4) Male sterilization is restricted by law to those men whose wives have been approved,
but are unable, to undergo sterilization for medical reasons. Thus, this policy
constrains men to undergo voluntary sterilization even though they recognize that
they can take the responsibility in contraception.
5
Contraceptive are being available in the country but they are more of the female
responsibility. The researcher wants to study on how to enhance male participation to
reduce maternal mortality among married population.
1. 3. Objectives of the Study
The general objective of this study is to assess the birth spacing policies and
programmes and determine policy strategies that will enhance male participation in
reducing MMR in Myanmar. Specifically the study aims to carry out the following
objectives:
1. To examine the adoption rate of various contraceptive methods in Myanmar;
2. To review and analyze existing policies and programmes on contraceptive use;
3. To determine policy option that would improve male participation to reduce
maternal mortality in the country; and
4. To identify strategies that would support the chosen policy option that will
enhance men’s effective participation in reproductive health in the country.
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CHAPTER 2
METHODOLOGY
2.1. Conceptual Framework
National policies provide the broader legal framework to improve men’
participation to reduce maternal mortality as such, awareness raising, peer education,
community health talks, dissemination of information, education, communication (IEC)
materials can be done using various channels. At the same time, promoting and providing
of quality and affordable male contraception services ensuring accessibility in the
communities can also be done. Specific activities include campaign, mobile clinics, and
male friendly centers to ensure effective men’s participation throughout the country.
There are all seen to contribute to reduction of maternal mortality ratio.
Figure 2. Conceptual Framework of Reducing Maternal Mortality by enhancing men’s
participation
National Policies and Programmes
on male participation
Awareness of - policies and
programmes - importance of
men’s role in women’s health
- the needs to promote men’s role
Community policy and
programmes on male
participation
Promotion and providing - male friendly
centers - quality and
affordable contraceptive services
- ensure accessibility
Maternal Mortality Ratio
Specific Activities
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2.2. Data and Sources
This study mainly used secondary data. These secondary data were collected from
publications, unpublished documents, reports, surveys of Ministry of Health in Myanmar
(MOH), United Nations Population Fund (UNFPA), World Health Organization (WHO),
United Nations Children Fund (UNICEF), International NGOs, Local NGOs in
Myanmar, thesis and studies, as well as from internet sources.
Data includes policy and programmes on contraceptives, use of contraceptive
among Myanmar married population and incidence of maternal mortality in the country.
Data and information generated through internet such as those from United Nations
Population Bureau, United Nations Population Fund, Ministry of health (Myanmar), and
some other websites were also used in this study.
2.3. Methods of Data Analysis
This study primarily made of policy content analysis, descriptive analysis and
trend analysis. These were used in the review and analysis of existing policies and
programmes on birth spacing for married population and analysis of contraceptives use.
Valuative and normative approaches were used for the policy options as well. Analysis
involved detailed scrutiny of these specific provisions or stipulations of the various
policies and programmes. Advantages and disadvantages of policy options, ranking for
the alternatives in terms of cost and benefits of the policy options were adapted from UN
publications. Ranking were ranked by the researcher according to the studies of
literatures. Finding and results were presented and summarized in tabular form and
graphic where applicable.
8
CHAPTER 3
RESULTS AND DISCUSSIONS
In this chapter, analysis of contraceptive use, existing policies and programmes on
contraceptives, policy alternatives to reduce unsafe abortion and maternal mortality ratio,
ranking on cost and benefits of policy alternatives, policy recommendation, and male
contraception in the developing world were discusses and data were discussed and results
were presented in tables and figures.
3.1. Incidence of Abortion and Maternal Mortality
The incidence of abortion by age groups in Myanmar is presented in Table 1.
Abortion within the age group (40-49) who may have attained desired number of children
is about 9 percent. The incidence of abortion among teenage group (15-19) is
comparatively high (11 percent) as compared with the other age groups. This is an
indication of high unwanted pregnancy among the teenage group. This might be due to
pre-marital sex.
Table 1. Percent of Abortion by Age Group (2007)
Age Group % of total abortion cases
15-19 11.39 20-24 7.27 25-29 5.63 30-34 5.12 35-39 4.28 40-44 4.04 45-49 4.69
Source: Family and Reproductive Health Survey (FRHS), 2007
9
As mentioned above, the incidence of maternal mortality of year 2004-2005 is
estimated at 316 per 100,000 live births for the entire country. Majority of the maternal
death (89 per cent) were reported in the rural areas. The maternal mortality ratio (MMR)
by age is presented in Table 2. MMR is the highest (921.66) at the age group of 45-49
who may have attained desired number of children. Data for the age group 35-44 is not
available from the source.
Table 2. Maternal Mortality Ratio (MMR) by Age (2004-2005)
Age Group Live Births MMR per 100,000 Live Births
15-19 1007 297.91 20-24 5091 196.43 25-29 6414 202.68 30-34 5267 265.81 35-44 - - 45-49 217 921.66 Total 22478 315.86
Source: Committee on the Elimination of Discrimination against Women (CEDAW), 2008
The trend of MMR is slightly decreasing within the period 1988-2006 (Table 3).
The rate of MMR in rural areas is comparatively higher than urban areas. This distinct
difference may be attributed to weaknesses in the areas of distributing contraceptives,
quality care services, accessibility of services and insufficient skilled health personnel in
public health sector. For the union, MMR is increasing (2.5 to 3.16) during the period
(1999-2005). This might be due to high MMR among older age groups.
10
Table 3. Maternal Mortality Ratio (MMR) by year (1988 to 2006) Health Index 1988 1999 2001 2002 2003 2004 2005 2006 Maternal Mortality Ratio (per 1,000 live births) Urban 1 1.8 1 1.1 0.98 0.98 0.96 0.96 Rural 1.9 2.8 1.8 1.9 1.52 1.45 1.43 1.41 Total* - 2.5 - - - - 3.16 -
Source: MOH, 2009 *Estimates for total not available the other years
3.2. Analysis of Contraceptive use
Analysis of contraceptive use in Myanmar was undertaken with the used of data
on methods and extent of contraceptives, trends in contraceptive use, and contraceptive
use of married women by age specific groups and number of living children.
3.2.1. Methods and Extent of Contraceptives
The different methods and prevalence of use of contraceptive among married
women age between 15 to 49 years old is presented (Figure.3). The use of contraceptive
is mostly by female. Only 41 per cent of women within this age group using
contraceptives, modern (e.g. pills, IUD, sterilization etc) and traditional methods.
Majority of the women do not practice contraceptive methods because of hormonal
changes of these methods. The use of all traditional methods (safe period, withdrawal and
massage) is only about 2 per cent. These are not being accepted as safe methods and also
not being promoted in the country.
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Figure. 3. Methods and Extent of Contraceptives, 2007
59.1
19.3
1.2
1.0
0.4
1.80.7
0.2
0.7
0.7
4.4
0.4
10.1
Pill (daily)
Pill (monthly)
IUD
Not using anymethodInjection (monthly)
Injection (3 month)
Condom
Female Sterilization
Male Sterilization
Safe Period
Withdrawal
Massage
Others
Source: FRHS 2007
Male participation in birth control is very minimal (3.8%). Male participation
methods include sterilization, safe period and condom methods. For these methods, only
the use of condom is being promoted by the government but its usage is generally low
(0.7 per cent) among married population. The use of the condom is not only for
contraception but also for prevention of HIV and sexually transmitted infections (STIs).
However, the acceptance of condoms in country is not prevalent among married
population because of strong traditional norms that they see condoms for sex trades. The
data on HIV/AIDS programmes show the use of condom is high among men but not in
contraception among married couples. Male sterilization is not yet legalized and
restricted by laws. However, the extent of male sterilization (1%) is slightly higher than
12
condom among married couple. It might be assumed as married men prefer male
sterilization than condom.
3.2.2. Trends in Contraceptive Use
The trend in the use of specific contraceptive methods among currently married
population over a decade (1991 PCFS and 2007 FRHS) is presented in Table 4. Within
the ten year period, the contraceptive prevalence rate has increased from 13.6 per cent in
1991 to 38.4 per cent in 2007. The increase of about 14.8 per cent may be attributed to
the high rate adoption of injection method (1 month and 3 months). Except for the use of
pills (daily) and injection (1 month and 3 month), there was no distinct pattern in the
usage of specific contraceptives. The use of monthly injection declined (0.4%) in 2007
but 3 month injection recorded 19% rate. This could be due to a number of reasons such
as: (a) injectables are more easily available and work for a relatively longer duration; (b)
convenient to use; and (c) less complicated to adopt. The use of pills and injectables (3
months) appear to gain popularity. On the other hand, female and male sterilization,
which are permanent methods of contraceptive, tend to decrease. This may be due to the
incidence of poverty since these methods are relatively costly and also are not being
promoted as widely as the temporary methods, such as pills and injections.
Sterilization remains limited to those who have achieved a certain age and family
size, and also is dependent upon the approval of government medical board. Due to
increase in publicity and promotional efforts, there was a slight increase in the use of IUD
13
and condom. However, demand for male sterilization was always higher compared to
condom in every survey.
The pattern of the traditional contraception that includes safe period, withdrawal,
massage and other are decreased (3.3 per cent to 2.5 per cent) during the period 1991-
2007.
Table 4. Trends in Contraceptive Methods Used by Married Population in
Myanmar
Current Use of Methods (in %) Methods 1991
PCFS 1997
FRHS 2001
FRHS 2007
FRHS
Modern Method: 13.6 28.4 32.8 38.4
Pill (daily) 4 7.4 8.6 10.1
Pill (monthly) - - 1.2 0.7
IUD 0.9 1.3 1.8 1.8
Injection (monthly) 3.1 11.7 14.8 0.4
Injection (3 month) - - - 19.3
Condom 0.1 0.1 0.3 0.7
Female Sterilization 3.7 5.5 4.6 4.4
Male Sterilization 1.8 2.2 1.5 1
Traditional Method: 3.3 4.3 4.2 2.5
Safe Period 2.4 2.4 1.8 1.2
Withdrawal 0.4 0.8 1 0.7
Massage 0.3 0.6 0.5 0.2
Others 0.2 0.6 0.8 0.4 Source: FRHS, 2007
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3.2.3. Contraceptive use of Married Population by Age Groups and Number of living Children
The pattern of contraceptive use of married women by specific age group and
number of children is presented in Table 5. Women in all age groups, except 45-49,
prefer 3 month injection. Sterilization is more common among older women (35-49) who
have achieved their desired family size and are more likely to stop child bearing. In
contrast, the use of pill (daily) and injection (three months) is popular among younger
women who are still in their early stages of family building. For male methods, condom
usage is higher than male sterilization in younger age groups of 15-39. There is a
preference of sterilization among married couple (specifically those who already attained
their desired number of children) compare to condom.
The general pattern observed is that women in younger age tend to use more
contraceptives. Similarly, those with less number of children, tend to practice use of
contraceptives. This may be because the younger women are more aware of the
contraceptives and access to services than older women. The more children they have, the
higher use of sterilization methods.
For the participation of male in traditional contraception methods, there are no
distinct changes in the pattern. For the modern methods, condom use is higher in couples
with 1 or two children than male sterilization. The use of male sterilization is higher than
condom among couple who have 3 and more children.
15
Table 5. Contraceptive use of Married Population by Specific Age Groups and Number of living Children (%) in Myanmar, 2007
Modern Methods Traditional Methods
Age Group Pill (daily)
Pill (monthly)
IUD Injection (monthly)
Injection (3 month)
Condom Female
Sterilization Male
Sterilization Safe
period Withdrawal Massage
15-19 23.3 0.7 0 0.7 17.8 0 1.4 0 0 0 0 20-24 13.9 0.6 0.8 0.6 25.2 0.3 0.3 0.1 1.1 0.8 0.1 25-29 13.3 0.7 1.8 0.2 26.1 0.7 1.2 0.4 1.3 0.3 0 30-34 11 0.8 2.1 0.4 25.4 1.1 3.4 0.6 1 0.7 0.1 35-39 11.1 0.7 2.4 0.7 22.8 1 6.5 1 1.2 1.2 0.1 40-44 7.9 0.8 2.2 0.3 13 0.6 6.6 1.7 1.5 1 0.5 45-49 2.8 0.4 0.8 0.3 4.6 0.2 6.6 1.7 1.2 0.3 0.3
Number of living children 1 12.1 0.2 1.8 0.3 25.3 0.6 1.1 0.2 1.2 1.2 0.2 2 11.2 1.1 2.7 0.6 24.7 1.3 5 0.9 1.3 0.6 0.2 3 9.4 0.5 1.8 0.5 17.3 0.8 9 1.9 1.2 0.6 0.3 4+ 6.3 0.8 1.5 0.3 14.6 0.4 5 1.2 1.2 0.9 0.2
Source: FRHS, 2007
16
3.2.4. Uses and Limitations of Condom
Condom is the only available contraceptive method for men in Myanmar.
Information, education and communication (IEC) on condoms has been initiated in the
country for the prevention of HIV/AIDS and Sexually Transmitted Infections (STIs).
Thus, condoms have been perceived only for prevention of HIV/AIDS and STIs and such
perception becomes barriers for the use of condom as contraceptive. The accessibility and
acceptance of condoms in rural areas is influenced by several factors such as: (a) strong
traditional norms; (b) lack of knowledge; (c) transportation and distribution of supply of
INGOs; and (d) unaffordable price for population in the areas. Condoms seem a logical
choice as a low-cost contraceptive that the governments should provide even though they
are not popular among married population. Condoms can be 98% effective against
pregnancy, if used properly and consistently. However, they have six main drawbacks:
(www.newmalecontraception.org; July 23, 2009)
1. Many men dislike them because they reduce sensation;
2. Many women are uncomfortable of insisting condoms, if their partners are
reluctant to use them;
3. Condoms are vulnerable to heat damage during transport and storage;
4. Condoms must be used every time a couple has intercourse, but it is difficult for
poor governments to provide an ample and consistent supply to their people
(United Nations Population Fund, 2005). Aid does not fill the gap; in 2003, donor
support paid for the equivalent of one condom per year for each man of
reproductive age in the developing world;
17
5. Condoms are a crucial part of the "contraceptive supermarket" and of disease
prevention, but they alone cannot meet everybody's needs; and
6. Condoms were seen for sex trade.
3.3. Existing Policies and Programmes on Birth Spacing
The International Conference on Population Development (ICPD) Program of
Action and comments from leaders emphasize the need to make men more aware of their
responsibilities to the family and the wider community in the matter of family planning
and reproductive health (United Nations 1995). Paragraph 4.27 of the Program of Action
specifically states as: “Special efforts should be made to emphasize men’s shared
responsibility and promote their active involvement in responsible parenthood, sexual
and reproductive behavior, including family planning; prenatal, maternal and child
health; prevention of sexually transmitted diseases, including HIV; prevention of
unwanted and high-risk pregnancies” (1995:197).
Table 6 presents the summary of birth spacing policies and programmes in
Myanmar. United Nations Population Fund (UNFPA) is the major benefactor in
Myanmar population and birth spacing programme since 1973. The National Health
Policy was developed in 1993 with the initiation and guidance of the National Health
Committee (NHC) (Annex I). The government aims to achieve a better quality of life for
all, by giving attention on the improvement of reproductive health status. Birth Spacing
services are provided by the public sector, private sector and also by international
organizations. Although birth spacing methods have been available in Myanmar since
1991, the government’s programmes on contraception was only initiated with a strategic
18
approach by World Health Organization (WHO) in mid-1995. Myanmar’s Reproductive
Health (RH) Policy was formulated in 2002 and approved by the Ministry of Health in
2003 (Annex II).
Table 6. Summary of Contraceptive Policies and Programmes in Myanmar
Policy Salient Provision
National Health Policy
(1993)
- Change from pro-nationalist policy to health-oriented
policy to integrate birth spacing
Reproductive Health Policy
(2003)
- Improve access to birth spacing methods, e.g., pills,
injectables, Intra-uterine devices (IUDs), condoms,
sterilization for women and emergency contraceptives
- Strengthen men’s role in the promotion of birth
spacing services, prevention of transmissions of
RTIs/STIs and in supporting reproductive health service
Source: MOH, 1993 & MOH, 2003
Ministry of Health (MOH) and UNFPA covered 93 of the country’s 324
townships in 2004. They plan to expand to 137 townships in the period 2007-2010, with
the collaboration of the Ministry of Population and Immigration, other government
ministries, selected United Nations agencies, and selected local and international non-
governmental organizations. Townships covered by UNFPA assisted Reproductive
Health (RH) programme is presented in Figure 4.
19
Source: UNFPA Myanmar
Figure 4. Contraceptive Programme Townships covered by MOH and UNFPA
On 18 November, the largest conference on family planning in fifteen years with
nearly 1,300 international experts, policy makers and representatives of civil society
concluded by reaffirming their commitment to family planning and revitalizing it by
sharing research findings and best practices (http://www.unfpa.org/public/neFS/pid/4376,
November 23, 2009). Efforts to prevent maternal deaths and ensure access to voluntary
20
family planning require political and financial commitment from a broad range of
partners; namely: men as well as women, international organizations, governments, civil
society and the media. Also, information and access to contraception on reproductive
health and rights for both men and women have to be included (UNFPA & Path, 2007).
On World Population Day 2008, the Minister of Immigration and Population said
that Myanmar is fully committed to the MDGs and is guided by the principles adopted by
the ICPD and also stated that “Our country, each and every family has the right to decide
their family size based on the choices of each individual and couple.” However, in the
RH policy, men were considered as effective channel to promote existing women
contraceptive methods. However, the participation and access of men in contraception
were not mentioned in existing policies. The government has yet to address and provide
the specific needs for men. The high-level decision makers have not considered yet
providing the need for male contraception in existing policies. Summary of contraceptive
programmes and participation of male and female in Myanmar is shown in Table 7.
21
Table 7. Summary of Contraceptive Programme for Married Population
Extant Involvement and Participation
Policy/Programme on Contraception
Female Male Birth Spacing 1. Education High Low 2. Techniques - Pills High None - Injections High None - IUD High None - Emergency pills High None - Norplant High None - Condoms Low Low - Sterilization Low Low 3. Promoting of program and activities (e.g, IEC materials, mass media, campaign)
High Low
4. Supportive specific policy High None
Source: MOH, 2009, MOH & UNFPA 2002
Both men and women have important contributions and co-equal responsibility in
reproductive health especially in marriage. According to many studies, responsibilities of
men include leading family and supporting family including protecting its health. Many
men are willing to take responsibility in contraception in order to lessen burden on
women which leads improving women’s health. Since 1991, the birth spacing
programmes have tended to focus on women in the country. Men’s role in birth spacing
has been neglected and their involvement in reproductive health programmes has been
only initiated in 2004. However, social integration programmes have unconsciously
ignored the needs of shared responsibility of men for contraception among married
population. Nevertheless, there is high demand on long term contraceptive services for
22
married men. Limited access to birth spacing services by men leads to increase maternal
death.
As mentioned above, even though male sterilization is illegal and not highly
promoted in the country, the use of male sterilization methods is higher than the use of
condom among married population. However, men has the barriers to undergo voluntary
sterilization even though they realize that they have a significant role in saving women’s
life by taking responsibility in contraception among married population and to improve
the status of women health.
3.4. Policy Alternatives to Reduce Maternal Mortality
There are three policy alternatives to reduce maternal deaths due to unwanted
pregnancies/births among married population particularly those who already have desired
number of children. These are;
Policy Alternative (1): Legalized Abortion (LA) to married women by providing
legalized services to avoid unsafe abortion based on specific criteria which are relevant
with cultural and social values. Although it seems difficult to take place in Buddhist
country and culture, it can contribute to reduce unsafe abortion in the community.
Specific criteria will be needed to have access to abortion such as to physical and mental
health of women.
Policy Alternative (2): Voluntary Male Sterilization (MS) or Vasectomy, of married
men who already have desired number of children by providing access to services and
reduce strict criteria. It can effectively address current issues regarding unwanted
23
pregnancies in the community especially among married couples living in rural and
remote areas. It can assure effective participation of men in contraception and
reproductive heath programmes across the country.
Policy Alternative (3): Female Sterilization (FS) with the least criteria to mothers who
already have their desired number of children by removing strict policies, decentralizing
of authority for sterilization approval, and rules and regulations. It can provide the needs
of the women in an effective way and can encourage and assure women of their rights to
decide their desired family size.
3.4.1. Advantages and Disadvantages of the Policy Alternatives
The three policy alternatives can solve the problem of high incidence of maternal
mortality. The advantages and disadvantages are presented in Table.8.
LA can reduce unwanted birth among married women because of contraceptive
failure, being raped, and economic and social reasons. It can save women’s lives,
however, it is culturally sensitive. It may have conflict with Myanmar Buddhism.
Abortion can cause heavy bleeding. Some abortion drugs can cause negative side effects
such as nausea, headache, fatigue, fever, diarrhea, vomiting and pain. In United States
deaths from abortion declined dramatically since abortion was legalize. Many
demonstrable health benefits such as physical, emotional and social health have accrued.
For more information, please refer to www.abortionsweb.com and
www.plannedparenthood.org.
24
Male Sterilization has the most advantages among the alternatives. It is
easy to use and effective. The use of method is less expensive because it can be
performed with minimal facilities. The services can suit almost every setting (i.e.,
doctor’s office, a hospital) and has low rate of complications. Male sterilization or
Vasectomy has been proven to have significantly fewer side effects such as bleeding,
pain, and infection. Vasectomy has no long-term adverse health affects. It does not affect
men’s ability to have sex or their general health. Contrary to common rumors, vasectomy
does not cause weakness, general aches and pains, poor vision, weight gain, or mental
impairments (John Hopkings, 2008). For further information and technological
procedures, please refer to Johns Hopkins, 2008 and Lissner, A. Elaine, 2006.
Female sterilization is a permanent method. There is a single procedure for
lifelong. It is safe and very effective (99%) family planning. Regular supply and repeated
clinic visits are not required after the surgery. It does not affect a woman’s ability to have
sex. It does not have long-term side effects or health risks. However, it has risk of major
surgery and costly. For more information, please refer to WHO & John Hopkins, 2007.
25
Table 8. Advantages and Disadvantages of Policy Alternatives
Policy Alternatives Advantages Disadvantages/Needs
Legalized Abortion (LA)
o Reduce unsafe abortion rate o reduce unwanted pregnancies o women’s lives can be saved
o need to be legislated o culturally sensitive o against with Buddhism
community o potential of misunderstanding
between couples o much health risk
Male Sterilization (MS)
o reduce pregnancy rate o reduce unsafe abortion rate o less religious and cultural
barriers o low rate of post-operative
complication o highly effective o less expensive o easy to use o can be performed with minimal
facilities o services can be provided in
hospitals, clinics and mobile camps for rural and remote areas
o need to be legislated o risk of minor surgery o seems to increase unfaithfulness
among couples
Female Sterilization (FS)
o reduce unintended pregnancies o reduce unsafe abortion rate o reduce MMR o highly effective
o risk of major surgery o costly o need more equipment and
infrastructure o takes time for hospitalization
Sources- Contraceptive Sterilization: Global Issues and Trends; Roy Jacobstein and John M. Pile, 2007; John Hopkins, 2008
26
3.4.2. Ranking Costs and Benefits of Policy Alternatives
3.4.2.1. Ranking Costs for the Policy Alternatives
Input costs can be classified in terms of: direct and indirect costs, joint and non-
joint costs, average and marginal costs and capital and recurrent costs. The general
classified costs and their ranking of the alternatives are shown in Table 9, with the range
of 3-high, 2-medium and 1-low.
Direct and indirect costs: Direct costs correspond to resources that can be explicitly
identified with a service or product. Indirect costs cannot be directly identified with a
service or product, but are related to the costs of supporting the direct activities. These
costs typically are incurred to administer or evaluate programs.
Joint and Non-joint costs: Non-joint costs are cost of resources that are used only for
one client, and are either fully consumed or thrown away at the end of the visit. Joint
costs can be defined as the costs of clinic resources used by more than one client.
Average and marginal costs: Average cost is defined as the total cost divided by the
number of units of output, whereas Marginal cost is the additional cost required in
producing one more unit of output.
Recurrent and capital costs: “Recurrent costs” usually are defined as the costs
associated with inputs that will be consumed or replaced in one year or less. “Capital
costs” are defined as the annual costs of resources that have a life expectancy of more
than one year, such as equipment or buildings.
27
MS can be performed by a single doctor (John Hopkins, 2008). Thus, staff
salaries (direct and indirect cost, joint and non-joint cost) for MS are ranked as low. More
people involve in LA and FS since they are major operations. Thus, the cost will
definitely be higher which include costs such as operation room fees, physician’s fee,
assistant doctors’ fees, nurses’ fees, and medical check-up fees before operation as these
are supposed to have major surgery. A physician may not be needed to perform
vasectomy. Some countries in Africa and Asia have trained other types of health
personnel to perform vasectomies. These include clinical officers, medical assistance,
medical students, nurses, midwives, and community health workers. Studies have found
that these service providers were as good as physicians at identifying and blocking the
vas (Johns Hopkins, 2008). The cost of procedure (direct and indirect cost) and required
medical supplies (joint and non-joint cost) for MS are also ranked as low compared to
other two alternatives (Lissner, A. Elaine, 2006). For the cost for infrastructure, MS can
be performed at a doctor’s clinic or hospital (John Hopkins, 2008). Thus, MS is ranked as
low. The other two require specific places such as hospitals, health centers and well-
equipped clinics based on the universal requirements for such operations. For these
reasons, the costs of infrastructure will be high for LA and FS.
For average and marginal cost, LA and FS are supposed to be major surgeries
which need well-equipped operating rooms, hospitalization, medical check-up, pre-
counseling visits, post-counseling visits and follow-up for surgery. Thus, from the
program side, relatively substantial fund will be needed to provide the requirements for
LA and FS. On the clients’ side, they will have to bear the cost of the services. For MS
28
programme, operating rooms are not necessary to perform vasectomy, pre and post-
counseling visits are probably the same but fewer post-operation visits. There are no costs
for client’s hospitalization; thus, the reduce cost on both the programme and the clients.
For these reasons, MS was ranked as low for those costs. All the costs for average and
marginal cost LA and FS are ranked as high since they are major surgeries.
Miscellaneous costs of medical materials and supplies will be low for MS as it
needs fewer materials and supplies compared to other two alternatives (John Hopkins,
2008). Thus, MS programme cost was ranked as low and high for the other alternatives.
Operation and maintenance cost may be needed for all of the three alternatives but lower
for MS. The training cost at the beginning of the programme and during the
implementation period for the staff and new staff will be probably the average for the
three alternatives. Thus, the three alternatives were ranked as 2-Medium.
29
Table 9. Ranking Cost for the Policy Alternatives
Classification of Costs* Legalized Abortion
(LA)
Male Sterilization
(MS)
Female Sterilization
(FS)
Direct and Indirect costs
Staff salaries (surgeons, assistant doctor to surgeons, nurses, programme administrators, etc.,)
3 1 3
Cost of method 3 1 3
Infrastructure 3 1 3
Joint and Non-joint costs
Staff salaries (surgeons, assitant doctor to surgeons, nurses, programme administrators, etc.,)
3 1 3
Medical supplies (e.g. cotton balls, antiseptic solutions, and utensils used for operation)
3 1 3
Average and Marginal costs
Operating rooms equipped to provide operation 3 1 3
Counseling visits pre-operative visits, follow up visits and post-operative visits
3 1 2
Hospitalization days after operation 3 1 3
Follow up after operation 3 1 3 Recurrent and Capital cost
Miscellaneous medical materials and supplies 3 1 3
Operation and maintenance (Building, equipment, furniture & vehicle)
3 2 3
Training and refresher training for staffs 2 2 2
Total 35 14 34 *Based on Janowitz & Bratt (UNFPA, 1994)
Ranking Scale: 3 – High; 2 – Medium; 1 – Low
According to the results of ranking of cost for the three policy alternatives, MS
has the least cost ranking (14) comparing to the other two options (35 and 34). Thus,
30
allowing male sterilization is the favorable policy option based on cost to both
programme (government) and client (individual). The MS policy option does not require
the government for new infrastructure and setting in health sector, since vasectomy can
be performed with minimal facilities and the recruitment new staff may not be necessary.
However, it would need a specific space for counseling and surgical procedure, utilities,
and adequate and well-maintained equipment which can be done and provided by sharing
existing settings and facilities. Male sterilization services can suit almost any setting,
from a doctor’s office to a hospital or mobile teams can visit towns and villages.
Therefore, it can be assumed that the cost is practically low for the government and the
individuals.
3.4.2.2. Ranking Benefits of the Policy Alternatives
Ranking on benefits of the policy alternatives is presented below (Table 10). The
alternatives have wide-ranging benefits beyond what is included in this study. Based on
Guttmacher Institute, the benefits of the policy alternatives were ranked in the range of
0 – No and 1 – Yes.
All of the policy options can reduce maternal death, newborn death, number of
children who lose their mothers among married populations and improve well-being of
families because of mother’s survival. Globally, it has been estimated that expanding
contraceptive services could prevent 850,000 deaths per year among children under age
five (World Bank, 1993). All of the options can reduce unmet need for contraceptive.
They do not have hormonal side affects. However, LA and FS may have risky surgery,
31
thus, they are ranked as 0. MS do not have hormonal effects, side effects and risky
operation procedure (Lissner, A. Elaine, 2006). Thus, MS is ranked 1.
Since MS and FS are long-term methods, these can effectively prevent high-risk
pregnancies. LA is not a long-term method, however, it can reduce high-risk pregnancies.
Thus, they are ranked 1. Families with fewer and healthier children can devote more
resources to their children e.g., adequate food, clothing, housing, and educational
opportunities (WHO, 1995). Thus, the parents can have more time and allocate income
for each child. They are ranked 1.
Contraceptives can prevent long term consequences of mothers’ and newborns’
health (UNFPA, 2006). All the policies can reduce public sector spending on health
services for long term consequences of mothers’ and newborns’ health. Moreover, they
have potential to improve productivity and higher income because the families may have
savings and investments which are the benefits of the policies. Thus, all options are
ranked 1 for the categories.
Even though abortion was legalized in neighboring Buddhist country, Thailand,
the abortion policy will definitely have conflicts with religion, culture and society as in
Myanmar, also a Buddhist country with strong social norms and values. Thus, it was
ranked as 0-no benefits. Majority of Myanmar women are Buddhist and believe in the
karma of previous lives and its effects on the present life. They believe that nobody
should hinder the formation of a human being and as such do not have a positive attitude
towards the use of contraception by young people (Aung Khin, 2008). They realize that
32
contraception is important for reproductive health, acceptable in Buddhism and more
appropriate for the older women. Thus, MS and FS are ranked as 1.
MS encourages effective men’s participation by taking responsibility for
contraception thus, promoting of equality between men and women in terms of
contraception, thus, rank of 0. For FS and LA, men may be involved in decision making
on female sterilization, accessing services and logistic arrangement for the women. It
encourages male participation in the contraceptive programme. However, this may not be
seen by all the stakeholders as effective participation, thus, the rank of 0 for FS and LA.
For the benefits of encouraging gender equality, LA and FS will remain
responsibilities only on women. They will not have men’s participation in any role and
not bring single gender equality. It does not enhance men’s responsibility in
contraceptive. Thus, they are ranked 0.
33
Table.10. Ranking Benefits of Policy Alternatives
Benefits* Legalized Abortion
(LA)
Male Sterilization
(MS)
Female Sterilization
(FS)
Reduce maternal death 1 1 1
Reduce newborn death 1 1 1
Reduce number of children who lose their mothers 1 1 1
Reduce unmet need for contraceptive regarding to avoid hormonal effects, side affects and risky operation procedure
0 1 0
Improve well-being of families because of mother’s survival
1 1 1
Prevention of high-risk pregnancies (i.e., those among women older than 35 and women with many children)
1 1 1
More of parents’ time and income allocate to each child
1 1 1
Reduced public sector spending on health services for long-term consequences of mothers’ and newborns’ health
1 1 1
Improve productivity and higher income: greater savings and investments
1 1 1
Less conflict with religion, cultural and social norms
0 1 1
Encourage men's participation 0 1 0
Promote Gender Equality 0 1 0
Total 8 12 9 *Based on Guttmacher Institute, 2009
Ranking Scale: 0 – No, 1 – Yes
Based on the results of the ranking for the policy benefits, male sterilization (MS)
policy has the highest score (12) compared to the other two alternatives (9 for women
sterilization and 7 for abortion). In all of the areas, MS has favorable facts and benefits
34
for both individuals and the government. Besides, it can contribute further health
improvement of the country.
3. 5. Recommended Policy Alternative to Reduce Maternal Mortality
Comparative analysis of these policy alternatives of contraceptive revealed that
male sterilization policy has more advantages with less disadvantages than the other two
alternatives. Hence, male sterilization has the least cost among the alternatives. It has the
least cost to both the government and individual users. In addition to contraception, male
sterilization policy has some other benefits such as reducing the burden for women in
shouldering the responsibility of contraception after marriage.
3.6. Male Sterilization in the Developing World
In the developing world, men are aware of “taking responsibility” and men also
want to take control of their own fertility (http://www.newmalecontraception.org). Men
realize that contraception is important for family building as one of the responsibilities
for being responsible partner for women’s health and reproductive rights. Many studies
proved that men are interested in contraception and willing to take responsibility.
Male sterilization has been accepted for family planning by approximately 42
million couples worldwide, the majority of who live in developing countries. Almost
three-fourth of the 37 million couples who use vasectomy live in Asia (USAID, 2007). In
Asia there are several countries adopt vasectomy as one of the contraceptive options.
Most of these countries have legalized male sterilization policy and programmes. In all
35
countries, vasectomy was supported by national reproductive health programs and
participation of male is rarely observed due to various factors such as ignorance, fear,
misconceptions and lack of information at the beginning of the programme interventions.
But, once the community realized that is effective for them, it became popular and
promoted by the community itself.
3.6.1. Experiences and practice of Contraceptive Programmes and Male
Sterilization Programmes in Asian countries
The usage of male sterilization in Asian countries is presented in Table. 11. Even
though Myanmar has restrictions on male sterilization, its rate of adoption is the same
with the countries which are implementing such programme at national level (i.e.,.
Thailand and India). In Vietnam, Indonesia, Cambodia and Bangladesh, male sterilization
is allowed but the prevalence of that practices were lower than Myanmar. Myanmar men
are adopting male sterilization as an option for contraception even though they have
limited services.
36
Table.11 Use of Male Sterilization in Asian Developing Countries
Country & Year Vasectomy (%)
Bangladesh 2007 0.7
Bhutan 2000 13.6
Cambodia 2005 0.1
China 2004 6.7
Democratic People's Republic of Korea (North Korea) 2002
0.8
India 2005-06 1
Indonesia 2002-03 0.4
Iran 2000 2.8
Myanmar 2007 1
Nepal 2006 6.3
Pakistan 2006-07 0.1
Philippines 2006 0.1
Republic of Korea (South Korea) 1997
12.7
Sri Lanka 2001 2.1
Thailand 2005-06 1
Vietnam 2006 0.5
Source: John Hopkins (2008), FRHS Myanmar (2007)
In India, one of the main purposes of the vasectomy programmes is to control
population. Thus the Indian government provides cash incentive to men as one of the
programme promotion strategies. According to PathFinder.com, every Indian male who
undergoes male sterilization were provided with post-operative counseling and
medicines, and given the 1100 rupee incentive. Times online reported on March 21, 2008
that Indian Government offers firearms permits for vasectomy. In India, Shivpuri district
37
in the state of Madhya Pradesh, an overpopulated area renowned for its machismo
culture, has started to offer fast-tracked gun licenses for those who agree to be sterilized.
Manish Shrivastav, the administrative chief of Shivpuri district and originator of the
lateral thinking behind the plan, indicated that “This is a state with a high number of
crimes, where people like to keep rifles. It also has a low level of vasectomies because of
a perceived notion of manliness. I decided to match that with a bigger symbol of
manliness - a gun license. It has been a success.”
In Thailand, physicians performed vasectomies monthly in rural areas via a
mobile vasectomy campaign under the government administration and programmes. The
campaign consisted of motivation and service teams. Private sector groups also involved
with mobile vasectomy included the Population and Community Development
Association and the Thai Association of Voluntary Sterilization. The Population and
Community Development Association (PDA) of Thailand used a modified commercial
marketing technique to inform people about its free vasectomy program. It has modified
the 4 Ps marketing technique (product, promotion, program, and pricing) of the business
sector to carry on promotion activities such as promoting specialists design and distribute
posters, leaflets, and advertising spots on radio and TV. Other promotion activities
include the PDA vasectomy festivals on Australian and Chinese national holidays, May
Day, Mothers' day, and King's birthday. This PDA program also operates out of clinics
and mobile vans so the clients can seek vasectomy services when and where they wish.
Its marketing technique has allowed it to surmount earlier obstacles and misconceptions
about vasectomy in Thailand.
38
In the Philippines, Reproductive Health and Population Development Act 2008,
Section 4 (i) states “Male involvement and participation – refers to the involvement,
participation, commitment and joint responsibility of men with women in all areas of
sexual and reproductive health, as well as reproductive health concerns specific to men.”
Joint responsibilities of men were considered in national policy. However, being a
democratic country, Reproductive Health Bill of the Philippines Congress has been
pending over a decade because religious leaders. Religious concern is the most difficult
barrier to handle for every government. As a republican country, agreement from the
many political leaders is necessary for approving bill. As a result, the progress of decision
making on the bill has been delayed.
3.6.2. Possibilities of Male Sterilization in Myanmar
In Myanmar, population growth is not a priority problem, thus Myanmar
government will not need to provide cash incentives (i.e., India’s male sterilization
programme) to pursue men to undergo male sterilization. Providing cash incentive may
not exist in Myanmar male sterilization programme.
Disseminating information on male sterilization can be provided through existing
health education and promotion programme supported by National Health Programme.
Several nationwide campaigns had been initiated and have significant successes, in all
campaigns such as mass measles campaign, polio campaign and vitamin ‘A’ campaign.
Medical missions, medical tours, etc., have been organized across the country under
39
MOH. Mobile clinics are put up in rural and remote areas around the country. Therefore,
male sterilization programme can be included in these existing programmes without
adding much cost to the government. Thus, people from the areas will not have to worry
about travel cost, time for the travel and loss of time for their work. These mobile
programmes can be effectively performed in the areas without cost to both individual and
government, thus a win-win situation.
Myanmar, being predominately Buddhist country, generally, has no religious
barriers for any contraceptive programmes, unlike other countries such as the Philippines
(Catholic country). A Buddhist may accept all methods of family planning, but with
different degrees of reluctance. The gravest of all is abortion or “killing a human to be”
which all Buddhist traditions condemn the practice of abortion and euthanasia. Except
abortion, Buddhism community has no restrictions for any contraceptive methods
including male sterilization. There may be myths and misunderstanding on male
sterilization in the communities. However, according to the experiences of other
countries, these can be corrected by providing accurate information through information,
education and communication (IEC) programmes. These are currently supported by
National Health Programmes.
With the existing government system, Myanmar can easily decide to approve and
implement such programmes, because of lesser process for approving bills comparing to
other Asian countries (i.e., Philippines). For instance, Myanmar Reproductive Health
Policy was formulated and approved within only a year (i.e., in 2003). Reducing MMR to
40
meet target within 6 years needs urgent attention by the government. It has not much time
for making decision, approving and implementing processes.
The estimated population of married women (40-49) in rural areas is 22.8%
(Department of Labor, 2006). The women in that age group already have their desired
family size (FRHS, 2004). Thus, the women those who live in rural areas will have
benefits from recommended policy.
41
CHAPTER 4
CONCLUSIONS AND RECOMMENDATIONS
4.1. CONCLUSIONS
MMR is slightly decreasing during the surveys periods but remains high to meet
the targeted goal in 2015. Pregnancy related maternal death and abortion is higher in
older age group those who wanted to limit or stop bearing child. They are not using any
contraceptive mainly because of hormonal affects, side affects and unaffordable cost of
women contraceptive methods.
The usage of contraceptives is increasing during the survey periods. Specifically,
the older the age group, the more demand for permanent methods for both male and
female. Due to the promotion of male participation programmes since 2004, men were
informed their responsibility for improving women’s health. Men are aware of the usage
of condom but they are reluctant to use it with their wives because of the culture and
social norms. According to surveys results, male sterilization was already well known as
an effective method among married population. By promoting male sterilization policy
for married population, the community will be more aware of the policy which is
responsive to their needs. It will also address constraints such as risk of hormonal affects,
unaffordable cost of female sterilization and accessibility of the service.
The policy and programme for men’s effective participation in contraception,
particularly in sterilization is lacking in existing policies and programmes. As mentioned
above, male sterilization can bring benefits (Table 10) with the least cost (Table 9)
42
among the options. Even though male sterilization policy alone can not reduce MMR, it
can effectively contribute to reduce MMR within married population. In addition, this is
the best option to reduce MMR which is the consequence of lack of affordable
sterilization among married women.
This study has shown that men lack supportive policy at national level and they
need specific policy and programme. Male sterilization policy is the only best option
regarding to cultural and religion. Myanmar government can easily approve policy and
promote services through existing various communication channels within shorter time
compare to other Asian countries. The targeted MMR must be attained by 2015, thus, it
has to act fast on this option.
4. 2. RECOMMENDATIONS
The government should provide policy for men sterilization with the intension of
reducing MMR among married population. Major roles for the government interventions
to expand male participation in contraception are:
• Political commitment, programmes and services are needed to be addressed to
provide male sterilization for married population with the aim of meeting
targeted MMR by 2015,
• Male sterilization is needed in reproductive health programmes in all stags of
development – from early stages in which community and political support is
important to later stages that focus on expanding and improving services,
43
• Data on men sterilization should also be collected for further policies and
programmes on male participation in contraception,
• Accessibility of men’s sterilization should be considered and included in
existing policies and programmes which would effectively contribute in
reducing unwanted pregnancies, unsafe abortions, and maternal mortality,
• Government should promote greater male participation in sterilization by:
(a) removing restrictive policies and regulations on male sterilization,
(b) looking for ways to adapt existing infrastructure and services to meet men’s
need and preferences,
(c) supporting IEC interventions that encourage male sterilization,
(d) ensuring that male sterilization services and information are offered
throughout existing systems and
Key programme areas that government should give more attention are:
(a) education and services on male sterilization,
(b) training (e.g. counseling for male clients and couples, and technical training
for vasectomy) for health providers to ensure providing quality services,
(c) promotion of male sterilization through mass media and IEC, and
(d) research on benefits of male sterilization.
* * * * *
44
LITERATURE CITED
Books
- Alan Guttmacher Institute, No date, In Their Own Right, Addressing the Sexual and Reproductive Health Needs of Men World Wide, New York
- Alan Guttmacher Institute, 2002, Sexual and Reproductive Health: Women and Men,
Facts in Brief, New York - Aung Khin, Mi Mi (2008), Unmet Need of Injectable Contraception Among Rural
Myanmar Women, Mahidol University - Ba-Thike, Katherine, 1997, Reproductive Health Matters, Abortion: A Public Health
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51
Annex I
National Health Policy, Ministry of Health (1993)
1. To raise the level of health of the country and promote the physical and mental
wellbeing of the people with the objective of achieving “Health for all” goal, using
primary health care approach.
2. To follow the guidelines of the population policy formulated in the country.
3. To produce sufficient as well as efficient human resource for health locally in the
context of broad frame work of long term health development plan.
4. To strictly abide by the rules and regulations mentioned in the drug laws and by laws
which are promulgated in the country.
5. To augment the role of co-operative, joint ventures, private sectors and
nongovernmental organizations in delivering of health care in view of the changing
economic system.
6. To explore and develop alternative health care financing system.
7. To implement health activities in close collaboration and also in an integrated manner
with related ministries.
8. To promulgate new rules and regulations in accord with the prevailing health and
health related conditions as and when necessary.
9. To intensify and expand environmental health activities including prevention and
control of air and water pollution.
10. To promote national physical fitness through the expansion of sports and physical
education activities by encouraging community participation, supporting outstanding
athletes and reviving traditional sports.
11. To encourage conduct of medical research activities not only on prevailing health
problems but also giving due attention in conducting health system research.
12. To expand the health service activities not only to rural but also to border areas so as
to meet the overall health needs of the country.
52
13. To foresee any emerging health problem that poses a threat to the health and
wellbeing of the people of Myanmar, so that preventive and curative measures can be
initiated.
14. To reinforce the service and research activities of indigenous medicine to
international level and to involve in community health care activities.
15. To strengthen collaboration with other countries for national health development.
53
Annex II
Policy Implementation Guidelines for Birth Spacing Programmes
(Myanmar Reproductive Health Policy, 2003)
• Daily combined contraceptives, progesterone-only-pills, three-monthly injectable
contraceptives, Intra-uterine devices and condoms will be available and accessible
to all individuals of reproductive age and provided with informed choice.
• Other contraceptive methods such as monthly injectables and implants may be
introduced to broaden choice and to improve quality of birth spacing services
after considering evidenced based information, the needs of the community and
the cost effectiveness.
• Easy access to sterilization will be encouraged for those women requiring
permanent contraception on medical ground.
• Introduction of emergency contraceptive methods into the existing birth spacing
services will be considered.
• Service providers in public and private sectors will be trained in the provision of
quality birth spacing services.
• Mechanism will be sought to review and revise the existing rules and regulations
periodically, impacting the availability of commodities to ensure that safe and
effective birth spacing methods are easily available.
Men’s role in reproductive health
• Awareness of critical reproductive health needs and the importance of
enhancement of men’s reproductive health status in improving the reproductive
health of the family will be raised.
• Men’s role in promotion of birth spacing service, prevention of transmissions of
RTI/STI and in supporting reproductive health service for the family and the
community will be strengthened.