Birth Spacing Policy Issue Paper

Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Birth Spacing Code in Myanmar

In partial fulfillment in the Course DM 220 (Public Policy and Programme Administration for Development)

Submitted to Dr. Wilfredo B. Carada, Professor, IDMG, CPAf

Submitted by, Hla Myat Tun 2008-2009 Second Semester Student ID: 2008-96531

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

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, MMR is high and one of the factors that affect maternal mortality is high unsafe abortion in the community due to the lack of access to contraceptive methods. The contraceptive programmes are especially targeted to women and there are still needs to be reached to community. There are several alternatives the National Health Committee (NHC), highest policy making body for health matters in the country and it also takes the leadership role to implement health programmes, could consider including existing birth spacing policies for reducing needs in the community. One option is putting the policy that allows women to be aborted in specific criteria. Another option is to allow and promote male sterilization, and provide vasectomy services in the community. The last option is promote birth spacing methods to unmarried women with the intension of preventing unsafe abortion. Among these options, male sterilizing policy will be the best option for the families to ensure that men and women are equal partners in building family life. On the other hand, there are no male oriented contraceptive policy and programmes except condom promotion for family health in existing birth spacing code. Building family is partnership and also having children and maternal health is partnership. Men are essential as partners, fathers, brothers, husbands, policy makers and community and religious leaders with women in the fight to reduce maternal mortality. Women have a right to health, but protecting that right often depends on a partner’s support and participation. This study addresses to legislate and include male contraception in existing birth spacing code to National Health Committee (NHC). The committee will aware of the barrier which encourage the gap between contraception and male shared-responsibility in birth spacing. NHC will also be aware of the impact of providing the efforts to emphasize men’s shared responsibility and promote their active involvement in responsible parent hood, birth spacing and preventing of unwanted and high risk pregnancies.

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Background

The total population of Myanmar is estimated at 55.4 millions with annual growth rate of 2.02 percent in 2006.1 The government has committed to achieve the Millennium Development Goals (MDGs) 5 to reduce maternal mortality by 2015. Supportive men’s role in reproductive health/birth spacing must be emphasized to meet the targeted aim in 6 years ahead. In public health sector, birth spacing services have long been offered mostly through the existing outlets of maternal and child health centers, which only women and mother attend. As the part of this reason, high policy makers, development, population and health agencies have largely ignored men’s influence on women’s reproductive decisions and actions and reproductive needs for men including contraceptive programmes. The government provides birth spacing services in health centers since 1991, contraceptive prevalence rate (modern methods) among married women in reproductive age (15-49) is 32.8 percent in 2001.2 According to Fertility and Reproductive Health Survey (FRHS) in Myanmar 2001, the prevalence of male sterilization is 1.3% and condom use is 0.3% in the community and also 20% of women did not want to get pregnant, 14% wanted to limit their births and 6% wanted to delay their next pregnancies. Knowledge on condom increased to prevent transmission of HIV/AIDS and sexually transmitted infections for use by men with sex workers; they are not seen as a birth spacing methods. There is a gap between male sharedresponsibility in existing birth spacing programmes. Major reasons to expend male involvement programmes including birth spacing are: Lack of political commitment – High level decision makers have yet to take the necessary steps to set up male involvement in existing programmes. Policy obstruction – Outdated policies and regulations obstruct male access to contraception such as strict eligibility criteria for obtaining vasectomies.

1 Statistical Year Book 2006, Central Statistical Organization, Ministry of National Planning and economic Development, The Government of the Union of Myanmar 2 UNFPA Statistics < http://www.unfpa.org/worldwide/indicator.do?filter=getIndicatorValues>

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Problem Magnitude Abortion is illegal but the rate of unsafe abortion is significant and tends to be the leading cause of maternal mortality because of unintended pregnancies. In Myanmar, at least 50 percent of maternal death and 20% of all hospital admission resulting from complication from unsafe abortion due to the lake of access to contraceptive methods and insufficient male support in birth spacing plays significant role of increasing abortion rate across the country.3 However, there is high demand on contraceptive services for married women and men. Limited access to birth spacing services to women and men lead to increase the risk of unintended pregnancies, unsafe abortion and maternal death. It is estimated that one in three deaths related to pregnancy and childbirth could be avoided if all the women had access to contraceptive services. The unmet need for contraception is estimated at 16.8 per cent among married women of reproductive age (15-49) and could be higher if unmarried women were also included in the calculation.4 Government targets on maternal mortality rate (MMR) 56 per live births by 2015 based on 2001 data but MMR stands 361 per 100,000 live births in 2005.5 Reducing MMR is challenging on 6 years ahead and male participation have to take part as significant role in birth spacing to save women’s lives.

Present and Past policies to Reduce Unwanted Pregnancies The National Health Policy, which changed pro-nationalist policy to health-oriented policy to integrate birth spacing with the aim of improving the health status of women and children and raising awareness on birth spacing in the community, was developed with initiation and guidance of NHC in 1993. (Annex I) Myanmar’s Reproductive Health Policy was formulated in 2002 and approved by the Ministry of Health in 2003. The government is aiming to achieve a better quality of life for all, by giving focus attention on the improvement of reproductive health status. The policies for birth spacing are stated as;

3

Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and Population, Yangon 2003 4 Nationwide Cause Specific Maternal Mortality Survey 2004-2005 5 Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and Population, Yangon 2003

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531




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 injectable 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 was stated as follow in Myanmar Reproductive Health

Policy:


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. Access to male contraception was not mentioned in existing policies. The high-level

decision makers did not consider yet the access of male reproductive health/birth spacing activities in existing policies to reduce MMR. Men are poorly informed sexuality and reproduction and need information about male and female contraception. They also need the confidence and guidance on how to share decisions and negotiate choices with their partners for taking responsibility as part of reducing MMR. And also political commitment and clinical services are needed to be addressed to provide voluntary male sterilization.

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Major Stakeholders Major stakeholders are women and men in the community as direct beneficiaries of the programmes and policy. Ministry of Health is the significant stakeholder and United Nations Population Fund, World Health Organization, other health related international and local NGOs will be indirect beneficiaries. The government and International Organization will be involved as legislation, administration, implementation, monitoring and evaluation.

Goals of Objectives The goal of this study is to analyze the different policy options for reducing MMR, to support and empower to get effective male participation, performance and taking responsibility in birth spacing to reduce unwanted pregnancies and unsafe abortion which is the major cause of increasing maternal mortality.

Policy Options / Alternatives There are several policy alternatives to reduce unwanted pregnancies, unsafe abortions and MMR. They are; a). Allow abortion to women (both married and unmarried women) with specific criteria. Although it seems to face conflicts with culture and religion, it can contribute in reducing unsafe abortion in the community. Specific criteria will need to have access abortion for example; when the women were being raped, to preserve physical health of women, to preserve mental health, etc..;. b). Allow Male Sterilization to married men by providing easily accessible to services and reduce strict criteria for obtain vasectomies. It can be effectively address the current issues regarding unwanted/unplanned pregnancies in the community especially married couple living in rural and remote areas who already have enough children and needing effective contraception. c). Promote birth control methods easily access to unmarried women with intension of reducing unintended pregnancies which is the root cause of unsafe abortion by disseminating information, promoting and providing contraceptive methods and services for both married and unmarried women. Service providers will have to lessen the criteria for having contraceptive services.

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Comparison of the Policies Policy

Advantages

Disadvantages

Allow abortion to o reduce unsafe abortion rate

o need to be legislated

women

o culturally and religiously

o reduce unwanted pregnancies o reduce unwanted pregnancies o women lives can be saved

sensitive o takes time to be familiar with community o abortion

rate

among

women can be increased o misunderstanding between couples

Allow

Male o reduce pregnancy rate

o need to be legislated

to o reduce unsafe abortion rate

Sterilization married men

o less

religious

and

cultural o seems

barriers o low

rate

o risk of minor surgery to

increase

unfaithfulness of

post-operative

complication o highly effective

among

couples o religious

barriers

for

some ethnic groups

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 Promote

birth o reduce unintended pregnancies o culturally sensitive

control methods

among unmarried women

easily access to o reduce abortion rate unmarried

o seems to empower premarital sex

o reduce MMR

women

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Recommended Policy Evaluation Rating: 1 – very low

2 – low

3 – moderate

4 – high

5 – very high

Evaluation Criteria Proposed Policy

Sustainability

Impact

Total

Option Rank

Efficiency

Effectiveness

Social Acceptability

Legal Abortion to both married and unmarried women

3

4

1

4

3

15

3

Legal Male Sterilization to marreid men

5

5

5

5

5

25

1

Promote birth control methods to unmarried women

4

4

2

4

3

17

2

Allowing male sterilization is the most appropriate policy for reducing unsafe abortion rate that affect maternal death as a part of important issues. As a Buddhism country, social acceptability is also high for male sterilization rather then other two policy options. Building separate infrastructure to deliver male services in unnecessary; men services can be provided by specific hours or minor adaption to existing facilities such as establishing a separate waiting area. Outreach activities to remote areas can also be provided for vasectomy services as mobile clinics and also be motivated as countrywide campaign. Disseminating information on male contraception will be provided through health education and promoting programme supported by National Health Programme.

6

The health benefits associated with the use of male

contraception outweigh the cost and also high effective and also visible the direct men’s sharedresponsibility in family health.

6

Information, Education and Communication (IEC) project under the health system development for health education, Ministry of Health

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Policy Implementation Guidelines The following initiatives are the guidelines for the policy implementation when the male sterilization policy was adopted:


Pursuit of legislative agenda for effective programme administration




Develop guiding principle




Advocacy meeting at all level with UN agencies and international organizations




Adaptation of male programmes in existing female programmes/infrastructure




Develop joint work-plan for administrative and management system, implementation and coordination system with health related UN agencies and international organizations, logistic system and monitoring and evaluation system




Information, education, communication (IEC) on key messages related to benefits of male-shared responsibility in birth spacing will be provided to married population




Men will have access to services for counseling on voluntary male sterilization and management of family health and promotion of related services




Upgrading skills training to medical doctors and nurses to provide effective performance




Upgrading interpersonal skills training to service providers

to ensure the

effective counseling for birth spacing


Vasectomy services will be made male-friendly by using male promoters and providers to ensure greater responsibility and participation of male in birth spacing




Male involvement in birth spacing will be encourage and visible in the provision of information and support to address issues concerning unintended pregnancies and unsafe abortion




Develop joint monitoring and evaluation plan (using performance benchmark) -

develop M&E plan

-

collect/analyze data

-

set/review targets

-

develop programme action plan and workplan

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Conclusion

Interest in male participation in reproductive health is growing, and there is increasing evidence that such policy can be effective in improving maternal health and contraceptive use. Male involvement elements are needed in reproductive health programmes in all stags of development – from early stages in which community and political support is critical to later stages that focus on expanding and improving services. Government should promote greater male participation by: (a) removing restrictive policies and regulations; (b) looking for ways to adapt existing infrastructure and services to meet men’s need and preferences; (c) supporting IEC interventions that encourage male involvement and shared-responsibility; (d) ensuring that male services and information are offered throughout existing systems; and (e) ensuring that policy and programme performance indicators include male involvement activities. Key programme areas that government should give more attention are: (a) education and services for men: (b) training for health providers such as counseling male clients and couples: (c) promotion of male involvement behavior in the mass media: (d) research on male knowledge, attitude, practices, male contraceptive methods and effective interventions and (e) vasectomy promotion. Men’s role in reducing MMR becomes important part in the country and men have great responsibility for families’ well-being. Government should consider removing restriction to support effective participation of male to achieve target aim in 2015.

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

References

- Myanmar Reproductive Health Policy, Maternal and Child Health Department, Ministry of Health, the Government of the Union of Myanmar - Myanmar Fertility and Reproductive Health Survey, 2001, Preliminary Report, Ministry of Immigration and Population, Yangon 2003 - World Health Organization South-East Asia Regional Office (WHO/SEARO) 2004. Family Planning Fact Sheets: Myanmar and Birth Spacing: An Overview Web site: - Nationwide Cause Specific Maternal Mortality Survey 2004-2005 - Statistical Year Book 2006, Central Statistical Organization, Ministry of National Planning and economic Development, The Government of the Union of Myanmar - Exploring Strategic Change, Second Edition, Julia Balogun and Veronica Hope Hailey - The Rise and Fall of Strategic Planning, Reconceiving Roles for Planning, Plans, Planners, Henry Mintzberg - Strategic Management 2nd Edition, Alex Miller & Gregory G. Dess - Population Policies and Programmes in Singapore, Saw Swee-Hock, Institute of

Southeast

Asian Studies - Fifth Asia and Pacific Population Conference, by United Nations Economic and Social Commission for Asia and Pacific, United Nations (online book) http://books.google.com/books?hl=en&lr=&id=bhkyyFiqtsoC&oi=fnd&pg=PA253&dq=male+invo lvement+in+Myanmar&ots=v-jqO6L0q8&sig=BX0B6Ls-jQEQLcKuZt7DUwRZDuM#PPA261,M1> - Male Involvement in Reproductive Health, Including family Planning and Sexual Health, United Nations Population Fund - Population Policies and Programmes: Determinants and Consequences in Eight Developing Countries, by London School of Hygiene and Tropical Medicine and United Nations Population Fund - The value of Family Planning Programmes in Developing Countries, by A RAND Programme of Policy-Relevant Research Communication - - <www.un.org/esa/population/publications/abortion/doc/myanmar.doc>

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Annex I

National Health Policy 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 bylaws 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. 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.

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Prepared and Submitted by: Hla Myat Tun, Second Semester 2008-2009, Student ID: 2008-96531

Annex II Advocacy Framework Steps

in

the Target Audience

Message to be sent

Policy Process Formation

Implementation

How will you deliver the Messages in behavior you want to message

create

National legislators, High- “It’s time to encourage Organize Advocacy meetings

Realize to allow male birth spacing

level decision makers

men for women’s health!”

programmes

Married population

“Let’s be the best partner Use mass media, pamphlets, Aware and committed of male to for women’s health!”

participate effectively in birth spacing

human stories, celebrities Use community-based health workers, peer educators and volunteers

Evaluation

Implementers

“Is the policy effectively Organize

annual

Married population

providing benefits to the monitoring

and

people?” Termination

High

level

meeting at all level

joint Committed to preserve with more

evaluation effort to provide better service/ to build healthy family

decision “Did the policy provide Organize meeting for high level Realize

makers

benefits to the people?”

decision makers

to

environment

provide for

supportive

further

health

development programmes Maintenance

Married Population

“Does men role effectively Use community-based health Realize and maintain male effective contribute to the health of workers, peer educators and participation in birth spacing/family your family?”

volunteers

health

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