Birth Spacing Policy Issue Paper

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

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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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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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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 shared-

responsibility 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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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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� 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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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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Comparison of the Policies

Policy Advantages Disadvantages

Allow abortion to

women

o reduce unsafe abortion rate

o reduce unwanted pregnancies

o reduce unwanted pregnancies

o women lives can be saved

o need to be legislated

o culturally and religiously

sensitive

o takes time to be familiar

with community

o abortion rate among

women can be increased

o misunderstanding

between couples

Allow Male

Sterilization to

married men

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

o religious barriers for

some ethnic groups

Promote birth

control methods

easily access to

unmarried

women

o reduce unintended pregnancies

among unmarried women

o reduce abortion rate

o reduce MMR

o culturally sensitive

o seems to empower pre-

marital sex


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Recommended Policy

Evaluation Rating:

1 – very low 2 – low 3 – moderate 4 – high 5 – very high

Evaluation Criteria

Proposed Policy Efficiency Effectiveness

Social

Acceptability Sustainability Impact Total

Option

Rank

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 shared-

responsibility 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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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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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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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:

<http://w3.whosea.org/LinkFiles/Family_Planning_Fact_Sheets_Myanmar.pdf>

- 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

- <http://planet.unescap.org/esid/psis/population/journal/Articles/2000/V15N4A3.pdf>

- <www.un.org/esa/population/publications/abortion/doc/myanmar.doc>


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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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Annex II

Advocacy Framework

Steps in the

Policy Process

Target Audience Message to be sent How will you deliver the

message

Messages in behavior you want to

create

Formation National legislators, High-

level decision makers

“It’s time to encourage

men for women’s health!”

Organize Advocacy meetings Realize to allow male birth spacing

programmes

Implementation Married population

“Let’s be the best partner

for women’s health!”

Use mass media, pamphlets,

human stories, celebrities

Use community-based health

workers, peer educators and

volunteers

Aware and committed of male to

participate effectively in birth spacing

Evaluation Implementers

Married population

“Is the policy effectively

providing benefits to the

people?”

Organize annual joint

monitoring and evaluation

meeting at all level

Committed to preserve with more

effort to provide better service/ to

build healthy family

Termination High level decision

makers

“Did the policy provide

benefits to the people?”

Organize meeting for high level

decision makers

Realize to provide supportive

environment for further health

development programmes

Maintenance Married Population

“Does men role effectively

contribute to the health of

your family?”

Use community-based health

workers, peer educators and

volunteers

Realize and maintain male effective

participation in birth spacing/family

health

Documents

Birth Spacing Policy Issue Paper