Integration of Post-Abortion Care: The Role of Township Medical Officers and Midwives in Myanmar

Abstract

Complications of unsafe abortion are a significant cause of maternal morbidity and mortality in Myanmar, and are recognised by the Ministry of Health as a priority. The Department of Health developed a strategy to address the problem of abortion complications by integrating post-abortion care and contraceptive services into the existing township health system. The quality of post-abortion care was assessed by the Department of Health in 2000, using a baseline survey of health providers and post-abortion women in Bago Division. The integration of post-abortion care was led by the Township Medical Officers, who provided monthly in-service training and supervision of health care workers in each township. Hospital-based doctors and nurses, clinic midwives, village midwives and other volunteer health providers, including traditional birth attendants, were all trained. The role of the local clinic midwife was extended to make follow-up home visits to the women with post-abortion complications and provide them with contraception when requested. Preliminary results show positive outcomes. However, donor-funded projects may have a destabilising effect on township services by diverting attention and resources; donors need to work with government to support its priorities for health care. The future nationwide integration of post-abortion care services into township services should be planned in consultation with Township Medical Officers and midwives, the key providers of these services.

Résumé

Les complications des avortements non médicalisés sont une cause importante de mortalité et morbidité maternelles au Myanmar, et une priorité du Ministère de la santé. Le Département de la santé a décidé d'intégrer les soins post-avortement et les services de contraception dans le système de santé municipal et il a évalué la qualité des soins post-avortement avec une enquête auprès des agents de santé et des femmes ayant subi un avortement à Bago. L'intégration des soins post-avortement a été menée par les médecins municipaux, qui ont assuré des cours mensuels de formation et supervisé des agents de santé dans chaque municipalité. Les médecins et les infirmières des hôpitaux, les sages-femmes des cliniques, les sages-femmes de village et les autres agents de santé bénévoles, notamment les accoucheuses traditionnelles, ont tous été formés. Le rôle des sages-femmes de village a été élargi pour qu'elles examinent à domicile les femmes présentant des complications et leur distribuent des contraceptifs sur demande. Les conclusions préliminaires révèlent des résultats positifs. Néanmoins, les projets financés par des donateurs peuvent déstabiliser les services municipaux en détournant l'attention et les ressources; les donateurs doivent travailler avec l'administration pour soutenir ses priorités de santé. L'intégration future dans tout le territoire de soins post-avortement dans les services municipaux devrait être planifiée avec les médecins et les sages-femmes municipaux, prestataires essentiels de ces services.

Resumen

Las complicaciones de aborto en condiciones de riesgo son una causa importante de la morbimortalidad materna en Myanmar. El problema es prioritario para el Ministerio de Salud, y se ha propuesto como estrategia integrar la atención postaborto y los servicios anticonceptivos al sistema de salud municipal. Se evaluó la calidad de la atención postaborto utilizando una encuesta de lı́nea de base administrada a los prestadores de atención en salud y a mujeres postaborto en la División Bago. Los Oficiales Sanitarios Municipales dirigieron la integración de la atención postaborto y proporcionaron capacitación y supervisión mensual en cada municipio. Capacitaron a los médicos y enfermeras de planta en los hospitales, a parteras profesionales, parteras tradicionales y otros prestadores de atención en salud. Se amplió el papel de la partera tradicional para incluir visitas a domicilio a mujeres con complicaciones postaborto y la provisión de anticonceptivos cuando sean solicitados. Los resultados preliminares han sido positivos, pero los proyectos financiados por donantes pueden tener un efecto desestabilizador sobre los servicios municipales al distraer la atención y los recursos. Los donantes deben trabajar con el gobierno y apoyar sus prioridades en materia de salud. Se debe planificar la futura integración de los servicios de atención postaborto a los servicios municipales a nivel nacional en consulta con los Oficiales Sanitarios Municipales y las parteras, quienes son los prestadores claves de dichos servicios.

Key Words:

• post-abortion care
• contraception and unplanned pregnancy
• integration of services
• decentralisation of services
• training of service providers
• Myanmar

The Ministry of Health in Myanmar ranks abortion as the ninth most important health problem¹ and the third leading cause of morbidity,² with complications from unsafe abortion a leading cause of burden of disease. Induced abortion is illegal in Myanmar except under circumstances where the life of the mother is at risk. The maternal mortality ratio has been estimated to be at least 255/100,000 live births.³ Complications following abortion are responsible for up to 60% of direct obstetric deaths recorded in hospital-based studies;⁴ there are limited data available on mortality due to abortion complications at community level.

Myanmar is one of the signatories to the 1994 ICPD Programme of Action. In line with this commitment, the Ministry of Health conducted an assessment of the reproductive health needs in the country in 1998.⁵ Addressing abortion-related morbidity and mortality was one of the specific recommendations, and donor support was obtained to implement the programme. This paper describes the process undertaken by the Department of Health (DOH) in Myanmar to address the issue of abortion complications, by integrating post-abortion care and contraceptive service delivery into existing health care services.

Department of Health post-abortion care strategy

The Department of Health (DOH) organised a Post-Abortion Care (PAC) meeting in August 1999, which was attended by policymakers, programme managers, service providers and national and international NGOs working in the field, including representatives of women's groups. During the course of the meeting a post-abortion care strategy was outlined by participants, and further developed by a DOH sub-committee, the components of which included:

• training of hospital and clinic staff in clinical management of post-abortion complications (or stabilisation and referral), counselling (emphasising non-judgmental attitudes) and infection prevention;

• training of volunteer community health providers (TBAs, auxiliary midwives, community health workers) in early warning signs of post-abortion complications, early referral and use of contraception to prevent unwanted pregnancies;

• provision of health education materials—pamphlets to take home and an audiotape on contraceptive methods for women to listen to in hospital;

• advocacy meetings with community leaders and members of the Myanmar Maternal and Child Welfare Association (MMCWA), to discuss the need for early referral and community support for women with complications of abortion or miscarriage, and to provide information on and access to contraceptive services for women in the community; and

• provision of manual vacuum aspiration (MVA) in tertiary-level training hospitals with a view to its introduction at township level.

There were several other important outcomes of this meeting. It was agreed to carry out a baseline study of the quality of post-abortion care services in Bago Division, the selected pilot site for testing this strategy. Another was the development of a project integrating post-abortion care services into the public health care services, using the DOH strategy. The training, IEC and advocacy components were conducted in all 28 townships of the Division. Another was a pilot project to introduce the use of MVA for post-abortion cases into South Okkalappa Hospital, a tertiary-level teaching hospital in Yangon.

To address the situation of repeat abortion and unwanted pregnancy occurring while women were using a contraceptive method, in four townships within the Bago Division, two new activities were introduced to strengthen the linkage of post-abortion care with contraceptive services after discharge. These were linked with the ongoing contraceptive services provided by midwives in the community, and training of private general practitioners and private drug store personnel on the correct information to give when supplying contraceptives.

Lastly, discussions were held on the need to include training on post-abortion care in midwifery training, and the need to change policy to allow midwives to give parenteral injections, necessary for the emergency management of complications before referral. The proposed changes to midwives' job description, allowing the provision of parenteral injections, have been submitted to the Ministry of Health for approval.

Some preliminary findings from the baseline study and each of these interventions are described below. An operations research study on these aspects of the intervention is ongoing at this writing; the complete results are expected to be available in July 2003.

Baseline study: methodology

The baseline study of the quality of post-abortion care services was conducted by the DOH with technical assistance from the Population Council in August 2000. Bago Division has a total population of approximately 4.5 million (8.8% of the country's population) with 80% of the population living in rural areas. In four of the 28 townships in Bago Division (which were selected on criteria of size, facilities, staffing and location to be representative of average townships), a total of 122 hospital and clinic staff and 163 volunteer community health providers were interviewed. Four township hospitals, four station hospitals, nine rural health centres and 11 health sub-centres were visited, chosen to represent a range of facilities in urban and rural areas. Due to difficulties with communication, several of the smaller facilities had inadvertently not received notification of the researchers' visit before their arrival, but they were still included. The structured interview covered knowledge of clinical care for post-abortion complications, counselling and attitudes, and was supplemented by several focus group discussions with both hospital/clinic staff and village volunteer health staff. The focus group discussions covered a range of topics, including obstacles that staff encounter referring or managing patients, and their attitudes towards abortion and patients with complications.

An inventory of equipment and supplies within health facilities was taken in each of the 28 facilities visited. An assessment of clinical care was made by asking an observer (another member of staff) to fill in a checklist of patient management from admission to discharge, for five cases per township hospital. This information was supplemented by an informal ward round in the township hospitals visited, three times in a period of 18 months (August 2000–February 2002), asking about current management of in-patients with abortion complications.

In addition, 170 women treated for post-abortion complications were surveyed in the hospitals (one station and four township hospitals) prior to discharge. This was conducted over a period of nine months (January–September 2001) as, on average, township hospitals were admitting six post-abortion patients per month. A questionnaire, covering topics such as attitudes of staff, information provided, pain and pain relief, and costs associated with admission, was administered by research assistants, some of whom were health staff, others university students.

Existing post-abortion care and contraceptive services

In Myanmar, there are 324 townships, which provide preventative and curative health services under the guidance of Township Medical Officers (TMOs). Townships are the functional equivalent of districts in many other countries, and are usually comprised of a township hospital and up to three station hospitals, usually staffed by a physician with basic medical, surgical and obstetric training. At lower levels, rural health centres support four or five rural health sub-centres run by a midwife, which serve 5–10 local villages each. Health providers treat approximately three women with abortion complications per 100 pregnant women in the community.⁶ Complications tend to be severe, with 40% of women presenting with severe haemorrhage requiring blood transfusion, and about 25% presenting with sepsis. Post-abortion complications in the township are managed in the public hospitals (i.e. the township or station hospital), and are rarely referred out of the township. Health providers in the community clinics (rural health centres and sub-centres) refer women with post-abortion complications directly to the nearest hospital for treatment.

Both spontaneous and induced abortions are recorded in the hospital register under the general term tha-pyet (abortion/aborted). A similar term tha-phyet is used specifically for induced abortion, as phyet indicates interference; however, this is not recorded in the hospital register due to the sensitivity and illegality of induced abortion. Abortions that are septic are recorded as such, and sepsis was usually associated with induced abortion. In the focus group discussions, providers said that between a quarter and two-thirds of the abortions they saw were induced (tha-phyet); this was put at closer to two-thirds of women seen in larger facilities. In some cases, the woman or her family would say the abortion was induced, in others the staff inferred that it was induced by the presence of sepsis or trauma. It was thought that traditional birth attendants (TBAs) in the villages were the main providers of induced abortion in the townships, usually through the use of abdominal massage or traditional medicine, though sometimes by introducing foreign bodies into the cervix.

Quality of post-abortion care in township hospitals

The results of the survey indicated a need for training of health providers at all levels. Although none of the health providers in the township had received specific training in post-abortion care, most, including volunteer community health providers, had attended a woman with post-abortion bleeding in the previous 12 months. Over half the women seeking abortion-related hospital care (57.1%) had consulted another health provider before admission, most commonly a midwife, but some also a general medical practitioner.

In general, observation of clinical management in both the township and station hospitals showed that patients appeared to receive adequate clinical care, despite the fact that only very basic resources were available and that women had to purchase most medications, including antibiotics and contraceptives. Hospitals and clinics had adequate staffing, waiting times both in emergency cases and before procedures were generally short, and infection prevention such as sterilisation of equipment was being carried out correctly. Post-abortion women had an average stay of 3.1 days, with a range of 1–20 days. Curettage was still the routine form of management, however, as MVA was not yet available in the township hospitals. In the six months prior to the survey, 96% of women admitted to township or station hospitals had received antibiotics, mostly penicillin and gentamycin±metronidazole. 38% of women received a blood transfusion, which corresponded with the percentage classified as having severe haemorrhage.

However, amongst providers, there was a lack of information on what appropriate counselling consisted of, both on post-abortion care and contraceptive methods. While the majority of providers (80%) mentioned heavy bleeding as a warning sign of post-abortion complications, fewer mentioned prolonged bleeding, fever and pain. The majority were not aware that fertility may return early after an abortion, with only 20% of both clinic and community providers correctly saying it was possible that fertility could return within a month of abortion. Half said they would wait for the next menstrual period or for six weeks before starting women on a contraceptive method post-abortion. Only hospital ward staff answered that they would usually give contraception before discharge. Most providers were counselling women to abstain from sex for 45 days (the traditional period of abstinence after birth) and less than a third thought that sexual intercourse could be resumed in cases without vaginal/cervical injury after bleeding had ceased. Nearly 80% of providers felt that they should inform the woman they did not approve of abortion.

“We feel very upset. We sympathise with the patient but also scold them for their benefit. We scold them and say you should not do that and should take precautions to prevent pregnancy.”

(Hospital provider)

Women's perceptions of quality of post-abortion care

Village women tended to delay seeking care for post-abortion complications after an induced abortion for two main reasons—fear of neighbours knowing and fear that health staff in the hospital would blame them.

The cost of treatment was not a big factor in the decision to delay seeking care. Over 95% of women said that the cost of care was reasonable; two-thirds of those interviewed were charged under 6,000 kyat for inpatient care and medication, and on average they had spent 1,500 kyat prior to admission to hospital on transport and medication.* An informal community support system exists for transport, and hospital staff keep a fund with donations for treatment of poor patients.

“The community supports transportation and food. The midwife accompanies the patient to hospital to get treatment free of charge if she is poor. The midwife makes this decision as she knows who in the village is rich or poor.”

(Volunteer community health provider)

The women patients interviewed said they were quite satisfied with the service provided by the hospitals, rating it either excellent or good. This finding was independent of whether the interviewer was medical or non-medical, but may have been influenced by the fact that the interviews took place in the hospital prior to discharge, in a culture of unequal power relations between health professionals and patients. When asked if the staff were friendly, only one of the 170 women found staff attitudes unfriendly, 8.2% found them neutral and 91.2% said staff were friendly. Most women (67.6%) said they were seen promptly after arrival at the hospital; a further 27.1% had to wait less than half an hour and 4.1% had to wait up to an hour. Five women (2.9%) felt somewhat embarrassed during the gynaecological examination, but only one woman felt that the staff had not made a big effort to make her comfortable.

One of the issues that requires improvement is the management of pain, particularly pre-operative pain. Nearly two-thirds of women experienced severe or moderate pain prior to treatment. Although nearly all the women reported receiving some pain medication if they were having a curettage, only 89% of women received analgesia while waiting for the procedure, and it appears that this was not sufficient for most of them to obtain sufficient pain relief. In post-abortion care programmes internationally, pain management is an area which has proven particularly resistant to improvement,⁷ and as this baseline research also demonstrates, special attention is needed regarding analgesic requirements after diagnosis and prior to the evacuation procedure.

Contraceptive provision and uptake

Of the women with post-abortion complications who wished to practise family planning, most (93%) received a contraceptive method before discharge from hospital. Of these, 98.3% had the method options explained to them by staff but 5.3% did not get the contraceptive method they preferred. Nearly two-thirds of the women received a three-monthly injectable, with IUDs next most common (24%) and then oral contraceptives (5%). However other studies in Myanmar have indicated that there is a problem with correct use of methods; 26–47% of women with post-abortion complications were reportedly using contraception at the time of becoming pregnant.^{4 8 9} Repeat abortion is also not uncommon; for example, several studies in the Yangon area found that approximately one-third of admissions for induced abortion had a history of previous abortion,⁴ indicating a need for better information on correct usage and follow-up.

Integrating post-abortion care into in-service training

It is routine in most townships for midwives and other health staff to come to the township hospital every month to collect their wages. Most Township Medical Officers (TMOs) take the opportunity to meet with staff, and conduct continuing medical education at this time. There is also an existing system whereby Lady Health Visitors (senior midwives with additional training) supervise the activities of volunteer community health providers from each rural health centre.

An effort was made by DOH staff to integrate post-abortion care training into existing training systems, so that the Bago Division pilot project could be duplicated in other States and Divisions without excessive additional resource requirements. Two training sessions for TMOs were conducted in Yangon (April and June 2001), with a trainer from EngenderHealth (a US-based international NGO) assisted by several obstetricians from Yangon. Having two separate sessions reduced the period of time that TMOs were away from the townships. The TMOs subsequently trained all hospital and clinic staff in their townships, with the timing of the training decided at township level. Most of the TMOs in the Division decided to incorporate the post-abortion care training into their regular monthly meetings. Many elements of the training are also applicable in other situations, e.g. non-directive counselling, infection prevention and emergency resuscitation of a patient in shock, and so fit well into a monthly CME format.

In most cases, voluntary community health providers (auxiliary midwives, community health workers and TBAs) were trained at the local rural health centre, so that the health workers had less distance to travel, and the training could be conducted with a smaller numbers of participants. Formerly, untrained TBAs had been excluded from the TMO training system, and they were initially reluctant to come for training as previously they had been blamed for providing abortions. Hence, it required additional efforts by the TMOs to encourage them to join the PAC training. Conducting the training locally at rural health centres helped to overcome this obstacle. At this level the training focused on the need for early referral of abortion complications (following either spontaneous or induced abortion), and prevention of unwanted pregnancy through contraceptive information and provision. Given the sensitivity of the topic, in focus group discussions no TBAs revealed that they provided abortions themselves. However, after the training, they said they had become more confident about referring women with complications to hospital, whereas previously they had not wanted to be involved in case they were blamed.

Drug store personnel and general practitioners had not usually been included in public health sector in-service training either. This was piloted in two townships in Bago Division. Although TMOs experienced difficulties persuading these private practitioners to leave their practices to attend the training, at the end of the session both general practitioners and drug store personnel expressed a desire for more training in future.

One limitation on the continuity of this in-service training programme has been due to the regular rotation of TMOs from one township to another so that untrained TMOs are replacing those who have been trained. In some cases the training of staff in a township has had to be rushed so that it was completed before the original TMO left, and in these circumstances staff have missed out on the supervisory support of the TMO who trained them. This will become less problematic in a standardised nationwide training structure. Other options to resolve the difficulty of rotation of TMOs might be the development of self-teaching manuals for TMOs and the inclusion of non-trained TMOs in the future training programmes of other Divisions. Discussions have also commenced on the possibility of including post-abortion care in the undergraduate medical curriculum in future as well.

Midwives' expanded role

An important new focus of the DOH strategy was to acknowledge the potential role midwives could play in post-abortion care. While hospital doctors and nurses already had responsibility for the clinical management of post-abortion clients, post-abortion care had not been integrated into the health services in rural health centres (which serve an average population of 22,000) or sub-centres (which serve a population of around 5,000). Midwives who staff the rural health centres and manage local health sub-centres have a significant role in township health services, performing nearly 45% of deliveries (usually in the woman's home) and providing antenatal care to nearly two-thirds of all pregnant women. These midwives provide clinic services one day a week and visit the villages in their area four days a week, providing antenatal, immunisation and family planning services, as well as services such as leprosy and tuberculosis treatment follow-up.

To help to reduce the number of repeat abortions and the number of women becoming pregnant whilst using a contraceptive method, the DOH decided to train midwives to provide follow-up, with the aim of improving the coverage and quality of contraceptive use post-abortion. This approach was piloted in two townships where, after training the midwives in post-abortion care, TMOs initiated a monthly process in which they informed midwives of any woman discharged after post-abortion care in the previous month who wanted a follow-up visit.

Preliminary post-intervention research has shown that involving midwives in these ways has had positive results, with midwives having improved knowledge and confidence to counsel women post-abortion. Midwives felt that women welcomed their visits and the information they provided. The attitudes of the midwives towards women post-abortion were also much more sympathetic than prior to training:

“Previously I blamed the abortion patient and now I don't. Before, even if it was a miscarriage, I suspected induced abortion and blamed them. I would tell them: ‘You don't need to solve the problem this way, you have to deliver the baby—the baby is innocent.’”

“Before this training, abortion patients did not come here as they were afraid of us. Now they come to the clinic.”

“After training, we feel confident about when to start birth spacing and telling patients when they can have sex again; before we did not discuss this.”

After the training, the midwives were visiting an estimated 80% of post-abortion women after discharge. While the follow-up research with the women has not been completed, the midwives themselves felt that they were providing a useful service. As their normal village visiting routine involved home visits for many health care reasons, a visit to women post-abortion would not endanger their privacy. None of the midwives interviewed felt that the additional workload was a burden, as they had only a few additional women to see in their areas. While many post-abortion women were receiving a three-monthly injectable contraceptive before discharge from hospital, during follow-up midwives now make a special effort to assess individual contraceptive needs and address women's own concerns about contraception, as illustrated below:

“Kyi Kyi Tan is a 21-year-old married woman with one child, aged 18 months. After the birth of her first child she had a three-monthly injection 45 days after delivery because the midwife said she should. But when she did not get her period she was afraid, so she stopped using the injection, to wait for her next period. Her next period did not come but she became pregnant during this time. Although she eventually wanted another child, she felt that this pregnancy came too soon. She had no money to deliver and needed to work in the rice fields. When she was four months pregnant she went to see an old lady in the village, who put a liquid medicine inside her, and four days later she had heavy bleeding. Now she is using the injectable again, but this time she is happy using it as the midwife visited her and explained that having no period was safe for her health (a bit like when you are pregnant), and she did not need to worry about not having periods.” (Case study, from interviews with a woman four months after hospital discharge)

Involvement of international NGOs and donors

International organisations working with the Department of Health supporting post-abortion care and contraceptive counselling now include Family Planning International Assistance, UNFPA, EngenderHealth and Population Council. Several of these organisations are also training general practitioners in the private sector, as is Population Services International. The Department of Health is coordinating this international assistance, and technical resources have been shared in most cases, so there is little duplication of effort, as has occurred in many other countries.

However, with an increasing number of international NGOs and donors now interested in funding health projects in Myanmar, some negative impacts on the public health system have emerged. With regard to reproductive health programmes more broadly, the limited number of DOH staff at the national-level Maternal Child Health/Birth Spacing section are being severely overstretched with conducting and supervising the activities funded by international NGOs and donors on top of their DOH responsibilities. Many of the donor projects require separate planning and supervision visits to the field, as well as different accounting and reporting systems. In the townships as well, an emphasis on donor-funded projects is appearing (including post-abortion care activities which are funded separately from the public sector programme), to the detriment of non-funded, routine activities. Township medical officers need to attend national level trainings conducted by donor-supported programmes/projects so frequently that several commented in the course of this study that they had no time to do their routine work. The influence of donor programmes also extends to the townships, where health staff now receive per diems to attend donor-related training programmes, where previously they had attended the monthly in-service training by the TMOs without payment.

Informal discussions of the issue of donor-supported programmes with township staff, national level DOH and international NGO staff have elicited feelings of frustration that donors appear to fund training only, and not the necessary supplies and equipment for providing services. It is also perceived as unfair that staff in specific programmes receive per diems for training and outreach, whereas other staff with similar workloads are not rewarded. Several alternatives to a per diem system were suggested, including using donor funding to supplement the total township health training/outreach budget; provision of additional basic equipment/medications for health centres; support of development activities and/or salary bonuses for all staff, based on hours worked.

Discussion

Preliminary results of the Department of Health's strategy to address post-abortion complications as part of reproductive health care have shown several positive outcomes. Despite the legal restrictions and the cultural sensitivity of the topic of abortion in Myanmar, within the Department of Health, policymakers and other officials have been willing to discuss the problem openly and consider a number of approaches. The broad-ranging components of the strategy, incorporating community advocacy and collaboration with the private sector, as well as in-service training for both untrained and trained health providers, are setting a standard for other health programmes to follow.

The main lesson learned in the course of trying the post-abortion care strategy has been the importance of working within and building up the township health system, despite its limitations. Whilst the danger of introducing a separate vertical programme (“the post-abortion care project”) was always present, the focus on the township level and the Township Medical Officer's control of post-abortion care activities has meant that, in practice, all components of the initiative have been integrated into other township-level basic health care activities.

The Myanmar health system has definite strengths at township level despite the low financial resources available. The existing monthly in-service training provided by the TMO for all hospital and clinic staff provides the opportunity for refresher training and supervisory support of staff at low cost. Similarly, the majority of midwives, despite a low salary, provide an efficient reproductive health service, integrated with other health services, visiting households in each village regularly.

Myanmar, with a recent past of relative isolation from external aid, is in an ideal position to learn from the experience of other developing countries that have had an influx of international NGOs and donors in the health sector. There is a need to consider carefully the implications at township level of funding vertical programmes, or specific parts of programmes. In general, to avoid donor-funded projects having a destabilising effect on township services, donors need to work with government to support its own priorities for health care. A meeting of the DOH and TMO and midwives' representatives with donors and international NGOs who support the health sector would be useful to plan the integration of programmes at township level. Issues that need to be discussed include staffing requirements and job descriptions at national and township level to support the planned health activities; priority setting within the townships; coordinated timetables for township-level training programmes; and consideration of alternatives to per diems for rewarding township staff for attending training and other work.

Policy developments and the future

The Ministry of Health developed a draft reproductive health policy in 2001, which is awaiting approval by the National Health Committee. It includes the provision of post-abortion care within essential obstetric care and post-abortion counselling.¹⁰ In the wider context of reducing abortion complications in the country, the Ministry of Health has included in the policy the provision of an affordable, effective contraceptive service, including emergency contraception, to prevent unwanted pregnancy. Since the 1999 post-abortion care meeting, the initiation of the post-abortion care project in Bago Division and the MVA pilot project in Yangon, the Ministry of Health has approved the provision of MVA in a second tertiary hospital, supported by Family Planning International Assistance.

Although the Union of Myanmar is pursuing a pronatalist policy, they acknowledge the health benefits of birth spacing for mothers and children and support the birth spacing programme. The Department of Health is continuing in-service training on birth spacing for health staff in the public sector in all 324 townships in the country, which now includes information on post-abortion contraception. The DOH cooperates closely with the MMCWA, whose large membership throughout the country provide contraceptive information and some services. While in some cases MMCWA members received training on post-abortion care in the Bago Division, more comprehensive integration of post-abortion care into the existing in-service training of MMCWA members would be valuable, especially on early warning signs of complications and the need for early referral from the community.

The Department of Health, as stated in the draft reproductive health policy,¹⁰ aims to create and strengthen effective partnerships with the private sector in providing reproductive health care. The private sector, both general practitioners and drug stores, has a large role in the provision of contraceptive methods in Myanmar. The Department of Health and the Myanmar Medical Association have conducted projects to provide training on contraceptive methods and contraceptive counselling to general practitioners, to increase the standard of information and services available to women and their husbands. Expansion of these projects and inclusion of drug store personnel in training on the provision of correct contraceptive information and services, including emergency contraception, would help reduce the number of unplanned pregnancies.

As regards next steps for post-abortion care in Myanmar, discussions have now commenced on how to expand the integration of post-abortion care nationwide, using the lessons learnt in the townships of Bago Division. With the completion of the research into the impact of these interventions due mid-2003, a meeting will be held with DOH policymakers, TMOs, midwives and international organisations to plan the next steps. Incorporating the views of the TMOs and midwives will be the key to integrating post-abortion care within the township health service, the core of health service provision in the country.

Acknowledgements

The authors are grateful to Dr Htay Lwin, Director (Public Health), Department of Health, Myanmar; Dr Jean Ahlborg, EngenderHealth, who provided training on PAC and MVA; Dr Win Myint, Dr Theingi Myint, Dr Hla Mya Thway Einda, Dr Hta Hta Yi and the TMOs and midwives of Bago Division. Project activities and technical assistance from the Population Council and EngenderHealth were funded by the Packard Foundation, USA.

Notes

* 7,500 kyat=US$12.50 at time of survey, the cost of about 105kg of rice.