community perspective on maternal mortality in myanmar · 2019-01-10 · and injections on our arms...

Community Perspective on Maternal Mortality in Myanmar

Kyaw Thu Hein

Wai Wai Han

Kyaw Thu

Kyaw Thet Aung

Ei Ei Swe

Khaing Nwe Tin

Hla Mya Thway Einda

Department of Medical Research

Department of Medical Research

Department of Medical Research

Department of Medical Research

Department of Medical Research

Maternal and Reproductive Health Division

Maternal and Reproductive Health Division

Background

453

178

0

50

100

150

200

250

300

350

400

450

500

Maternal Mortality Ratio (Gapminder (2010) and World Bank (2015)) (deaths

per 100,000 live births) 215

197

178 161

126 114

54 40

23 20 10

0

50

100

150

200

250

Maternal Mortality Ratio (World Bank (2015)) deaths per 100,000 live births)

Maternal Mortality Ratio in Myanmar by State/Regions (Census 2014)

• Severe bleeding • High blood

pressure • Unsafe abortion

INDICATORS CURRENT STATUS DATA SOURCE

TARGET BY 2018

Maternal mortality 178/100,000 LB UN reports2015

129/100,000 LB

AN care coverage (at least 4 times) 59% DHS 2015-16 80%

Skilledbirth attendant rate 60% DHS 2015-16 85%

Facilitydelivery 37% DHS 2015-16 60%

Postnatal care coverage 71% DHS 2015-16 75%

Aim

Goal of reduction

MMR (<70/100,000

LB in 2030)

Demand side factors

Supply side factors

Methods

Exploratory study using qualitative method

Mothers, relatives of maternal death cases

Magway and Ayeyarwaddy Regions

Feb-September 2018

2 villages having maternal death cases in 2017

2 townships with highest MMR

Region (Magway and Ayeyarwaddy)

Mothers with under one year old child

Relatives of all maternal death cases

Sampling

Data collection

28 FGDs with mothers who delivered within one year before data collection (home delivery with TBA, home delivery with SBA, facility delivery)

10 Key informant interviews with relatives of maternal death cases which occurred within one year before data collection

• The audio-recordings from the qualitative interviews were transcribed verbatim into text in Burma language.

• Transcripts were read and re-read to obtain the thematic coding framework through consensus among research teams following the approaches described by Creswell

• A common list of concepts was drawn up in a nonhierarchical order and the data were coded deductively using derived codes

• Thematic analysis was performed

Data management

Ethics consideration

• Ethics approval was obtained from Ethics Review Committee, Department of Medical Research.

• The respondents were explained thoroughly about the purpose of the study and written informed consent was attained before each FGD and KII.

• Anonymity, privacy and confidentiality issues were strictly observed.

Results

Table-1 Background information of FGD respondents

Variables Number (total-102)

Education of mothers Primary school and below Middle school and above

57 45

Birth place and attendants Facility delivery Home delivery with SBA Home delivery with unskilled

37 31 34

Mean age of mothers Facility delivery SBA at home Home delivery with unskilled

29 years 30 years 31 years

Table-2 Background information of maternal death cases

Description (n=10) Number Total

Magway (n=5) Ayeyar waddy (n=5)

Mean age of maternal death cases 32 years (18-46)

30 years (16-43)

31 years (16-46)

Number of children First pregnancy 2-3 4-7

2 2 1

3 2 -

5 4 1

Condition of child Alive Death

2 3

- 5

2 8

AN care utilization for last pregnancy Yes No

4 1

4 1

8 2

Description (n=10) Number Total

Magway (n=5) Ayeyarwaddy (n=5)

Causes of death PPH/APH Pre-eclampsia/eclampsia Septic induced abortion Prolong/obstructed labour Amniotic fluid embolism Uterine injury

2 1 - - 1 1

- 1 1 3 - -

2 2 1 3 1 1

Possible delay Delay 1 Delay 2 Delay 3 No delay

2 1 1 1

5 - - -

7 1 1 1

Description (n=10) Number Total

Magway (n=5)

Ayeyarwaddy (n=5)

Time of death AN Delivery PN

2 2 1

1 4 -

3 6 1

Initial place of delivery and birth attendant Health facility Home delivery with SBA Home delivery with TBA Died during AN period

1 - 2 2

- - 5 -

1 - 7 2

Place of death Health facility Home On the way to facility

3 1 1

3 2 -

6 3 1

1. Low utilization of maternal health care services

2. Lack of preparedness for emergency conditions and transportation barrier at the time of emergency referral

Key factors contributing maternal death

Low utilization of

maternal healthcare

Lack of preparedness

for emergency

Frequency

Quality

“Facilitator: Had your abdomen been checked (palpated) by midwives during your antenatal visits? Participants: No, we went there for three times. We got medicines and injections on our arms (ATT injection) but sayarma (midwife) did not check our abdomen. Every time she visited our village, she asked pregnant women to come to her to get injection (ATT). Facilitator: Have you discussed with midwife about where and with whom you would deliver when she visited your village? Participants: No. She did not tell us and we did not asked her either.” (FGD with mothers delivered with TBA, a village in Magway without health facility)

“P1,2: We deicided to deliver at home because of transport difficulties. Besides our family members were busy and could not take care of us if we would deliver at hospital. P 3: At home, we can also follow traditional practice (sitting/lying beside fire) and it is useful for our health.” (FGD with mothers delivered with TBA, Ayeyarwaddy)

• Proper antenatal care received among mothers who underwent home delivery with skilled birth attendants or facility delivery.

• They were more aware of danger signs in pregnancy than those who delivered with TBA.

• Choice in place of delivery is influenced by household elders

• Maternal deaths among TBA delivery occurred due to late or no referral of TBA in case of prolong/difficult labor or in emergency conditions.

Mothers who underwent facility delivery and skilled birth delivery at home were more likely to receive postnatal care services than those who delivered with TBA and those who lived in villages without health care providers.

• Majority of mothers in study area did not have the birth plan and plan for emergency conditions

• Encountered delay in reaching hospitals • It usually took at least an hour before the mothers could get into

the vehicle • They did not have any saving to be spent when they encountered

such obstetric emergencies

Gathering relatives and seeking decision from household head or elders

Finding money to spend for transportation and hospital charges (commonly borrow with high interest rates)

Communicating with their responsible midwife

Finding vehicle for transport to hospital

Going to hospital

Discussion and conclusion

• 2016 MDSR indicated (44%) of maternal deaths in Myanmar were related to delay, delay in decision to seek care.

• And literatures suggested delay in seeking care/ low utilization of maternal care serivces are contributed by awareness of women on pregnancy related complications & health service availability and family financial status to seek care

• This study also highlighted that choice of delivery

place and decision making during emergency

conditions is highly influenced by household

elders.

• Health education promotion interventions about

maternal health should focus not only on pregnant women but also on the household elders

• Systematic literature reviews showed demand

side financing modes had positive impact on maternal health care service utilization.

• To reduce the proportion of mothers encountering

delay due to concern on financial loss, demand

side financing approaches should be

considered as an intermediate measure

• Lack of emergency preparedness among the families was also an important factor that inhibit timely access to care

• Having a proper birth plan during antenatal period could enhance skilled and/or facility delivery

• Geographic barrier and financial loss due to transportation delay the decision making during emergnecy conditions

• Emergency referral support programs backed up with adequate supply of basic and emergency obstetric care at health centers and hospitals are highly relevant

Recommendations

1. To enhance quality of antenatal care ensuing effective health literacy promotion and birth preparedness

2. To consider demand side financing interventions to improve maternal health care utilization especially in high maternal mortality areas

3. To consider community-based emergency referral program as an effective way to enhance timely care in emergecy conditions

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Nay Pyi Taw.

Thank you