An Analysis of Policy Options for

Maternal Mortality Reduction in Myanmar

HLA MYAT TUN

Masters in Public Affairs

(Institute of Strategic Planning and Policy Studies)

MARCH 2010
 An Analysis of Policy Options for Maternal Mortality Reduction in Myanmar

HLA MYAT TUN

A Field Study Submitted to the Institute of Strategic Planning and Policy Studies
University of the Philippines Los Baños, Los Baños, Laguna,
In partial fulfillment of the requirement for the degree of
Masters in Public Affairs

MARCH 2010
 ii

This field study entitled “AN ANALYSIS OF POLICY OPTIONS FOR

MATERNAL MORTALITY REDUCTION IN MYANMAR” prepared by HLA
MYAT TUN in partial fulfillment of the requirement for graduation with the degree of
MASTERS IN PUBLIC AFFAIRS major in STRATEGIC PLANNING AND
PUBLIC POLICY is hereby accepted.

ADVISORY COMMITTEE

Dr. Merlyne M. Paunlagui Dr. Dulce D. Elazegui

Member Member
Guidance Committee Guidance Committee

______________________ __________________
Date Signed Date Signed

Dr. Rogelio N. Tagarino

Chairman
Guidance Committee
_____________________
Date Signed

Dr. Rogelio N. Tagarino

Director
Institute of Strategic Planning and Policy Studies
____________________
Date Signed
 iii

ACKNOWLEDGEMENT

The author wishes to express his sincerest gratitude to the following persons who have
helped make this field study possible:

U Nyo Tun and Daw Yi Yi Cho, his parents, for giving him a precious life, love, supports
and wisdom they provide. This study is dedicated to you May May.

Dr. Rogelio N. Tagarino, Dr. Merlyne M. Paunlagui and Dr. Dulce D. Elazegui, his
Adivser and Members of Guidance Committee, for their inspiration, patience,
encouragement, precious advices, constructive comments and recommendations;

Asia Pacific Scholarship Consortium, his scholarship organization, for the financial
support and everything he needed for his master degree;

Daw Khin May Aung, his beloved Aunty, for her strong support for his study and
assistance for important data for his field study. This study is dedicated to you also May
May Aung.

Daw Khin Ma Ma Aye, Daw Pansy Tun Thein and Dr. Ne Win, his former supervisors in
United Nations Population Fund (UNFPA) Myanmar and professional mentors, for their
supports, guidance, concepts and opportunities they provided;

His Professors in the College of Public Affairs, for giving him ideas, concepts and
knowledge;

His beloved Titas as well as his Filipino mothers especially from Institute of Strategic
Planning and Policy Studies, Graduate School and all the staff members of College of
Public Affairs, for their love, warmth, kindness and support during his stay in the
Philippines;

Hla Myat Moore and Isidra B. Bagaras, for their support, guidance and being part of his
achievement;

His PuPuChit for the caring, understanding, supporting, making his study to be more
meaningful and being part of his achievement;

His country mates in Los Baños and Manila, classmates and friends for the Myanmar
foods, and great and memorable moments they shared together.

Those people whom he failed to mention.

Hla Myat Tun

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ABBREVIATIONS AND ACRONYMS

AIDS Acquire Immune Deficiency Syndrome

CEDAW Committee on the Elimination of Discrimination against Women
FRHS Family and Reproductive Health Survey
HIV Human Immunodeficiency Virus
ICPD International Conference on Population Development
INGOs International Non-Government Organizations
IEC Information, Education and Communication
IUD Intra Uterine Device
LA Legalized Abortion
MDGs Millennium Development Goals
MMR Maternal Mortality Ratio
MOH Ministry of Health
MS Male Sterilization
NGOs Non-Government Organizations
NHC National Health Committee
PFCS Population Changes and Family Health Survey
RH Reproductive Health
RTIs Reproductive Tract Infections
STIs Sexually Transmitted Infections
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
WHO World Health Organization
WS Women Sterilization
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EXECUTIVE SUMMARY

Maternal health plays important role in health sector of every developing country

around the world. Maternal Mortality Ratio (MMR) shows the status of health of the

countries and quality of life of people in the country. In Myanmar, target MMR in 2015 is

56 per 100,000 live births but MMR in 2005 is 316 per 100,000 live births. MMR is high

especially among married population due to inadequate access to permanent

contraceptive methods. This study focuses on enhancing male participation particularly in

contraception, analysis of existing policy and programmes, and determines policy

strategies that will enhance male participation to reduce MMR. This study primarily

made of policy content analysis, descriptive analysis, trend analysis of various policies

and programmes. Valuative and normative approaches were used for the policy options.

Comparative analysis of benefits cost ranking for policy alternatives are also included.

There are several alternatives the National Health Committee (NHC), highest

policy making body for health matters in the country, could consider including existing

birth spacing policies. One option is putting the policy that allows women for abortion

with specific criteria. Another option is to allow and promote male sterilization and the

last option is to remove strict policies for women sterilization. Among these options,

male sterilizing policy comes out as the best option. It has the least cost with high

benefits for government and the community.

Based on the experiences of Asian countries, male sterilization policy can be

effectively implemented in Myanmar with the existing government system. Myanmar has
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no religious barriers for the recommended policy option. The government will not need

much public expenditure to implement the policy since it can be put into existing

programme and activities.

This study addresses to National Health Committee (NHC) to legislate and

include male sterilization in existing birth spacing policy. NHC should consider removing

barriers for male sterilization and providing supportive programmes for men

contraception. As results, pregnancy related death among married population will be

reduced and it contributes achieving targeted MMR goal by 2015.

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An Analysis of Policy Options for Maternal Mortality Reduction in Myanmar

Table of Contents

Pages

Title page ……………………………………………………………………… i

Approval Sheet ………………………………………………………………... ii
Acknowledgment ……………………………………………………………… iii
Abbreviation and Acronyms …………………………………………………... iv
Executive Summary..……………………………………………………….….. v
Table of Contents ……………………………………………………………… vii
List of Tables ……………………………………………………….................. ix
List of Figures …………………………………………………………………. x

Chapter 1. INTRODUCTION
1. 1. Rationale …………………………………………………………… 1
1. 2. Statement of Problem ……………………………………………… 4
1. 3. Objectives of the Study ……………………………………………. 5

Chapter 2. METHODOLOGY
2. 1. Conceptual Framework …………………………………………….. 6
2. 2. Data and Sources …………………………………………………… 7
2. 3. Methods of Data Analysis..…………………………………………. 7

Chapter 3. RESULTS AND DISCUSSION

3. 1. Incidence of Abortion and Maternal Mortality …………………….. 8
3. 2. Analysis of Contraceptive Use …………………………………....... 10
3. 2. 1. Methods and Extent of Contraceptives ……………………… 10
3. 2. 2. Trends in Contraceptive Use ………………………………… 12
3. 2. 3. Contraceptive use of Married Women by Age Groups
and Number of living Children ...…………………………... 14
3. 2. 4. Uses and Limitations of Condom …………………………… 16
3. 3. Existing Policies and Programmes on Birth Spacing ……………… 17
3. 4. Policy Alternatives to Reduce Maternal Mortality ……………….... 22
3. 4. 1. Advantages and Disadvantages of the Policy Alternatives....... 23
3. 4. 2. Ranking Costs and Benefits of Policy Alternatives …….…… 26
3. 4. 2. 1. Ranking Costs for the Policy Alternatives ……………. 26
3. 4. 2. 2. Ranking Benefits for Policy Alternatives ………….…. 30
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3. 5. Recommended Policy Alternative to Reduce Maternal Mortality …. 34

3. 6. Male Sterilization in the Developing World……………….………... 34
3. 6. 1. Experiences of Contraceptive Programmes and Male
Sterilization Programmes in Asian Countries..………..……… 35
3. 6. 2. Possibilities of Male Sterilization in Myanmar ……………… 38

Chapter 4. CONCLUSION AND RECOMMENDATIONS

4. 1. Conclusions ………………………………………………………… 41
4. 2. Recommendations ………………………………………………….. 42

LITERATURE CITED………………………………………..……………….. 44

ANNEX I ………………………………………………………………………... 51
ANNEX II ……………………………………………………………………..... 53
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List of Tables

1. Percent of Abortion by Age Group (2007) ……………………………… 8

2. Maternal Mortality Ratio (MMR) by Age (2004-2005) ………………… 9
3. Maternal Mortality Ratio (MMR) by Year (1988 to 2006) ……………… 10
4. Trends in Contraceptive Methods Used by Married Population in
Myanmar ………………………………………………………………… 13
5. Contraceptive use of Married Population by Specific Age Groups and
Number of living Children (%) in Myanmar, 2007 ………………....….. 15
6. Summary of Contraceptive Policies and Programmes in Myanmar ……. 18
7. Summary of Contraceptive Programmes for Married Population ……… 21
8. Advantages and Disadvantages of Policy Alternatives ………………… 25
9. Ranking Costs for the Policy Alternatives ……………………………… 29
10. Ranking Benefits of Policy Alternatives ……………………………….. 33
11. Use of Male Sterilization in Asian Developing Countries ……………… 36
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List of Figures

1. Map of Myanmar……………………………………………………….. 3
2. Conceptual Framework…………………………………………………. 6
3. Contraceptive Prevalence Rate of Married Population by Specific
Methods in Myanmar…………………………………………………… 11
4. Contraceptive Programme Covered Townships by MOH and UNFPA… 19
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CHAPTER 1

INTRODUCTION

1.1. Rationale

Maternal mortality is defined as the death of a woman while pregnant or within 42

days after termination of pregnancy from any cause related to or aggravated by the

pregnancy or its management. This includes death as a complication of abortion at any

stage of pregnancy (United Nations Population Fund (UNFPA)). Maternal health plays an

important role in health sector of every developing country. Maternal Mortality Ratio

(MMR) shows the status of health of the countries and quality of life of people in the

country. Women died due to lack of family planning, skilled birth attendance or

emergency obstetric care (UNFPA). Ms. Thoraya Ahmed Obaid, Executive Director of

UNFPA, indicated during The Partnership Launch at United Nations, New York that

“Globally, estimates show that ensuring the access of women and couples to voluntary

family planning could reduce maternal deaths by 20 to 35 per cent, and child deaths by as

much as 20 per cent” on 12 September 2005 (www.unfpa.org/safemotherhood/ , Feb 12,

2008).

The study was done in the Union of Myanmar, United Nations member country,

which is bounded by India and Bangladesh in the North-West, China in the North-East

and Laos and Thailand in the South-East (Figure 1). Myanmar’s population is estimated

at 56.515 million with annual growth rate of 2.02 percent in 2006-2007 (Myanmar

Ministry of Health & WHO, 2008). Majority of the people in Myanmar are Buddhist with

predominantly Theravada tradition, practiced by 89.20% of the country's population

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(http://asiarecipe.com/burreligion.html, Date access: July 9, 2009). The average

population density for the whole country is 77 persons per square kilometers. It ranges

from 14 persons per square kilometers in Chin State, the western part of the country to

595 person per square kilometers in Yangon Division, where the city of Yangon is

located.

In 1994, the United Nations (UN) coordinated International Conference on

Population and Development (ICPD). At the conference, they set four goals, and the

reduction of maternal mortality is one of the goals (http://www.un.org/popin/icpd2.htm,

December 15, 2009). In 2000, UN member countries set eight Millennium Development

Goals (MGDs). Among these MDGs, the fifth goal is to improve maternal health by

reducing maternal mortality to 75 per cent below 1990 levels by 2015 and providing

universal access to reproductive health which include contraceptive prevalence rate and

need for family planning (http://www.undp.org/mdg/basics.shtml, December 7, 2009). In

Myanmar target MMR is 56 per 100,000 live births in 2015 but MMR in 2005 is 361 per

100,000 live births (UNFPA).

MMR remains high because of inadequate programmes for birth spacing. In the

public health sector, birth spacing services have long been offered mostly through the

existing programmes of maternal and child health centers but these centers were only

visited by women and mothers. Target can not be achieved without the effective men’s

participation in birth spacing programme. Public policy decision makers, development,

population and health agencies have largely ignored men’s participation in birth spacing,

even if there are no significant barriers regarding culture and religion in the country.
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Figure. 1. Map of Myanmar

The government has been providing birth spacing services in health centers since

1991. However, male’s access to contraception and their participation has not been

stipulated in existing policies. The general perception and knowledge among men on the

need for reproductive health is primarily for the prevention of HIV/AIDS and Sexually

Transmitted Infections (STIs). There is a very low appreciation of the role of men and the

importance of birth spacing purpose is yet to be appreciated. Generally, men have yet to

be informed and educated on the use of contraceptive. Political commitment, supportive

policy and programmes are needed to enhance male participation in birth spacing

programmes. Supportive men’s role in reproductive health and birth spacing programmes

must be emphasized to meet the target

.
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1.2. Statement of the Problem

Maternal Mortality can be reduced if all women who want no more additional

children were able to stop child bearing (WHO, 1995). Limited access to permanent

contraceptive service is one of the factors of having unwanted pregnancies which is the

root cause of high incidence of maternal mortality among married women. The problems

which married population confront are;

1) Abortion, large part the result of unmet contraceptive need among women, is illegal

but the rate of occurrence of this practice is significant among women. At least 54 per

cent of maternal death and 20 per cent of all hospital admission have resulted from

complication of abortion (UNFPA, 2004). Thus, abortion tends to be the leading

cause of maternal mortality.

2) Fear of perceived side effects, hormonal affects, inconvenience and poverty are the

main reasons for not using contraceptives such as pills, injectables and intra uterine

devices (IUDs).

3) Female sterilization is only available after approval by a sterilization board. The use

of female sterilization is low due to a lengthy and difficult approval process.

4) Male sterilization is restricted by law to those men whose wives have been approved,

but are unable, to undergo sterilization for medical reasons. Thus, this policy

constrains men to undergo voluntary sterilization even though they recognize that

they can take the responsibility in contraception.

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Contraceptive are being available in the country but they are more of the female

responsibility. The researcher wants to study on how to enhance male participation to

reduce maternal mortality among married population.

1. 3. Objectives of the Study

The general objective of this study is to assess the birth spacing policies and

programmes and determine policy strategies that will enhance male participation in

reducing MMR in Myanmar. Specifically the study aims to carry out the following

objectives:

1. To examine the adoption rate of various contraceptive methods in Myanmar;

2. To review and analyze existing policies and programmes on contraceptive use;

3. To determine policy option that would improve male participation to reduce

maternal mortality in the country; and

4. To identify strategies that would support the chosen policy option that will

enhance men’s effective participation in reproductive health in the country.

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CHAPTER 2

METHODOLOGY

2.1. Conceptual Framework

National policies provide the broader legal framework to improve men’

participation to reduce maternal mortality as such, awareness raising, peer education,

community health talks, dissemination of information, education, communication (IEC)

materials can be done using various channels. At the same time, promoting and providing

of quality and affordable male contraception services ensuring accessibility in the

communities can also be done. Specific activities include campaign, mobile clinics, and

male friendly centers to ensure effective men’s participation throughout the country.

There are all seen to contribute to reduction of maternal mortality ratio.

National Policies
and Programmes
on male Specific Activities
participation
Awareness of Promotion and
- policies and providing
programmes - male friendly
Community - importance of centers Maternal
policy and men’s role in - quality and Mortality
programmes women’s health affordable Ratio
on male - the needs to contraceptive
participation promote men’s services
role - ensure
accessibility

Figure 2. Conceptual Framework of Reducing Maternal Mortality by enhancing men’s

participation
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2.2. Data and Sources

This study mainly used secondary data. These secondary data were collected from

publications, unpublished documents, reports, surveys of Ministry of Health in Myanmar

(MOH), United Nations Population Fund (UNFPA), World Health Organization (WHO),

United Nations Children Fund (UNICEF), International NGOs, Local NGOs in

Myanmar, thesis and studies, as well as from internet sources.

Data includes policy and programmes on contraceptives, use of contraceptive

among Myanmar married population and incidence of maternal mortality in the country.

Data and information generated through internet such as those from United Nations

Population Bureau, United Nations Population Fund, Ministry of health (Myanmar), and

some other websites were also used in this study.

2.3. Methods of Data Analysis

This study primarily made of policy content analysis, descriptive analysis and

trend analysis. These were used in the review and analysis of existing policies and

programmes on birth spacing for married population and analysis of contraceptives use.

Valuative and normative approaches were used for the policy options as well. Analysis

involved detailed scrutiny of these specific provisions or stipulations of the various

policies and programmes. Advantages and disadvantages of policy options, ranking for

the alternatives in terms of cost and benefits of the policy options were adapted from UN

publications. Ranking were ranked by the researcher according to the studies of

literatures. Finding and results were presented and summarized in tabular form and

graphic where applicable.

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CHAPTER 3

RESULTS AND DISCUSSIONS

In this chapter, analysis of contraceptive use, existing policies and programmes on

contraceptives, policy alternatives to reduce unsafe abortion and maternal mortality ratio,

ranking on cost and benefits of policy alternatives, policy recommendation, and male

contraception in the developing world were discusses and data were discussed and results

were presented in tables and figures.

3.1. Incidence of Abortion and Maternal Mortality

The incidence of abortion by age groups in Myanmar is presented in Table 1.

Abortion within the age group (40-49) who may have attained desired number of children

is about 9 percent. The incidence of abortion among teenage group (15-19) is

comparatively high (11 percent) as compared with the other age groups. This is an

indication of high unwanted pregnancy among the teenage group. This might be due to

pre-marital sex.

Table 1. Percent of Abortion by Age Group (2007)

% of total
Age Group
abortion cases
15-19 11.39
20-24 7.27
25-29 5.63
30-34 5.12
35-39 4.28
40-44 4.04
45-49 4.69
Source: Family and Reproductive Health Survey (FRHS), 2007
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As mentioned above, the incidence of maternal mortality of year 2004-2005 is

estimated at 316 per 100,000 live births for the entire country. Majority of the maternal

death (89 per cent) were reported in the rural areas. The maternal mortality ratio (MMR)

by age is presented in Table 2. MMR is the highest (921.66) at the age group of 45-49

who may have attained desired number of children. Data for the age group 35-44 is not

available from the source.

Table 2. Maternal Mortality Ratio (MMR) by Age (2004-2005)

MMR per 100,000
Age Group Live Births
Live Births
15-19 1007 297.91
20-24 5091 196.43
25-29 6414 202.68
30-34 5267 265.81
35-44 - -
45-49 217 921.66
Total 22478 315.86
Source: Committee on the Elimination of Discrimination against Women (CEDAW),
2008

The trend of MMR is slightly decreasing within the period 1988-2006 (Table 3).

The rate of MMR in rural areas is comparatively higher than urban areas. This distinct

difference may be attributed to weaknesses in the areas of distributing contraceptives,

quality care services, accessibility of services and insufficient skilled health personnel in

public health sector. For the union, MMR is increasing (2.5 to 3.16) during the period

(1999-2005). This might be due to high MMR among older age groups.
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Table 3. Maternal Mortality Ratio (MMR) by year (1988 to 2006)

Health Index 1988 1999 2001 2002 2003 2004 2005 2006
Maternal Mortality Ratio (per 1,000 live births)
Urban 1 1.8 1 1.1 0.98 0.98 0.96 0.96
Rural 1.9 2.8 1.8 1.9 1.52 1.45 1.43 1.41
Total* - 2.5 - - - - 3.16 -
Source: MOH, 2009 *Estimates for total not available the other years

3.2. Analysis of Contraceptive use

Analysis of contraceptive use in Myanmar was undertaken with the used of data

on methods and extent of contraceptives, trends in contraceptive use, and contraceptive

use of married women by age specific groups and number of living children.

3.2.1. Methods and Extent of Contraceptives

The different methods and prevalence of use of contraceptive among married

women age between 15 to 49 years old is presented (Figure.3). The use of contraceptive

is mostly by female. Only 41 per cent of women within this age group using

contraceptives, modern (e.g. pills, IUD, sterilization etc) and traditional methods.

Majority of the women do not practice contraceptive methods because of hormonal

changes of these methods. The use of all traditional methods (safe period, withdrawal and

massage) is only about 2 per cent. These are not being accepted as safe methods and also

not being promoted in the country.

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Figure. 3. Methods and Extent of Contraceptives, 2007

Pill (daily)

59.1 Pill (monthly)

0.4 IUD

Not using any

method
Injection (monthly)

Injection (3 month)

Condom

Female Sterilization
1.8
0.7 19.3
0.7 M ale Sterilization
0.4
Safe Period
10.1 0.2 1.0 4.4
Withdrawal
0.7 1.2
M assage

Others

Source: FRHS 2007

Male participation in birth control is very minimal (3.8%). Male participation

methods include sterilization, safe period and condom methods. For these methods, only

the use of condom is being promoted by the government but its usage is generally low

(0.7 per cent) among married population. The use of the condom is not only for

contraception but also for prevention of HIV and sexually transmitted infections (STIs).

However, the acceptance of condoms in country is not prevalent among married

population because of strong traditional norms that they see condoms for sex trades. The

data on HIV/AIDS programmes show the use of condom is high among men but not in

contraception among married couples. Male sterilization is not yet legalized and

restricted by laws. However, the extent of male sterilization (1%) is slightly higher than
 12

condom among married couple. It might be assumed as married men prefer male

sterilization than condom.

3.2.2. Trends in Contraceptive Use

The trend in the use of specific contraceptive methods among currently married

population over a decade (1991 PCFS and 2007 FRHS) is presented in Table 4. Within

the ten year period, the contraceptive prevalence rate has increased from 13.6 per cent in

1991 to 38.4 per cent in 2007. The increase of about 14.8 per cent may be attributed to

the high rate adoption of injection method (1 month and 3 months). Except for the use of

pills (daily) and injection (1 month and 3 month), there was no distinct pattern in the

usage of specific contraceptives. The use of monthly injection declined (0.4%) in 2007

but 3 month injection recorded 19% rate. This could be due to a number of reasons such

as: (a) injectables are more easily available and work for a relatively longer duration; (b)

convenient to use; and (c) less complicated to adopt. The use of pills and injectables (3

months) appear to gain popularity. On the other hand, female and male sterilization,

which are permanent methods of contraceptive, tend to decrease. This may be due to the

incidence of poverty since these methods are relatively costly and also are not being

promoted as widely as the temporary methods, such as pills and injections.

Sterilization remains limited to those who have achieved a certain age and family

size, and also is dependent upon the approval of government medical board. Due to

increase in publicity and promotional efforts, there was a slight increase in the use of IUD
 13

and condom. However, demand for male sterilization was always higher compared to

condom in every survey.

The pattern of the traditional contraception that includes safe period, withdrawal,

massage and other are decreased (3.3 per cent to 2.5 per cent) during the period 1991-

2007.

Table 4. Trends in Contraceptive Methods Used by Married Population in

Myanmar

Current Use of Methods (in %)

Methods 1991 1997 2001 2007
PCFS FRHS FRHS FRHS
Modern Method: 13.6 28.4 32.8 38.4
Pill (daily) 4 7.4 8.6 10.1
Pill (monthly) - - 1.2 0.7
IUD 0.9 1.3 1.8 1.8
Injection (monthly) 3.1 11.7 14.8 0.4
Injection (3 month) - - - 19.3
Condom 0.1 0.1 0.3 0.7
Female Sterilization 3.7 5.5 4.6 4.4
Male Sterilization 1.8 2.2 1.5 1
Traditional Method: 3.3 4.3 4.2 2.5
Safe Period 2.4 2.4 1.8 1.2
Withdrawal 0.4 0.8 1 0.7
Massage 0.3 0.6 0.5 0.2
Others 0.2 0.6 0.8 0.4
Source: FRHS, 2007
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3.2.3. Contraceptive use of Married Population by Age Groups and Number of

living Children

The pattern of contraceptive use of married women by specific age group and

number of children is presented in Table 5. Women in all age groups, except 45-49,

prefer 3 month injection. Sterilization is more common among older women (35-49) who

have achieved their desired family size and are more likely to stop child bearing. In

contrast, the use of pill (daily) and injection (three months) is popular among younger

women who are still in their early stages of family building. For male methods, condom

usage is higher than male sterilization in younger age groups of 15-39. There is a

preference of sterilization among married couple (specifically those who already attained

their desired number of children) compare to condom.

The general pattern observed is that women in younger age tend to use more

contraceptives. Similarly, those with less number of children, tend to practice use of

contraceptives. This may be because the younger women are more aware of the

contraceptives and access to services than older women. The more children they have, the

higher use of sterilization methods.

For the participation of male in traditional contraception methods, there are no

distinct changes in the pattern. For the modern methods, condom use is higher in couples

with 1 or two children than male sterilization. The use of male sterilization is higher than

condom among couple who have 3 and more children.

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Table 5. Contraceptive use of Married Population by Specific Age Groups and Number of living Children (%) in Myanmar, 2007
Modern Methods Traditional Methods

Age Group Pill Pill Injection Injection Female Male Safe

IUD Condom Withdrawal Massage
(daily) (monthly) (monthly) (3 month) Sterilization Sterilization period

15-19 23.3 0.7 0 0.7 17.8 0 1.4 0 0 0 0

20-24 13.9 0.6 0.8 0.6 25.2 0.3 0.3 0.1 1.1 0.8 0.1
25-29 13.3 0.7 1.8 0.2 26.1 0.7 1.2 0.4 1.3 0.3 0
30-34 11 0.8 2.1 0.4 25.4 1.1 3.4 0.6 1 0.7 0.1
35-39 11.1 0.7 2.4 0.7 22.8 1 6.5 1 1.2 1.2 0.1
40-44 7.9 0.8 2.2 0.3 13 0.6 6.6 1.7 1.5 1 0.5
45-49 2.8 0.4 0.8 0.3 4.6 0.2 6.6 1.7 1.2 0.3 0.3
Number of living children
1 12.1 0.2 1.8 0.3 25.3 0.6 1.1 0.2 1.2 1.2 0.2
2 11.2 1.1 2.7 0.6 24.7 1.3 5 0.9 1.3 0.6 0.2
3 9.4 0.5 1.8 0.5 17.3 0.8 9 1.9 1.2 0.6 0.3
4+ 6.3 0.8 1.5 0.3 14.6 0.4 5 1.2 1.2 0.9 0.2
Source: FRHS, 2007
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3.2.4. Uses and Limitations of Condom

Condom is the only available contraceptive method for men in Myanmar.

Information, education and communication (IEC) on condoms has been initiated in the

country for the prevention of HIV/AIDS and Sexually Transmitted Infections (STIs).

Thus, condoms have been perceived only for prevention of HIV/AIDS and STIs and such

perception becomes barriers for the use of condom as contraceptive. The accessibility and

acceptance of condoms in rural areas is influenced by several factors such as: (a) strong

traditional norms; (b) lack of knowledge; (c) transportation and distribution of supply of

INGOs; and (d) unaffordable price for population in the areas. Condoms seem a logical

choice as a low-cost contraceptive that the governments should provide even though they

are not popular among married population. Condoms can be 98% effective against

pregnancy, if used properly and consistently. However, they have six main drawbacks:

(www.newmalecontraception.org; July 23, 2009)

1. Many men dislike them because they reduce sensation;

2. Many women are uncomfortable of insisting condoms, if their partners are

reluctant to use them;

3. Condoms are vulnerable to heat damage during transport and storage;

4. Condoms must be used every time a couple has intercourse, but it is difficult for

poor governments to provide an ample and consistent supply to their people

(United Nations Population Fund, 2005). Aid does not fill the gap; in 2003, donor

support paid for the equivalent of one condom per year for each man of

reproductive age in the developing world;

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5. Condoms are a crucial part of the "contraceptive supermarket" and of disease

prevention, but they alone cannot meet everybody's needs; and

6. Condoms were seen for sex trade.

3.3. Existing Policies and Programmes on Birth Spacing

The International Conference on Population Development (ICPD) Program of

Action and comments from leaders emphasize the need to make men more aware of their

responsibilities to the family and the wider community in the matter of family planning

and reproductive health (United Nations 1995). Paragraph 4.27 of the Program of Action

specifically states as: “Special efforts should be made to emphasize men’s shared

responsibility and promote their active involvement in responsible parenthood, sexual

and reproductive behavior, including family planning; prenatal, maternal and child

health; prevention of sexually transmitted diseases, including HIV; prevention of

unwanted and high-risk pregnancies” (1995:197).

Table 6 presents the summary of birth spacing policies and programmes in

Myanmar. United Nations Population Fund (UNFPA) is the major benefactor in

Myanmar population and birth spacing programme since 1973. The National Health

Policy was developed in 1993 with the initiation and guidance of the National Health

Committee (NHC) (Annex I). The government aims to achieve a better quality of life for

all, by giving attention on the improvement of reproductive health status. Birth Spacing

services are provided by the public sector, private sector and also by international

organizations. Although birth spacing methods have been available in Myanmar since

1991, the government’s programmes on contraception was only initiated with a strategic
 18

approach by World Health Organization (WHO) in mid-1995. Myanmar’s Reproductive

Health (RH) Policy was formulated in 2002 and approved by the Ministry of Health in

2003 (Annex II).

Table 6. Summary of Contraceptive Policies and Programmes in Myanmar

Policy Salient Provision

National Health Policy - Change from pro-nationalist policy to health-oriented

(1993) policy to integrate birth spacing

Reproductive Health Policy - Improve access to birth spacing methods, e.g., pills,

(2003) injectables, Intra-uterine devices (IUDs), condoms,

sterilization for women and emergency contraceptives

- Strengthen men’s role in the promotion of birth

spacing services, prevention of transmissions of

RTIs/STIs and in supporting reproductive health service

Source: MOH, 1993 & MOH, 2003

Ministry of Health (MOH) and UNFPA covered 93 of the country’s 324

townships in 2004. They plan to expand to 137 townships in the period 2007-2010, with

the collaboration of the Ministry of Population and Immigration, other government

ministries, selected United Nations agencies, and selected local and international non-

governmental organizations. Townships covered by UNFPA assisted Reproductive

Health (RH) programme is presented in Figure 4.

 19

Source: UNFPA Myanmar

Figure 4. Contraceptive Programme Townships covered by MOH and UNFPA

On 18 November, the largest conference on family planning in fifteen years with

nearly 1,300 international experts, policy makers and representatives of civil society

concluded by reaffirming their commitment to family planning and revitalizing it by

sharing research findings and best practices (http://www.unfpa.org/public/neFS/pid/4376,

November 23, 2009). Efforts to prevent maternal deaths and ensure access to voluntary
 20

family planning require political and financial commitment from a broad range of

partners; namely: men as well as women, international organizations, governments, civil

society and the media. Also, information and access to contraception on reproductive

health and rights for both men and women have to be included (UNFPA & Path, 2007).

On World Population Day 2008, the Minister of Immigration and Population said

that Myanmar is fully committed to the MDGs and is guided by the principles adopted by

the ICPD and also stated that “Our country, each and every family has the right to decide

their family size based on the choices of each individual and couple.” However, in the

RH policy, men were considered as effective channel to promote existing women

contraceptive methods. However, the participation and access of men in contraception

were not mentioned in existing policies. The government has yet to address and provide

the specific needs for men. The high-level decision makers have not considered yet

providing the need for male contraception in existing policies. Summary of contraceptive

programmes and participation of male and female in Myanmar is shown in Table 7.

 21

Table 7. Summary of Contraceptive Programme for Married Population

Extant Involvement and
Policy/Programme
Participation
on Contraception
Female Male
Birth Spacing
1. Education High Low
2. Techniques
- Pills High None
- Injections High None
- IUD High None
- Emergency pills High None
- Norplant High None
- Condoms Low Low
- Sterilization Low Low
3. Promoting of
program and
activities (e.g, IEC High Low
materials, mass
media, campaign)
4. Supportive
specific policy High None
Source: MOH, 2009, MOH & UNFPA 2002

Both men and women have important contributions and co-equal responsibility in

reproductive health especially in marriage. According to many studies, responsibilities of

men include leading family and supporting family including protecting its health. Many

men are willing to take responsibility in contraception in order to lessen burden on

women which leads improving women’s health. Since 1991, the birth spacing

programmes have tended to focus on women in the country. Men’s role in birth spacing

has been neglected and their involvement in reproductive health programmes has been

only initiated in 2004. However, social integration programmes have unconsciously

ignored the needs of shared responsibility of men for contraception among married

population. Nevertheless, there is high demand on long term contraceptive services for
 22

married men. Limited access to birth spacing services by men leads to increase maternal

death.

As mentioned above, even though male sterilization is illegal and not highly

promoted in the country, the use of male sterilization methods is higher than the use of

condom among married population. However, men has the barriers to undergo voluntary

sterilization even though they realize that they have a significant role in saving women’s

life by taking responsibility in contraception among married population and to improve

the status of women health.

3.4. Policy Alternatives to Reduce Maternal Mortality

There are three policy alternatives to reduce maternal deaths due to unwanted

pregnancies/births among married population particularly those who already have desired

number of children. These are;

Policy Alternative (1): Legalized Abortion (LA) to married women by providing

legalized services to avoid unsafe abortion based on specific criteria which are relevant

with cultural and social values. Although it seems difficult to take place in Buddhist

country and culture, it can contribute to reduce unsafe abortion in the community.

Specific criteria will be needed to have access to abortion such as to physical and mental

health of women.

Policy Alternative (2): Voluntary Male Sterilization (MS) or Vasectomy, of married

men who already have desired number of children by providing access to services and

reduce strict criteria. It can effectively address current issues regarding unwanted
 23

pregnancies in the community especially among married couples living in rural and

remote areas. It can assure effective participation of men in contraception and

reproductive heath programmes across the country.

Policy Alternative (3): Female Sterilization (FS) with the least criteria to mothers who

already have their desired number of children by removing strict policies, decentralizing

of authority for sterilization approval, and rules and regulations. It can provide the needs

of the women in an effective way and can encourage and assure women of their rights to

decide their desired family size.

3.4.1. Advantages and Disadvantages of the Policy Alternatives

The three policy alternatives can solve the problem of high incidence of maternal

mortality. The advantages and disadvantages are presented in Table.8.

LA can reduce unwanted birth among married women because of contraceptive

failure, being raped, and economic and social reasons. It can save women’s lives,

however, it is culturally sensitive. It may have conflict with Myanmar Buddhism.

Abortion can cause heavy bleeding. Some abortion drugs can cause negative side effects

such as nausea, headache, fatigue, fever, diarrhea, vomiting and pain. In United States

deaths from abortion declined dramatically since abortion was legalize. Many

demonstrable health benefits such as physical, emotional and social health have accrued.

For more information, please refer to www.abortionsweb.com and

www.plannedparenthood.org.
 24

Male Sterilization has the most advantages among the alternatives. It is

easy to use and effective. The use of method is less expensive because it can be

performed with minimal facilities. The services can suit almost every setting (i.e.,

doctor’s office, a hospital) and has low rate of complications. Male sterilization or

Vasectomy has been proven to have significantly fewer side effects such as bleeding,

pain, and infection. Vasectomy has no long-term adverse health affects. It does not affect

men’s ability to have sex or their general health. Contrary to common rumors, vasectomy

does not cause weakness, general aches and pains, poor vision, weight gain, or mental

impairments (John Hopkings, 2008). For further information and technological

procedures, please refer to Johns Hopkins, 2008 and Lissner, A. Elaine, 2006.

Female sterilization is a permanent method. There is a single procedure for

lifelong. It is safe and very effective (99%) family planning. Regular supply and repeated

clinic visits are not required after the surgery. It does not affect a woman’s ability to have

sex. It does not have long-term side effects or health risks. However, it has risk of major

surgery and costly. For more information, please refer to WHO & John Hopkins, 2007.
 25

Table 8. Advantages and Disadvantages of Policy Alternatives

Policy Alternatives Advantages Disadvantages/Needs

Legalized Abortion o Reduce unsafe abortion rate o need to be legislated

(LA) o reduce unwanted pregnancies o culturally sensitive
o women’s lives can be saved o against with Buddhism
community
o potential of misunderstanding
between couples
o much health risk

Male Sterilization o reduce pregnancy rate o need to be legislated

(MS) o reduce unsafe abortion rate o risk of minor surgery
o less religious and cultural o seems to increase unfaithfulness
barriers among couples
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
Female Sterilization o reduce unintended pregnancies o risk of major surgery
(FS) o reduce unsafe abortion rate o costly
o reduce MMR o need more equipment and
o highly effective infrastructure
o takes time for hospitalization

Sources- Contraceptive Sterilization: Global Issues and Trends; Roy Jacobstein and John
M. Pile, 2007; John Hopkins, 2008
 26

3.4.2. Ranking Costs and Benefits of Policy Alternatives

3.4.2.1. Ranking Costs for the Policy Alternatives

Input costs can be classified in terms of: direct and indirect costs, joint and non-

joint costs, average and marginal costs and capital and recurrent costs. The general

classified costs and their ranking of the alternatives are shown in Table 9, with the range

of 3-high, 2-medium and 1-low.

Direct and indirect costs: Direct costs correspond to resources that can be explicitly

identified with a service or product. Indirect costs cannot be directly identified with a

service or product, but are related to the costs of supporting the direct activities. These

costs typically are incurred to administer or evaluate programs.

Joint and Non-joint costs: Non-joint costs are cost of resources that are used only for

one client, and are either fully consumed or thrown away at the end of the visit. Joint

costs can be defined as the costs of clinic resources used by more than one client.

Average and marginal costs: Average cost is defined as the total cost divided by the

number of units of output, whereas Marginal cost is the additional cost required in

producing one more unit of output.

Recurrent and capital costs: “Recurrent costs” usually are defined as the costs

associated with inputs that will be consumed or replaced in one year or less. “Capital

costs” are defined as the annual costs of resources that have a life expectancy of more

than one year, such as equipment or buildings.

 27

MS can be performed by a single doctor (John Hopkins, 2008). Thus, staff

salaries (direct and indirect cost, joint and non-joint cost) for MS are ranked as low. More

people involve in LA and FS since they are major operations. Thus, the cost will

definitely be higher which include costs such as operation room fees, physician’s fee,

assistant doctors’ fees, nurses’ fees, and medical check-up fees before operation as these

are supposed to have major surgery. A physician may not be needed to perform

vasectomy. Some countries in Africa and Asia have trained other types of health

personnel to perform vasectomies. These include clinical officers, medical assistance,

medical students, nurses, midwives, and community health workers. Studies have found

that these service providers were as good as physicians at identifying and blocking the

vas (Johns Hopkins, 2008). The cost of procedure (direct and indirect cost) and required

medical supplies (joint and non-joint cost) for MS are also ranked as low compared to

other two alternatives (Lissner, A. Elaine, 2006). For the cost for infrastructure, MS can

be performed at a doctor’s clinic or hospital (John Hopkins, 2008). Thus, MS is ranked as

low. The other two require specific places such as hospitals, health centers and well-

equipped clinics based on the universal requirements for such operations. For these

reasons, the costs of infrastructure will be high for LA and FS.

For average and marginal cost, LA and FS are supposed to be major surgeries

which need well-equipped operating rooms, hospitalization, medical check-up, pre-

counseling visits, post-counseling visits and follow-up for surgery. Thus, from the

program side, relatively substantial fund will be needed to provide the requirements for

LA and FS. On the clients’ side, they will have to bear the cost of the services. For MS
 28

programme, operating rooms are not necessary to perform vasectomy, pre and post-

counseling visits are probably the same but fewer post-operation visits. There are no costs

for client’s hospitalization; thus, the reduce cost on both the programme and the clients.

For these reasons, MS was ranked as low for those costs. All the costs for average and

marginal cost LA and FS are ranked as high since they are major surgeries.

Miscellaneous costs of medical materials and supplies will be low for MS as it

needs fewer materials and supplies compared to other two alternatives (John Hopkins,

2008). Thus, MS programme cost was ranked as low and high for the other alternatives.

Operation and maintenance cost may be needed for all of the three alternatives but lower

for MS. The training cost at the beginning of the programme and during the

implementation period for the staff and new staff will be probably the average for the

three alternatives. Thus, the three alternatives were ranked as 2-Medium.

 29

Table 9. Ranking Cost for the Policy Alternatives

Legalized Male Female
Classification of Costs* Abortion Sterilization Sterilization
(LA) (MS) (FS)
Direct and Indirect costs
Staff salaries (surgeons, assistant doctor to
3 1 3
surgeons, nurses, programme administrators, etc.,)
Cost of method 3 1 3
Infrastructure 3 1 3
Joint and Non-joint costs
Staff salaries (surgeons, assitant doctor to
3 1 3
surgeons, nurses, programme administrators, etc.,)
Medical supplies (e.g. cotton balls, antiseptic
3 1 3
solutions, and utensils used for operation)
Average and Marginal costs
Operating rooms equipped to provide operation 3 1 3
Counseling visits pre-operative visits, follow up
3 1 2
visits and post-operative visits
Hospitalization days after operation 3 1 3
Follow up after operation 3 1 3
Recurrent and Capital cost
Miscellaneous medical materials and supplies 3 1 3
Operation and maintenance (Building, equipment,
3 2 3
furniture & vehicle)
Training and refresher training for staffs 2 2 2
Total 35 14 34
*Based on Janowitz & Bratt (UNFPA, 1994)

Ranking Scale: 3 – High; 2 – Medium; 1 – Low

According to the results of ranking of cost for the three policy alternatives, MS

has the least cost ranking (14) comparing to the other two options (35 and 34). Thus,
 30

allowing male sterilization is the favorable policy option based on cost to both

programme (government) and client (individual). The MS policy option does not require

the government for new infrastructure and setting in health sector, since vasectomy can

be performed with minimal facilities and the recruitment new staff may not be necessary.

However, it would need a specific space for counseling and surgical procedure, utilities,

and adequate and well-maintained equipment which can be done and provided by sharing

existing settings and facilities. Male sterilization services can suit almost any setting,

from a doctor’s office to a hospital or mobile teams can visit towns and villages.

Therefore, it can be assumed that the cost is practically low for the government and the

individuals.

3.4.2.2. Ranking Benefits of the Policy Alternatives

Ranking on benefits of the policy alternatives is presented below (Table 10). The

alternatives have wide-ranging benefits beyond what is included in this study. Based on

Guttmacher Institute, the benefits of the policy alternatives were ranked in the range of

0 – No and 1 – Yes.

All of the policy options can reduce maternal death, newborn death, number of

children who lose their mothers among married populations and improve well-being of

families because of mother’s survival. Globally, it has been estimated that expanding

contraceptive services could prevent 850,000 deaths per year among children under age

five (World Bank, 1993). All of the options can reduce unmet need for contraceptive.

They do not have hormonal side affects. However, LA and FS may have risky surgery,
 31

thus, they are ranked as 0. MS do not have hormonal effects, side effects and risky

operation procedure (Lissner, A. Elaine, 2006). Thus, MS is ranked 1.

Since MS and FS are long-term methods, these can effectively prevent high-risk

pregnancies. LA is not a long-term method, however, it can reduce high-risk pregnancies.

Thus, they are ranked 1. Families with fewer and healthier children can devote more

resources to their children e.g., adequate food, clothing, housing, and educational

opportunities (WHO, 1995). Thus, the parents can have more time and allocate income

for each child. They are ranked 1.

Contraceptives can prevent long term consequences of mothers’ and newborns’

health (UNFPA, 2006). All the policies can reduce public sector spending on health

services for long term consequences of mothers’ and newborns’ health. Moreover, they

have potential to improve productivity and higher income because the families may have

savings and investments which are the benefits of the policies. Thus, all options are

ranked 1 for the categories.

Even though abortion was legalized in neighboring Buddhist country, Thailand,

the abortion policy will definitely have conflicts with religion, culture and society as in

Myanmar, also a Buddhist country with strong social norms and values. Thus, it was

ranked as 0-no benefits. Majority of Myanmar women are Buddhist and believe in the

karma of previous lives and its effects on the present life. They believe that nobody

should hinder the formation of a human being and as such do not have a positive attitude

towards the use of contraception by young people (Aung Khin, 2008). They realize that
 32

contraception is important for reproductive health, acceptable in Buddhism and more

appropriate for the older women. Thus, MS and FS are ranked as 1.

MS encourages effective men’s participation by taking responsibility for

contraception thus, promoting of equality between men and women in terms of

contraception, thus, rank of 0. For FS and LA, men may be involved in decision making

on female sterilization, accessing services and logistic arrangement for the women. It

encourages male participation in the contraceptive programme. However, this may not be

seen by all the stakeholders as effective participation, thus, the rank of 0 for FS and LA.

For the benefits of encouraging gender equality, LA and FS will remain

responsibilities only on women. They will not have men’s participation in any role and

not bring single gender equality. It does not enhance men’s responsibility in

contraceptive. Thus, they are ranked 0.

 33

Table.10. Ranking Benefits of Policy Alternatives

Legalized Male Female

Benefits* Abortion Sterilization Sterilization
(LA) (MS) (FS)
Reduce maternal death 1 1 1
Reduce newborn death 1 1 1
Reduce number of children who lose their mothers 1 1 1
Reduce unmet need for contraceptive regarding to
avoid hormonal effects, side affects and risky 0 1 0
operation procedure
Improve well-being of families because of
1 1 1
mother’s survival
Prevention of high-risk pregnancies (i.e., those
among women older than 35 and women with 1 1 1
many children)
More of parents’ time and income allocate to each
1 1 1
child
Reduced public sector spending on health services
for long-term consequences of mothers’ and 1 1 1
newborns’ health
Improve productivity and higher income: greater
1 1 1
savings and investments
Less conflict with religion, cultural and social 0 1 1
norms
Encourage men's participation 0 1 0
Promote Gender Equality 0 1 0
Total 8 12 9
*Based on Guttmacher Institute, 2009

Ranking Scale: 0 – No, 1 – Yes

Based on the results of the ranking for the policy benefits, male sterilization (MS)

policy has the highest score (12) compared to the other two alternatives (9 for women

sterilization and 7 for abortion). In all of the areas, MS has favorable facts and benefits
 34

for both individuals and the government. Besides, it can contribute further health

improvement of the country.

3. 5. Recommended Policy Alternative to Reduce Maternal Mortality

Comparative analysis of these policy alternatives of contraceptive revealed that

male sterilization policy has more advantages with less disadvantages than the other two

alternatives. Hence, male sterilization has the least cost among the alternatives. It has the

least cost to both the government and individual users. In addition to contraception, male

sterilization policy has some other benefits such as reducing the burden for women in

shouldering the responsibility of contraception after marriage.

3.6. Male Sterilization in the Developing World

In the developing world, men are aware of “taking responsibility” and men also

want to take control of their own fertility (http://www.newmalecontraception.org). Men

realize that contraception is important for family building as one of the responsibilities

for being responsible partner for women’s health and reproductive rights. Many studies

proved that men are interested in contraception and willing to take responsibility.

Male sterilization has been accepted for family planning by approximately 42

million couples worldwide, the majority of who live in developing countries. Almost

three-fourth of the 37 million couples who use vasectomy live in Asia (USAID, 2007). In

Asia there are several countries adopt vasectomy as one of the contraceptive options.

Most of these countries have legalized male sterilization policy and programmes. In all
 35

countries, vasectomy was supported by national reproductive health programs and

participation of male is rarely observed due to various factors such as ignorance, fear,

misconceptions and lack of information at the beginning of the programme interventions.

But, once the community realized that is effective for them, it became popular and

promoted by the community itself.

3.6.1. Experiences and practice of Contraceptive Programmes and Male

Sterilization Programmes in Asian countries

The usage of male sterilization in Asian countries is presented in Table. 11. Even

though Myanmar has restrictions on male sterilization, its rate of adoption is the same

with the countries which are implementing such programme at national level (i.e.,.

Thailand and India). In Vietnam, Indonesia, Cambodia and Bangladesh, male sterilization

is allowed but the prevalence of that practices were lower than Myanmar. Myanmar men

are adopting male sterilization as an option for contraception even though they have

limited services.
 36

Table.11 Use of Male Sterilization in Asian Developing Countries

Country & Year Vasectomy (%)

Bangladesh 2007 0.7

Bhutan 2000 13.6
Cambodia 2005 0.1
China 2004 6.7
Democratic People's
Republic of Korea (North 0.8
Korea) 2002
India 2005-06 1
Indonesia 2002-03 0.4
Iran 2000 2.8
Myanmar 2007 1
Nepal 2006 6.3
Pakistan 2006-07 0.1
Philippines 2006 0.1
Republic of Korea (South
12.7
Korea) 1997
Sri Lanka 2001 2.1
Thailand 2005-06 1
Vietnam 2006 0.5
Source: John Hopkins (2008), FRHS Myanmar (2007)

In India, one of the main purposes of the vasectomy programmes is to control

population. Thus the Indian government provides cash incentive to men as one of the

programme promotion strategies. According to PathFinder.com, every Indian male who

undergoes male sterilization were provided with post-operative counseling and

medicines, and given the 1100 rupee incentive. Times online reported on March 21, 2008

that Indian Government offers firearms permits for vasectomy. In India, Shivpuri district
 37

in the state of Madhya Pradesh, an overpopulated area renowned for its machismo

culture, has started to offer fast-tracked gun licenses for those who agree to be sterilized.

Manish Shrivastav, the administrative chief of Shivpuri district and originator of the

lateral thinking behind the plan, indicated that “This is a state with a high number of

crimes, where people like to keep rifles. It also has a low level of vasectomies because of

a perceived notion of manliness. I decided to match that with a bigger symbol of

manliness - a gun license. It has been a success.”

In Thailand, physicians performed vasectomies monthly in rural areas via a

mobile vasectomy campaign under the government administration and programmes. The

campaign consisted of motivation and service teams. Private sector groups also involved

with mobile vasectomy included the Population and Community Development

Association and the Thai Association of Voluntary Sterilization. The Population and

Community Development Association (PDA) of Thailand used a modified commercial

marketing technique to inform people about its free vasectomy program. It has modified

the 4 Ps marketing technique (product, promotion, program, and pricing) of the business

sector to carry on promotion activities such as promoting specialists design and distribute

posters, leaflets, and advertising spots on radio and TV. Other promotion activities

include the PDA vasectomy festivals on Australian and Chinese national holidays, May

Day, Mothers' day, and King's birthday. This PDA program also operates out of clinics

and mobile vans so the clients can seek vasectomy services when and where they wish.

Its marketing technique has allowed it to surmount earlier obstacles and misconceptions

about vasectomy in Thailand.

 38

In the Philippines, Reproductive Health and Population Development Act 2008,

Section 4 (i) states “Male involvement and participation – refers to the involvement,

participation, commitment and joint responsibility of men with women in all areas of

sexual and reproductive health, as well as reproductive health concerns specific to men.”

Joint responsibilities of men were considered in national policy. However, being a

democratic country, Reproductive Health Bill of the Philippines Congress has been

pending over a decade because religious leaders. Religious concern is the most difficult

barrier to handle for every government. As a republican country, agreement from the

many political leaders is necessary for approving bill. As a result, the progress of decision

making on the bill has been delayed.

3.6.2. Possibilities of Male Sterilization in Myanmar

In Myanmar, population growth is not a priority problem, thus Myanmar

government will not need to provide cash incentives (i.e., India’s male sterilization

programme) to pursue men to undergo male sterilization. Providing cash incentive may

not exist in Myanmar male sterilization programme.

Disseminating information on male sterilization can be provided through existing

health education and promotion programme supported by National Health Programme.

Several nationwide campaigns had been initiated and have significant successes, in all

campaigns such as mass measles campaign, polio campaign and vitamin ‘A’ campaign.

Medical missions, medical tours, etc., have been organized across the country under
 39

MOH. Mobile clinics are put up in rural and remote areas around the country. Therefore,

male sterilization programme can be included in these existing programmes without

adding much cost to the government. Thus, people from the areas will not have to worry

about travel cost, time for the travel and loss of time for their work. These mobile

programmes can be effectively performed in the areas without cost to both individual and

government, thus a win-win situation.

Myanmar, being predominately Buddhist country, generally, has no religious

barriers for any contraceptive programmes, unlike other countries such as the Philippines

(Catholic country). A Buddhist may accept all methods of family planning, but with

different degrees of reluctance. The gravest of all is abortion or “killing a human to be”

which all Buddhist traditions condemn the practice of abortion and euthanasia. Except

abortion, Buddhism community has no restrictions for any contraceptive methods

including male sterilization. There may be myths and misunderstanding on male

sterilization in the communities. However, according to the experiences of other

countries, these can be corrected by providing accurate information through information,

education and communication (IEC) programmes. These are currently supported by

National Health Programmes.

With the existing government system, Myanmar can easily decide to approve and

implement such programmes, because of lesser process for approving bills comparing to

other Asian countries (i.e., Philippines). For instance, Myanmar Reproductive Health

Policy was formulated and approved within only a year (i.e., in 2003). Reducing MMR to
 40

meet target within 6 years needs urgent attention by the government. It has not much time

for making decision, approving and implementing processes.

The estimated population of married women (40-49) in rural areas is 22.8%

(Department of Labor, 2006). The women in that age group already have their desired

family size (FRHS, 2004). Thus, the women those who live in rural areas will have

benefits from recommended policy.

 41

CHAPTER 4

CONCLUSIONS AND RECOMMENDATIONS

4.1. CONCLUSIONS

MMR is slightly decreasing during the surveys periods but remains high to meet

the targeted goal in 2015. Pregnancy related maternal death and abortion is higher in

older age group those who wanted to limit or stop bearing child. They are not using any

contraceptive mainly because of hormonal affects, side affects and unaffordable cost of

women contraceptive methods.

The usage of contraceptives is increasing during the survey periods. Specifically,

the older the age group, the more demand for permanent methods for both male and

female. Due to the promotion of male participation programmes since 2004, men were

informed their responsibility for improving women’s health. Men are aware of the usage

of condom but they are reluctant to use it with their wives because of the culture and

social norms. According to surveys results, male sterilization was already well known as

an effective method among married population. By promoting male sterilization policy

for married population, the community will be more aware of the policy which is

responsive to their needs. It will also address constraints such as risk of hormonal affects,

unaffordable cost of female sterilization and accessibility of the service.

The policy and programme for men’s effective participation in contraception,

particularly in sterilization is lacking in existing policies and programmes. As mentioned

above, male sterilization can bring benefits (Table 10) with the least cost (Table 9)
 42

among the options. Even though male sterilization policy alone can not reduce MMR, it

can effectively contribute to reduce MMR within married population. In addition, this is

the best option to reduce MMR which is the consequence of lack of affordable

sterilization among married women.

This study has shown that men lack supportive policy at national level and they

need specific policy and programme. Male sterilization policy is the only best option

regarding to cultural and religion. Myanmar government can easily approve policy and

promote services through existing various communication channels within shorter time

compare to other Asian countries. The targeted MMR must be attained by 2015, thus, it

has to act fast on this option.

4. 2. RECOMMENDATIONS

The government should provide policy for men sterilization with the intension of

reducing MMR among married population. Major roles for the government interventions

to expand male participation in contraception are:

• Political commitment, programmes and services are needed to be addressed to

provide male sterilization for married population with the aim of meeting

targeted MMR by 2015,

• Male sterilization is needed in reproductive health programmes in all stags of

development – from early stages in which community and political support is

important to later stages that focus on expanding and improving services,

 43

• Data on men sterilization should also be collected for further policies and

programmes on male participation in contraception,

• Accessibility of men’s sterilization should be considered and included in

existing policies and programmes which would effectively contribute in

reducing unwanted pregnancies, unsafe abortions, and maternal mortality,

• Government should promote greater male participation in sterilization by:

(a) removing restrictive policies and regulations on male sterilization,

(b) looking for ways to adapt existing infrastructure and services to meet men’s

need and preferences,

(c) supporting IEC interventions that encourage male sterilization,

(d) ensuring that male sterilization services and information are offered

throughout existing systems and

Key programme areas that government should give more attention are:

(a) education and services on male sterilization,

(b) training (e.g. counseling for male clients and couples, and technical training

for vasectomy) for health providers to ensure providing quality services,

(c) promotion of male sterilization through mass media and IEC, and

(d) research on benefits of male sterilization.

* * * * *
 44

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 51

Annex I

National Health Policy, Ministry of Health (1993)

1. To raise the level of health of the country and promote the physical and mental
wellbeing of the people with the objective of achieving “Health for all” goal, using
primary health care approach.
2. To follow the guidelines of the population policy formulated in the country.
3. To produce sufficient as well as efficient human resource for health locally in the
context of broad frame work of long term health development plan.
4. To strictly abide by the rules and regulations mentioned in the drug laws and by laws
which are promulgated in the country.
5. To augment the role of co-operative, joint ventures, private sectors and
nongovernmental organizations in delivering of health care in view of the changing
economic system.
6. To explore and develop alternative health care financing system.
7. To implement health activities in close collaboration and also in an integrated manner
with related ministries.
8. To promulgate new rules and regulations in accord with the prevailing health and
health related conditions as and when necessary.
9. To intensify and expand environmental health activities including prevention and
control of air and water pollution.
10. To promote national physical fitness through the expansion of sports and physical
education activities by encouraging community participation, supporting outstanding
athletes and reviving traditional sports.
11. To encourage conduct of medical research activities not only on prevailing health
problems but also giving due attention in conducting health system research.
12. To expand the health service activities not only to rural but also to border areas so as
to meet the overall health needs of the country.
 52

13. To foresee any emerging health problem that poses a threat to the health and
wellbeing of the people of Myanmar, so that preventive and curative measures can be
initiated.
14. To reinforce the service and research activities of indigenous medicine to
international level and to involve in community health care activities.
15. To strengthen collaboration with other countries for national health development.
 53

Annex II

Policy Implementation Guidelines for Birth Spacing Programmes

(Myanmar Reproductive Health Policy, 2003)

• Daily combined contraceptives, progesterone-only-pills, three-monthly injectable

contraceptives, Intra-uterine devices and condoms will be available and accessible
to all individuals of reproductive age and provided with informed choice.
• Other contraceptive methods such as monthly injectables and implants may be
introduced to broaden choice and to improve quality of birth spacing services
after considering evidenced based information, the needs of the community and
the cost effectiveness.
• Easy access to sterilization will be encouraged for those women requiring
permanent contraception on medical ground.
• Introduction of emergency contraceptive methods into the existing birth spacing
services will be considered.
• Service providers in public and private sectors will be trained in the provision of
quality birth spacing services.
• Mechanism will be sought to review and revise the existing rules and regulations
periodically, impacting the availability of commodities to ensure that safe and
effective birth spacing methods are easily available.

Men’s role in reproductive health

• Awareness of critical reproductive health needs and the importance of
enhancement of men’s reproductive health status in improving the reproductive
health of the family will be raised.
• Men’s role in promotion of birth spacing service, prevention of transmissions of
RTI/STI and in supporting reproductive health service for the family and the
community will be strengthened.