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

Birth Spacing Code in Myanmar

In partial fulfillment in the Course

DM 220 (Public Policy and Programme Administration for Development)

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

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

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

Executive Summary

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

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

Background

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

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

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

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

Present and Past policies to Reduce Unwanted Pregnancies

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

3
Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and
Population, Yangon 2003
4
Nationwide Cause Specific Maternal Mortality Survey 2004-2005
5
Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and
Population, Yangon 2003

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

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

contraceptives, Intra-uterine devices and condoms will be available and accessible to all
individuals of reproductive age and provided with informed choice.

Other contraceptive methods such as monthly injectable and implants may be
introduced to broaden choice and to improve quality of birth spacing services after
considering evidenced based information, the needs of the community and the cost
effectiveness.

Easy access to sterilization will be encouraged for those women requiring permanent
contraception on medical ground.

Introduction of emergency contraceptive methods into the existing birth spacing
services will be considered.

Service providers in public and private sectors will be trained in the provision of quality
birth spacing services.

Mechanism will be sought to review and revise the existing rules and regulations
periodically, impacting the availability of commodities to ensure that safe and effective
birth spacing methods are easily available.
Men’s role in reproductive health was stated as follow in Myanmar Reproductive Health
Policy:

Awareness of critical reproductive health needs and the importance of enhancement of
men’s reproductive health status in improving the reproductive health of the family will
be raised.

Men’s role in promotion of birth spacing service, prevention of transmissions of RTI/STI
and in supporting reproductive health service for the family and the community will be
strengthened.
Access to male contraception was not mentioned in existing policies. The high-level
decision makers did not consider yet the access of male reproductive health/birth spacing
activities in existing policies to reduce MMR. Men are poorly informed sexuality and
reproduction and need information about male and female contraception. They also need the
confidence and guidance on how to share decisions and negotiate choices with their partners
for taking responsibility as part of reducing MMR. And also political commitment and clinical
services are needed to be addressed to provide voluntary male sterilization.

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

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

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

Policy Options / Alternatives

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

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

Comparison of the Policies

Policy Advantages Disadvantages
Allow abortion to o reduce unsafe abortion rate o need to be legislated
women o reduce unwanted pregnancies o culturally and religiously
o reduce unwanted pregnancies sensitive
o women lives can be saved o takes time to be familiar
with community
o abortion rate among
women can be increased
o misunderstanding
between couples

Allow Male o reduce pregnancy rate o need to be legislated

Sterilization to o reduce unsafe abortion rate o risk of minor surgery
married men o less religious and cultural o seems to increase
barriers unfaithfulness among
o low rate of post-operative couples
complication o religious barriers for
o highly effective some ethnic groups
o less expensive
o easy to use
o can be performed with minimal
facilities
o services can be provided in
hospitals, clinics and mobile
camps for rural and remote
areas
Promote birth o reduce unintended pregnancies o culturally sensitive
control methods among unmarried women o seems to empower pre-
easily access to o reduce abortion rate marital sex
unmarried o reduce MMR
women

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

Recommended Policy
Evaluation Rating:
1 – very low 2 – low 3 – moderate 4 – high 5 – very high

Evaluation Criteria
Option
Proposed Policy Social
Efficiency Effectiveness Sustainability Impact Total Rank
Acceptability
Legal Abortion to
both married and 3 4 1 4 3 15 3
unmarried women

Legal Male
Sterilization to 5 5 5 5 5 25 1
marreid men

Promote birth
control methods to 4 4 2 4 3 17 2
unmarried women

Allowing male sterilization is the most appropriate policy for reducing unsafe abortion
rate that affect maternal death as a part of important issues. As a Buddhism country, social
acceptability is also high for male sterilization rather then other two policy options. Building
separate infrastructure to deliver male services in unnecessary; men services can be provided by
specific hours or minor adaption to existing facilities such as establishing a separate waiting
area. Outreach activities to remote areas can also be provided for vasectomy services as mobile
clinics and also be motivated as countrywide campaign. Disseminating information on male
contraception will be provided through health education and promoting programme supported
6
by National Health Programme. The health benefits associated with the use of male
contraception outweigh the cost and also high effective and also visible the direct men’s shared-
responsibility in family health.

6
Information, Education and Communication (IEC) project under the health system development for
health education, Ministry of Health

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

Policy Implementation Guidelines

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

Pursuit of legislative agenda for effective programme administration

Develop guiding principle

Advocacy meeting at all level with UN agencies and international organizations

Adaptation of male programmes in existing female programmes/infrastructure

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

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

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

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

Upgrading interpersonal skills training to service providers to ensure the
effective counseling for birth spacing

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

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

Develop joint monitoring and evaluation plan (using performance benchmark)
- develop M&E plan
- collect/analyze data
- set/review targets
- develop programme action plan and workplan

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

Conclusion

Interest in male participation in reproductive health is growing, and there is increasing

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

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

References

- Myanmar Reproductive Health Policy, Maternal and Child Health Department, Ministry of
Health, the Government of the Union of Myanmar
- Myanmar Fertility and Reproductive Health Survey, 2001, Preliminary Report, Ministry of
Immigration and Population, Yangon 2003
- World Health Organization South-East Asia Regional Office (WHO/SEARO)
2004. Family Planning Fact Sheets: Myanmar and Birth Spacing: An Overview
Web site:
<http://w3.whosea.org/LinkFiles/Family_Planning_Fact_Sheets_Myanmar.pdf>
- Nationwide Cause Specific Maternal Mortality Survey 2004-2005
- Statistical Year Book 2006, Central Statistical Organization, Ministry of National Planning and
economic Development, The Government of the Union of Myanmar
- Exploring Strategic Change, Second Edition, Julia Balogun and Veronica Hope Hailey
- The Rise and Fall of Strategic Planning, Reconceiving Roles for Planning, Plans, Planners, Henry
Mintzberg
- Strategic Management 2nd Edition, Alex Miller & Gregory G. Dess
- Population Policies and Programmes in Singapore, Saw Swee-Hock, Institute of Southeast
Asian Studies
- Fifth Asia and Pacific Population Conference, by United Nations Economic and Social
Commission for Asia and Pacific, United Nations (online book)
http://books.google.com/books?hl=en&lr=&id=bhkyyFiqtsoC&oi=fnd&pg=PA253&dq=male+invo
lvement+in+Myanmar&ots=v-jqO6L0q8&sig=BX0B6Ls-jQEQLcKuZt7DUwRZDuM#PPA261,M1>
- Male Involvement in Reproductive Health, Including family Planning and Sexual Health, United
Nations Population Fund
- Population Policies and Programmes: Determinants and Consequences in Eight Developing
Countries, by London School of Hygiene and Tropical Medicine and United Nations Population
Fund
- The value of Family Planning Programmes in Developing Countries, by A RAND Programme of
Policy-Relevant Research Communication
- <http://planet.unescap.org/esid/psis/population/journal/Articles/2000/V15N4A3.pdf>
- <www.un.org/esa/population/publications/abortion/doc/myanmar.doc>

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

Annex I

National Health Policy

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

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

Annex II
Advocacy Framework
Steps in the Target Audience Message to be sent How will you deliver the Messages in behavior you want to
Policy Process message create
Formation National legislators, High- “It’s time to encourage Organize Advocacy meetings Realize to allow male birth spacing
level decision makers men for women’s health!” programmes
Implementation Married population “Let’s be the best partner Use mass media, pamphlets, Aware and committed of male to
for women’s health!” human stories, celebrities participate effectively in birth spacing
Use community-based health
workers, peer educators and
volunteers
Evaluation Implementers “Is the policy effectively Organize annual joint Committed to preserve with more
Married population providing benefits to the monitoring and evaluation effort to provide better service/ to
people?” meeting at all level build healthy family
Termination High level decision “Did the policy provide Organize meeting for high level Realize to provide supportive
makers benefits to the people?” decision makers environment for further health
development programmes
Maintenance Married Population “Does men role effectively Use community-based health Realize and maintain male effective
contribute to the health of workers, peer educators and participation in birth spacing/family
your family?” volunteers health

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