Myanmar - Unicef

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Maternal and Newborn Health Country Profiles: Myanmar. 1. 1990. 2010. MDG target 2015. Under-5 mortality rate. Infant mortality rate. Neonatal mortality rate.

Maternal and Newborn Health Country Profiles

Myanmar Myanmar has made progress in improving child survival with its annual rate of under-5 mortality rate reduction at 2.6 between 1990 and 2011. Pneumonia, diarrhoea and newborn complications are the leading causes of child mortality. Rural children and the poorest children are less likely to survive than children in urban areas or are of a richer socio-economic status. The country has made significant progress towards MDG 5, although the target has yet to be achieved. Trends for skilled birth attendance at delivery reflect significant disparities by residence and wealth quintiles.

TRENDS AND POLICIES

Trends in child mortality 1990

2010

MDG target 2015

Deaths per 1,000 live births

79 50 37

44

17

28

Infant mortality rate

Midwifery personnel authorized to administer core set of lifesaving interventions

32

Neonatal mortality rate

Trends in maternal mortality Deaths per 100,000 live births

Per capita total expenditure on health (US$), 2007–20111

Specific notification of maternal deaths

66

1990

Availability

Out-of-pocket expenditure (% of private expenditure on health), 2007–20111

112

Under-5 mortality rate

National health policies and services

2010

MDG target 2015

520

200

Costed national implementation plans for maternal, newborn and child health available Number of basic emergency obstetric and newborn care facilities2

92.4

Yes Partial

No

7,394

Community treatment of pneumonia with antibiotics

No

Oral rehydration solution and zinc for management of diarrhoea

Yes

Oral rehydration solution and zinc for management of diarrhoea

Yes

130 Sources: 1World Health Organization National Health Account database 2012 (retrieved from www.data.worldbank.org); 2United Nations Population Fund, The State of the World’s Midwifery 2012.

Maternal mortality ratio

Trends in maternal indicators FRHS 2001

Per cent (%)

37

MICS 2010

FRHS 2007

46 19.1

17.7

17.4 7.4

Contraceptive Unmet family Women 20-24 prevalence rate planning need married before (met need) age 18

16.9

Adolescent birth rate

Sources for figures: Trends in child mortality: 1990 and 2010 child data from UN Interagency Group for Child Mortality Estimation, Levels & Trends in Child Mortality, 2011; Myanmar Multiple Indicator Cluster Survey (MICS) 2009–2010; 2015 targets from WHO/ UNICEF, Countdown to 2015 Myanmar Country Profile, 2012 (U5MR) and Myanmar MDG report 2006 (IMR). Trends in maternal mortality: Myanmar MICS 2009–2010; 2015 targets from WHO/UNICEF, Countdown to 2015 Myanmar Country Profile, 2012. Trends in maternal indicators: Myanmar Fertility and Reproductive Health Survey (FRHS) 2001 and 2007 and Myanmar Multi Indicator Cluster Survey (MICS) 2009–2010. Notes: Contraceptive prevalence rate proportion of currently married women aged 15–49 who were using some method of family planning at the time of the survey; unmet family planning need: % of women with an unmet need for family planning (spacing or limiting); adolescent birth rate: annual number of births among women aged 15–19 per 1,000 women in the age group.

Maternal and Newborn Health Country Profiles: Myanmar

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Indicators of quality of care Antenatal care 100

Postnatal care

93.1 80.1

80 Per cent (%)

Intrapartum/delivery

70.6

73 63.6

60

72.4

56.9 36.2

40

23.6 20 0 ANC1+

ANC4+ BP Wgt Urine measured* measured sample*

SBA

Inst. delivery

BF (excl.) Birth reg.

Source: Myanmar MICS 2009–2010. Notes: ANC1+: % of women who received ≥1 ANC visit; ANC4+: at ≥4 ANC visits; *% of ANC visit that included measuring blood pressure (BP) and collecting blood and urine samples; SBA: % of births delivered by a skilled birth attendant (doctor, nurse, midwife); inst. delivery: % of births delivered at a health facility; BF (excl.): % of children younger than 6 months who were exclusively breastfed; birth reg.: % of children younger than 5 years whose birth was registered with the State.

Availability of national policies1 for high-impact interventions shown to improve neonatal survival throughout the continuum of care2

Preconception1

Antenatal1

Intrapartum1

Postnatal1

- Folic acid supplmentation

- Tetanus toxoid immunization - Syphilis screening - Pre-eclampsia and eclampsia prevention - Presumptive malaria treatment - Detection and treatment of asymptomatic bacteriuria

- Skilled maternal and neonatal care - Emergency obstetric care - Antibiotics for PROM - Steroids for preterm labour - C-section - PMTCT - Labour surveillance - Clean delivery practices

- Resuscitation of newborn baby - Breastfeeding - Prevention and management of hypothermia - Kangaroo mother care - Community-based pneumonia management - Emergency neonatal care

Legend: green: intervention addressed or mentioned in policy; red: intervention not addressed or no clear guideline/limited intervention. Sources: 1From these sources unless otherwise indicated: Myanmar Ministry of Health, Five-Year Strategic Plan for Reproductive Health 2009–2013 and Myanmar Ministry of Health/WHO/ UNICEF, Five-Year Strategic Plan for Child Health Development in Myanmar 2010–2014; 2Darmstadt et al., 2005; Notes: PROM: premature rupture of membranes; emergency obstetric care: management of complications-obstructed labour, haemorrhage, hypertension, infection; C-section: caesarean section (detection and management of breech); PMTCT: prevention of mother-to-child transmission of human immunodeficiency virus (HIV); labour surveillance (including partograph) for early diagnosis of complications); kangaroo mother care (care for low birth weight infants in health facilities); emergency neonatal care: management of serious illness (infections, asphyxia, prematurity, jaundice). Reference: Darmstadt, G.L. et al., ‘Evidence-Based, Cost-Effective Interventions: How many newborn babies can we save?’ The Lancet, 2005: 365 (9463).

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Maternal and Newborn Health Country Profiles: Myanmar

READINESS FOR NATIONAL SCALING UP OF NEWBORN CARE

Agenda setting

Policy formulation

Policy implementation

- Local evidence generated for newborn survival - Existence of a convening mechanism for newborn health issues - Focal person for newborn health in Ministry of Health - Maternal and newborn indicators included in national surveys (e.g. neonatal mortality rate) - Local evidence disseminated for newborn survival

- Essential drug list includes injectable antibiotics for primary level care (health assistants only) - Midwives authorized to perform neonatal resuscitation - Community-based cadres authorized to perform neonatal resuscitation (auxilliary midwives) - Primary-level cadres authorized to perform neonatal resuscitation - National targets to track newborn health established - Maternal and newborn indicators included in national health information systems

- Supervision system for maternal, newborn and child health established at primary health centre level - Protocol or standard for district hospital care of sick newborns in place - Integrated management of childhood illness algorithm adapted to include the first week of life - Resource requirement for primary health care level available for newborns (partial - only in project townships) - Resource requirement for secondarylevel health care available for newborns (inadequate) - System for neonatal death audits exists - Cadre identified for home-based newborn care - In-service newborn care training materials for community-based cadres - In-service newborn care training materials for facility-based cadres - Pre-service newborn care education for community-based cadres - Pre-service newborn care education for facility-based cadres

Agenda setting

Policy formulation

Policy implementation

- National needs assessment for newborn care conducted

- National newborn policy endorsed - Newborn policy integrated into other health policies or strategies - National behaviour change communication strategy - Community-based cadres authorized to administer injectable antibiotics for newborn infections - Primary-level cadres authorized to administer injectable antibiotics for newborn infections - Costed implementation plan for maternal, newborn and child health - Reproductive, maternal, newborn and child expenditure per child younger than 5 years and per woman aged 1949

- Resource requirement for scaling up home-based newborn care available - System for perinatal death audits exists

Legend: green: benchmark met; red: benchmark not met. Source: Moran, A.C. et al., 2012. Availability of benchmarks as per the UNICEF Myanmar Country Office. Reference: Moran, A.C. et al., ‘Benchmarks to Measure Readiness to Integrate and Scale Up Newborn Survival Interventions’, Health Policy Planning, 2012: 27 (iii29-iii39).

Maternal and Newborn Health Country Profiles: Myanmar

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CONTINUING INEQUITIES: Indicators by residence, wealth quintiles and provinces

Disparities Disparitiesby byresidence residence

49.2 49.2

42.8 42.8

37.5 37.5 24.5 24.5

52.9 52.9

ANC1 ANC1

IMR IMR

Per cent (%) Per cent (%)

Deaths per 1,000 live births Deaths per 1,000 live births

U5MR U5MR

Disparities Disparitiesby byresidence residence

Rural Rural Urban Urban

62.4 62.4

46.1 46.1

29.1 29.1

13.2 13.2 17.2 17.2

Birth Birth reg. reg.

24.8 24.8

24.3 24.3 23.6 23.6

93.5 93.5 89.6 89.6

6363 Rural Rural

24.4 24.4 50.4 50.4

72.4 72.4

63.5 63.5

70.6 70.6

5151

95.9 95.9 96.1 96.1

Urban Urban Country Country Poorest Poorest Wealthiest Wealthiest total total

93.1 93.1

Urban Urban Country Country Poorest PoorestWealthiest Wealthiest total total

67.3 67.3

74.4 74.4

69.3 69.3

62.5 62.5

47.4 47.4

57.3 57.3

50.3 50.3

43.8 43.8

65.3 65.3

BPBP measured measured

Urine Urine sample sample

97.8 97.8

91.2 91.2

63.2 63.2 50.2 50.2

24.4 24.4

16.2 16.2

1.3 1.3 Chin ChinShan Shan East East Chin Chin Shan Shan East EastRakhine Rakhine Mon Mon

77.3 77.3

Urban Urban Country Country Poorest Poorest Wealthiest Wealthiest total total

99.6 99.6

4747

DPT3 DPT3

99.2 99.2 97.5 97.5

ANC1 ANC1

Excl. Excl. BFBF

38.9 38.9

99.2 99.2

86.2 86.2

97.8 97.8

95.4 95.4

94.5 94.5

98.3 98.3

97.8 97.8

62.9 62.9

Most Mostand andleast leastaffected affectedprovinces provinces

Per cent (%) Per cent (%)

Deaths per 1,000 live births Deaths per 1,000 live births

Birth Birth reg. reg.

80.1 80.1

98.2 98.2

97.7 97.7

Rural Rural

Most Mostand andleast leastaffected affectedprovinces provinces SBA SBA

35.7 35.7

94.3 94.3

ORT/CONT. ORT/CONT. forfor feeding feeding TxTx PNA PNA

Excl. Excl. BFBF

20.8 20.8

74.4 74.4

Disparities Disparitiesby bywealth wealthquintiles quintiles

Per cent (%) Per cent (%)

Deaths per 1,000 live births Deaths per 1,000 live births

SBA SBA

87.1 87.1 56.9 56.9

45.8 45.8

Rural Rural

Disparities Disparitiesby bywealth wealthquintiles quintiles

Urine Urine sample sample

84.5 84.5

9191

Country CountryPoorest Poorest Wealthiest Wealthiest total total

BPBP measured measured

Shan Shan North North

Mon Mon Shan Shan North North Mon Mon Chin Chin

Mon Mon

Source: Myanmar MICS 2009–2010. Notes: Comparison of data is by residence (rural versus urban versus country total), wealth quintiles (poorest versus richest versus country total) and by states/divisions (most affected versus least affected); U5MR: Mortality for children younger than 5 years of age; IMR: infant mortality rate; urine sample (obtained during antenatal care (ANC) visit); SBA: % of pregnancies delivered by skilled birth attendant; birth reg.: % of children younger than 5 years whose birth was registered with the State. Excl. BF: % of children younger than 6 months who were exclusively breastfed; ORT/cont. feeding: % of children with diarrhoea who received oral rehydration therapy or increase intake and at the same time was continuously fed; Tx for PNA: % of children younger than 5 with symptoms of ARI and/or fever whom advice or treatment was sought from a health facility or any appropriate provider; ANC1: % of pregnant women who received ANC 1 or more times during pregnancy.

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Maternal and Newborn Health Country Profiles: Myanmar

EQUITY FOCUS: Indicators by residence, wealth quintiles and provinces

Residence Indicator

Quintiles

Most and least affected provinces

Rural

Urban

Poorest

Wealthiest

U5MR (country avg: 46.1 per MICS; 50 per Countdown 2012 report)

52.9

29.1

62.4

17.2

-

IMR (country avg: 37.5 per MICS; 66 per Countdown 2012 report)

42.8

24.5

49.2

13.2

-

91

98.3

86.2

992.

M: Shan North (63.2); L: Mon State (99.6)

Blood pressure taken (country avg: 80.1%)

74.4

94.3

62.9

97.8

M: Shan North (50.7); L: Mon State (97.8)

Weight taken (country avg: 63.6%)

53.4

88.9

43.7

90.7

M: Chin (37.3); L: Mon (90.1)

Urine sample taken at ANC, % (country level 56.9%)

45.8

84.5

35.7

87.1

M: Chin (16.2); L: Mon (91.2)

% of mothers with a birth in the last 24 months who are protected against tetanus (country avg: 91.8%)

90.7

94.6

87.2

96.2

M: Shan (North; 59.5); L: Mon State (98.9)

63

89.6

51

96.1

M: Chin 38.9; L: Shan (East) (94.5)

24.5

65.2

12.4

77.5

M: Chin (5.6); L: Yangon (68.9)

Birth registration (country avg: 72.4%)

63.5

93.5

50.4

95.9

M: Chin (24.4); L: Shan East (95.4)

Exclusive breastfeeding (country %: 23.6)

24.8

20.8

24.4

24.3

M: Rakhine State (1.3); L: Mon State (47)

% who received ORS or RHF (country level %: 66.3)

61.8

77.1

58.2

79.2

M: Shan (North) (27.7)***; L: Tanintharyi (90.2)

% continued feeding and given ORT and/or increased fluids (country avg: 50.3%)

47.4

57.3

43.8

65.3

M: Shan (North) (32.6)***; L: Shan (South) (80)***

% of under-5 children with symptoms of ARI and/or fever whom advice or treatment was sought from a health facility or any appropriate provider1 (country avg: 69.3%)**

67.3

74.4

62.5

77.3

-

% of children aged 0–59 months with suspected pneumonia who received antibiotics in the last two weeks (34.2%)

34

34.8

29.2

31.8

-

97.7

98.2

97.5

99.2

M: Chin (91); L: Mon State, Shan South, Magwe (100%)

Antenatal ANC1 (% of pregnant women receiving ANC 1 or more times during pregnancy; country avg: 93.1%)

Intrapartum Skilled birth attendant at delivery (country level: 70.6%) Institutional delivery (36.2%) Postpartum

Children younger than 5 years

DPT3 (country avg: 97.8%)

Source: Source: All data from MICS 2010 except for U5MR and IMR which includes WHO/UNICEF, Countdown to 2015 Myanmar Country Profile, 2012; 1“appropriate provider” not defined in the MICS survey. Notes: **Because the prevalence of suspected pneumonia is not very high, comparisons across states and divisions cannot indicate trends because they are based on small number of children in each; ORS: oral rehydration solution; RHF: recommended home fluids (increased fluids). ***Certain figures are based on 25–49 unweighted cases.

Maternal and Newborn Health Country Profiles: Myanmar

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Spotlight on UNICEF work

Community health volunteers make huge impact on child survival Myanmar experienced great success with the community case management of malaria for several years before the Government decided to test that approach in managing other common childhood illnesses, including pneumonia and diarrhoea – two of the major killers of children younger than 5 years. In December 2010, the Women and Child Health Development Division of the Ministry of Health, in collaboration with the Dawei Township Health Department, began piloting the community case management (CCM) model in one of its more topographically difficult areas. Located in Tanintharyi Region, which covers the long, narrow southern part of the country (bordering the Andaman Sea to the west and Thailand to the east), some of Dawei Township’s villages are out of the reach of basic health staff and many of its villages can only be accessed in the dry season.

Each volunteer received a digital thermometer, respiratory timer and a two-month supply of ORS, zinc sulphate, amoxicillin and paracetamol; due to transport difficulties during the rainy season, volunteers were later given threemonth supplies. To restock and to check their managing skills, the volunteers met with a supervisor fortnightly. Preference for existing volunteers, using midwives for supportive supervision, available trainers at the township level and prevailing processes for recording and reporting ensured that minimum incremental costs were incurred. The pilot successfully demonstrated the feasibility and efficacy of the CCM approach for a national scale-up. UNICEF, the Ministry of Health and partners are planning a phased scaling up of the initiative.

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Maternal and Newborn Health Country Profiles: Myanmar

The community case management of childhood illnesses has worked wonders for improving child health and survival in many resource-poor settings. Trained community health volunteers equipped with job aids and supervised by a skilled health worker can provide timely care to young children and refer serious cases to an appropriate facility when required.

Photo credit?

With UNICEF providing technical and financial assistance as well as monitoring and supervision support, the health authorities selected 48 scattered villages (with a total population of 20,000) where children had little or no access to a basic health centre. The township had a cadre of health volunteers who were selected by the community and already trained on recognition and management of malaria, many of whom joined the pilot programme along with new recruits. A five-day training course (with two extra days for those who failed an exam) covered the use of early intervention oral rehydration salts (ORS) and zinc sulphate tablets for diarrhoea and antibiotics for pneumonia to children younger than 5 years. Through this approach, the health volunteers would work from their home, treat non-complicated cases, refer severe cases to health facilities and only make house calls for follow up.

Background

“I really appreciate the CCM volunteers,” explained a Kauk Mae Taung basic health staff member. “Because of them, severe cases are not seen anymore, and it’s really a relief that someone is there for the children because I cannot go there in the rainy season and even now it takes approximately 24 hours to get there by motorcycle.”