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Wai M M, et al.

3.1.2. Delivery care
During the MDG era, the MMR decline in the Southeast Asia region was occurred in line with improvements in the
proportion of deliveries attended by SBA (WHO-SEARO, 2016). The reduction of MMR in Myanmar also found
together with increased SBA coverage (correlation coefficient; r=−0.76 between MMR [UN estimates] and SBA coverage
[surveys data]).
The percentage of deliveries attended by skilled providers increased in the reviewed period (Figure 3). The SBA
coverage as indicated in the routine HMIS revealed significant progress from 52% in 1996 to 78% in 2016 (Department
of Health Planning, 2014; Department of Public Health, 2015; 2017). However, the progress measured in the surveys’
data was not significant as the estimates are sparse around the (fitted) trend line. The series of FRHS reports show a
gradual increase in SBA coverage 48% in 1991 to nearly 64% in 2007 (Department of Population and UNFPA, 2002;
2009). The 2005 and 2010 IHLCA gave higher estimates as 73% and 78%, respectively (Ministry of National Planning
and Economic Development and UNDP, 2011). The 2009-2010 MICS data were in-between these estimates at 70.6%
(Ministry of National Planning and Economic Development and Ministry of Health, 2011). Despite the high coverage
reported in the earlier reports, the most recent 2015-2016 MDHS reveals a much lower coverage: Only 60% of deliveries
had been attended by skilled persons, with a noticeably lower rate in the rural areas at 52.3% (Ministry of Health and
Sports, 2017b).
On examination of the discrepancies between these estimates, we found that 40 selected clusters were not visited
during the fieldwork of MICS because of inaccessibility due to security reasons. These sites were then replaced with other
clusters of similar size. However, the situation in these new geographical areas is likely to systematically differ from the
inaccessible areas (Ministry of National Planning and Economic Development and Ministry of Health, 2011). Thus, SBA
coverage is more likely to be overestimated in the new areas when compared to the inaccessible areas, and as such, the
overall average is exaggerated.
The IHLCA reports also show higher estimates of SBA coverage. The coverage could be exaggerated due to differences
in the definition of a SBA, which varies nationally. In Myanmar, SBAs are defined to include doctors, nurses, lady health
visitors (LHVs, who are experienced midwives [MWs] and supervisor of the MWs) and MWs (Ministry of Health and
Sports, 2017b). The auxiliary MWs (AMWs) and traditional birth attendants (TBAs) are not included in SBA
On reviewing the survey reports with regard to their SBA definition; the IHLCA reports mentioned as “skilled
personnel (doctor, nurse, or midwife), excluding TBAs” (Ministry of National Planning and Economic Development and
UNDP, 2007. p. 28). The IHLCA report did not mention regarding the role of the AMW, and if AMWs were considered as
SBA; the estimates for ANC and delivery by SBA tend to show a higher coverage than other reports.
Not only are deliveries supposed to be assisted by skilled persons but also the place of delivery is important to ensure
safe delivery. In Myanmar, the percentage of deliveries at a health facility is much lower than that of delivery by SBA:
More worsening in rural areas. According to the 2009-2010 MICS, the percentage of delivery in a health facility was
36.2% (65.2% urban vs 24.5% rural areas), while the SBA coverage was 70.6% (Ministry of National Planning and
Economic Development and Ministry of Health, 2011). Similarly, when the SBA percentage was 60.2% (urban 87.8% and
rural 52.3%), the institutional delivery was 37.1%: About 70.1% in urban versus 27.6% in rural areas (Ministry of Health

85
80 Trend in SBA coverage
75
SBA coverage (%) 70 R 2 =0.474
(Surveys data)
65
60
55
50
Trend in SBA coverage
45 (HMIS data)
R 2 =0.744
40
1990 1995 2000 2005 2010 2015 2020
HMIS data Surveys data
Figure 3. Trends in percentage of deliveries attended by skilled providers.
Data Sources: Health Management Information System data included estimates from Public Health Statistics reports (2012, 2013, and 2014-2016); surveys data included
estimates from Fertility and Reproductive Health Surveys (2001 and 2007), Integrated Household Living Conditions Survey (2009-2010), Multiple Indicator Cluster Survey
(2009-2010), and Myanmar Demographic and Health Survey (2015-2016).

International Journal of Population Studies | 2019, Volume 5, Issue 1 31