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Maternal mortality and fertility in Myanmar

2018c) and the random intercepts effects for countries, and regions are incorporated in the model estimates (Department
of Population, 2016a). On comparing MMR, the UN estimation for 2013 was 200 per100,000 live births with a range of
uncertainty from 120 to 350, and MMR of the 2014 Myanmar Census was 282/100,000 live births (95% CI: 176-387). Each
estimate was found to be within the range of the other, and the difference between these two estimates was considered as
not being statistically significant (Department of Population, 2016a). Thus, a trend analysis was applied to the UN estimates
and the 2014 census data, which reveals a significant reduction of MMR in Myanmar.
This significant decline in maternal mortality is believed to be as a result of improvements in the coverage of reproductive
health services: Care during pregnancy and delivery care by skilled health providers. Receiving ANC with a skilled person
helps the women to seek services for and understand the warning signs during pregnancy and childbirth (UNICEF, 2018).
Although ANC 1 coverage did not show a significant improvement, it reached the commitment expressed in the Five-
year Strategic Plan of Reproductive Health (2014-2018) to attain 80% ANC coverage (MCH section, 2014). However,
the ANC coverage of four visits and above (ANC 4+) was still very low, more pronounced in the rural areas as only half
of the pregnant women had ANC 4+. There is a need for improvement. The WHO recommends a minimum of four ANC
visits; and the recommended visits are now moving to eight contact points (WHO, 2016b). In addition to the number of
visits, the correct timing of ANC attendance and the quality ANC is equally important.
Another indicator closely related to MMR that is also included in SDG targets (target 3.1.2) is the proportion of births
attended by skilled health personnel. The SBA coverage in Myanmar increased to a certain extent, but did not show any
significant progress and is yet to reach a satisfactory level. The Five-year Strategic Plan of Reproductive Health (2014-
2018) had a target of ensuring the SBA assisted 80% of deliveries. However, the 2015-2016 MDHS reported only 60%
coverage (MCH section, 2014; Ministry of Health and Sports, 2017b), and many of these deliveries did not take place
in health facilities. Among the women delivered by SBA, 70% of urban women gave birth at health facilities, whereas
70% of rural women delivered at home (Ministry of Health and Sports, 2017b). The role of the enabling environment for
institutional delivery has come into attention, especially in rural areas. Along with increasing institutional deliveries, some
health facilities are poorly staffed and not well equipped. These conditions encourage home deliveries by skilled providers
in non-conducive environments; in case of pregnancy complications, there is a high likelihood of losing both the baby and
the mother. An inequitable distribution of the health workforce is often seen, even in countries with high national health
worker densities (WHO, 2017). Rural and hard-to-reach areas tend to be understaffed when compared to urban areas,
thereby contributing a negative effect on the accessibility to the service (WHO, 2017). This is the reality also in Myanmar.
The contraceptive prevalence in Myanmar significantly increased, both for modern and any methods. Myanmar was
able to reach the target set for FP 2020 commitments, i.e., to increase the CPR of modern methods to 50% by 2015, but
still need to increase more to meet the target of CPR 60% and above by 2020 (Ministry of Health and Sports, 2017b).
Even though all the reproductive health services are provided in an integrated manner to ensure the continuum of care; FP
services are easier to provide into the community as women are at liberty to choose suitable contraceptive methods. Being
a FP 2020 focused country also reinforces Myanmar toward universal access to FP and contraceptive services.
The improvement in contraceptive coverage also affects fertility level. Although the TFR of Myanmar did not
significantly reduce on a yearly basis, it did show a decreasing trend and stood nearly at the same level as the global and
regional averages (2.65 and 2.35) in 2015 (Department of Population, 2016b). However, TFR is not sufficient enough in
reflecting the country’s fertility situation; the TMFR which is twice that of TFR needs to be factored in as well. Increased
age of first marriage and the relatively high proportion of young, unmarried women in Myanmar have also contributed to
lower the average number of children per woman in the reproductive age (Department of Population, 2015).
In Myanmar, non-marriage generally results in a non-participation in reproduction; thus, the relatively high proportion
of women who never married plays a significant role in the determination of fertility (Department of Population and
UNFPA, 2009). According to the 2014 census, 12% of women in the age group of 50-54 were never married (Department
of Population, 2016b). Furthermore, in the 2015-2016 MDHS, only 60% of women in the reproductive age group
(15-49 years) were currently married; 14% of women in the age group of 45-49 were never married (Ministry of Health
and Sports, 2017b). For the above-stated reasons, it is advisable to include the estimates on TMFR in future demographic
and health surveys, as it was not reported in the recent MDHS.
Moreover, assessments of the fertility level in Myanmar have generally only included married women in the samples;
with a consideration of the socio-cultural aspect. The same reasoning is applied to surveys on contraceptive use. On the
other hand, even though contraceptive use increased among Myanmar women, many unintended pregnancies end up in
unsafe abortions, which also is an important factor linked to maternal mortality. In Myanmar, abortion is legally restricted
and only permitted to save the life of the woman (United Nations, 2014). This is not only the case from a legal point of
view but also a cultural and religious perspective that constraints access to induced abortion.

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