Date Published: December 23, 2008
Publisher: Public Library of Science
Author(s): Luke C Mullany, Catherine I Lee, Lin Yone, Palae Paw, Eh Kalu Shwe Oo, Cynthia Maung, Thomas J Lee, Chris Beyrer, Linda Wright
Abstract: BackgroundHealth indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services.Methods and FindingsSelected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15–45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or ≥ 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates ≤ 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95–2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21–25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23–15.8) times higher among those forcibly displaced.ConclusionsCoverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.
Partial Text: Decades of oppressive policies, low-intensity conflict, and human rights violations in eastern Burma have forced hundreds of thousands of Burmese ethnic nationalities to flee into neighboring Thailand as refugees and/or economic migrants. Approximately 560,000 individuals are internally displaced within Shan, Karenni, Karen, and Mon States along Burma’s eastern border . With one of the world’s least-functioning health systems , national health indicators in Burma (under-five mortality: 104/1,000) are among the worst in Southeast Asia . In conflict-affected regions of eastern Burma, population-based household surveys indicate that the risks of infant (89 per 1,000 live births) and child mortality (218 per 1,000 live births) are substantially higher [4–6] partially due to widespread exposure to gross human rights violations .
This survey was conducted within the pilot areas of the MOM Project (Figure 1) between September 2006 and January 2007. The design, implementation, and general operational method followed that of previous population-based surveys conducted in this setting [4,5].
In these selected populations in eastern Burma, access to essential maternal health interventions during pregnancy is generally low. Importantly, assistance at delivery by individuals who can provide skilled services—especially basic components of obstetric care—saves maternal lives but is universally rare; assistants are normally TBAs or neighbors and friends. More than 7% of ever-married reproductive aged women were positive for falciparum malaria, and parasitemia rates were significantly higher among pregnant women. Finally, there is substantial unmet need for modern contraceptives in all four of the areas.