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Impoverished Myanmar Has One of the Highest Maternal Mortality in the Southeast Asian Region

Abstract:

This paper imparts a general outlook on maternal health in Myanmar which is recorded to have one of the highest maternal mortality in the Southeast Asian region. There are various maternal health challenges facing women in Myanmar. However, various programs have been initiated to rectify the problems by its government. Though reproductive and maternal health services are provided in public health sector, majority of the women seem to avail the services of private health sector more considering its better quality service. Clinical social franchise program has also been induced in the private health sectors to provide well-regulated, affordable and high-quality health products and services, at the same time, giving awareness among women and ensuring discernable improvement in the accessibility and availability of family planning and reproductive health programs and services. Though awareness and practice of family planning in Myanmar have gradually increased, utilisation of contraception remain relatively low leading to rise in abortion cases contributing to the maternal morbidity and mortality rate. Perinatal depression is also an earnest maternal health problem. Antenatal care, safe delivery, essential obstetric care and family planning by skilled birth attendants must be ascertained to reduce maternal morbidity and mortality. In fact, there are various barriers including gender-based inequality that women must overcome in accessing health care facilities. This provides a cue to promote a sense of women’s empowerment in terms of socio-economic, cultural and educational sector.

Introduction

In the present era where women’s empowerment has become one of the most talked about subject matter globally, health status of women has now occupied a cardinal objective for the policy makers in every country. Motherhood is a momentous phase of life a woman has to brave. It is a phase in a woman’s life where blissful moments comes along with various challenges, especially, health issues leading to death in several cases. That being the case, it is crucial to investigate and invest on maternal health issues the women in the world are withstanding. As generally understood, maternal health is the health of women during pregnancy, childbirth and postpartum period. It embraces family planning, preconception, perinatal and postnatal care which is within the purview of women’s health care. Though maternal morbidity and mortality rates have considerably declined globally, it remains relatively high in low-and-middle income countries.

With the intention of providing improved quality maternal healthcare to ameliorate maternal health status, World Health Organisation (WHO) have proposed a global vision in 2015 where ‘every pregnant women and newborn receives quality care throughout pregnancy, childbirth and the postnatal period’ (Meghan A. Bohren, et al. 2018). As per WHO, quality care encompasses effective communication, respect, dignity, and emotional support as key domains of quality to improve women’s and newborn’s experiences of care (Meghan A. Bohren, et al. 2018). Further, in 2018, World Health Organisation had endorsed intrapartum care which incorporates woman-centered, rights-based approach (Meghan A. Bohren, et al. 2018) to ensure a cordial maternity care environment where women are ministered with respect and emotional support, simultaneously encouraging the women to participate and foster decision-making ability. Various measures have been taken up to prevent and eliminate disrespectful and abusive attitude from the healthcare service providers during labour and childbirth. This uncompassionate behaviour is one of the factors responsible for reluctance among women to utilise maternal healthcare facilities for childbirth.

Keeping in view the prevailing maternal health problems encountered by women and the initiatives taken up to curb the problems over the globe, a review on maternal health status in Myanmar, a low-and-middle income country which is known to have a high rate of maternal morbidity and mortality is significant.

An Outline of Maternal Health in Myanmar

Maternal health stands a major public health issue in Myanmar. Myanmar is recorded to have one of the highest maternal mortality in the Southeast Asian region. There are various maternal health challenges facing women in Myanmar. Risk factors for the maternal and reproductive health problems are multifactorial. There are many setbacks in health sector, especially, concerning women’s health in Myanmar. Though reproductive and maternal health services are provided in public health sector, majority of the population seems to avail the services of private health sector more considering its better quality service. How to ameliorate poor maternal health status and maternal mortality and morbidity should occupy a primary objective in policy making by the government of Myanmar.

In a country like Myanmar where development in socio-economic, education and health sectors have remained ambiguous, rapid population growth has amplified the difficulties in enhancing overall progress in the country. Broadly speaking, family planning plays a vital role in regulating population growth rate of a country. However, it is high time to understand, in depth, the crucial role of family planning in relation to maternal health. According to the World Health Organisation, “Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. A woman’s ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy.” The programmes of family planning also incorporate sex education, pre-conception as well as infertility counselling and management. An efficient and effective implementation of family planning not only regulates frequency of childbirth and prevents unwanted pregnancies and increased population growth, but also prevents from sexually transmitted diseases and abortions, a menace to women’s health that has a high risk of maternal morbidity and mortality.

Public health sector in Myanmar are already underfunded and understaffed, and family planning and maternal health services provided are not yet able to accomplish the desired level of performance. Family planning is often euphemized as access to and the use of contraception. As articulated by WHO, methods of contraception include oral contraceptive pills, implants, injectables, patches, vaginal rings, intra uterine devices (IUDs), condoms, male and female sterilization, lactational amenorrhea methods, withdrawal and fertility awareness based methods. In recent years, although awareness and practice of family planning has gradually increased in Myanmar, widespread utilisation of contraception remains relatively low. The most common contraceptive methods administered by the women in Myanmar are injectables, contraceptive pills and intrauterine devices (IUDs). Further, a considerable difference is visible in rate of use of contraceptives between the women in rural areas and that in urban areas. Comparatively, women in urban areas are more exposed to the use of contraceptives than the rural women. The reason behind the disparity could be lower availability of the contraception facility in rural areas, difficulty to access the opportunity of the different modern contraceptive methods, geographical remoteness, lack of education, and insufficient income to support the contraceptive methods.

As a matter of fact, factors related to unsuccessful implementation of family planning are multifaceted. The accessibility of family planning practices among women in Myanmar differs from region to region. In regions where health organisations are rendering family planning services and facilities, at the same time imparting essential knowledge and awareness, they probably have a higher percentage of women optimising family planning practices and services provided. On account of poor infrastructure and lack of appropriate reproductive and maternal health services and facilities in rural areas, women in these areas of Myanmar are more susceptible to the preventable problems of maternal morbidness and deaths as compared to women in urban areas. Lack of education and financial support are also some of the major reasons that have been hindering the women from resorting to family planning methods. The socio-cultural milieu in which the woman reside, too, influence her perception and decision-making ability towards family planning. Women need support from their family, peer group and also from the healthcare service providers as it directly affect the willingness of a woman to practice family planning. It has been asserted that, particularly in rural areas, the family planning services provided by the healthcare service providers hardly propagates knowledge and information on family planning, and lacks moral and emotional support. Proper care and support from healthcare service providers, family and society serves as essential reinforcing factors which could exert women to optimize family planning services and facilities. The influencing factor of family’s support should not be overlooked.

Likewise, it is imperative to inspire and inculcate an affirmative outlook towards family planning and its practices among the women in Myanmar. Using contraceptive methods as a part of family planning have a direct impact on health and well-being of a woman. Inaccurate administration of contraception methods, and fear of its side effects due to lack of knowledge and information are also some of the reasons for the reluctance of women in adopting contraception practices. Besides, women of younger age are said to have a higher rate of unintended pregnancies and abortions. Therefore, the Ministry Of Health of Myanmar had described plans for inclusion of family planning issues in the Strategic Plan (2009-2013). Consequently, the services had been integrated in the township health system focussing more on the younger age group (Ann Jirapongsuwon, et al. 2016).

In addition to inadequate essential and effective healthcare resource allocation, geographical and transportation difficulties, lack of education and financial problems responsible for the failure of optimum family planning practices among women in Myanmar, there are also many other influencing factors such as diversities in religion and ethnicity, relationship among household members, perceptions of healthcare practices, and readiness of health service providers that determines the accessibility of essential and efficient health care facilities by women. Apart from these, there is also the factor of pre-existing health conditions which could directly or indirectly influence maternal health. Indeed, maternal and reproductive health problems have, more or less, remained a hidden health emergency in Myanmar. Therefore, immediate problems hampering the effective optimisation of family planning facilities should be addressed at the soonest, failing which magnifies the maternal and reproductive health problems in Myanmar.

One of the most crucial factors largely contributing to maternal morbidity and mortality is abortion, both spontaneous and induced abortions. However, by the word abortion, it is generally understood as induced abortion. The rate of abortion among women in Myanmar is considerably high. While decline in maternal mortality appears to be evident in Myanmar in the past few decades accounting to the improved socio-economic conditions and health services, abortion mortality rate has nonetheless remained high and shows no considerable change. Lack of access to and inappropriate practice of contraception methods provided under family planning project is recognised as one of the major factors responsible for the increased rate of abortion. Abortion ought to constitute a sensitive health problem for women in Myanmar although it is not given utmost attention. Abortion not only carries a huge risk on a woman’s life but also contributes in the upsurge of morbidity and mortality in the country.

On the other hand, being a Buddhist society, abortion is considered a deed against their religion given their belief that killing a living creature is sinful. As a matter of fact, both induced and spontaneous abortions have been among the most serious public health problems with significant contribution to the maternal morbidity and mortality in Myanmar. Reasons for non-use of contraception which is a pivotal means of avoiding abortion could be that, women were either unaware or had very little knowledge about its efficiency, proper use and side effects. Also, there were cases of contraceptive failures. The lack of information, fear of side-effects, or perforations of womb (by the IUD), deformities in babies born in cases of contraceptive failure, cultural constraints and lack of social legitimacy to use of contraceptives increases the chance for women to go for abortion. Marital problems, family with more than desired number of children, narrow gap of childbirth and financial difficulties are the common factors responsible for women resorting to terminate pregnancy. However, it is worth mentioning that contraceptive practices among women in Myanmar were lower earlier as compared to the present day.

Women with no formal education and low income are recorded to have higher rate of abortion than educated women with higher income. The cost of contraceptives, though low, may still be a barrier for poor women. Unplanned and unwanted pregnancies are the decisive factors for women to undergo induced abortion, sometimes also as a method of family planning. They resort to certain traditional methods of abortion such as herbal preparations for menstrual regulation, abdominal massage and vaginal manipulations (Katherine Ba-Thike, 1997) which further induce a dire effect in some cases. The traditional means of abortion gives excruciating pain which could induce fever and other infection problems that can also lead to death at its ultimate effect. Unfortunately, women are not well-accustomed with the practice of different contraceptive methods. Majority population of women in Myanmar do not have proper knowledge on the efficacy, side effects and appropriate way of using contraceptives.

In fact, complications following abortion such as peritonitis and septicaemia, sepsis, renal failure, and disseminated intra-vascular coagulation have been projected as some of the important factors for maternal deaths. In addition, menstrual problems, pelvic inflammation, psychological sequelae, uterine perforation, cervical laceration, etc., are some of the post-abortion problems women have to face. These post-abortion morbidities pose threat to both mental and physical health of women and, thus, needs to apprise for an appropriate diagnosis and treatment. Deaths due to unsafe abortion are a significant factor for increase in maternal mortality. Consequently, widespread and effective use of family planning methods is essential to curb the increase in maternal morbidity and mortality rate. Expansion of contraceptive services and its quality improvement is mandatory for preventing unsafe abortions. This initiative would save women from the needless pain and sufferings, sometimes even death, in the pursuit of controlling their fertility.

Mental health of an individual is also a crucial determinant of his/her well being. There is a close relevance between maternal health and mental health of women. Mental distress or mental health problems are common among people in low-and-middle income countries and, women, particularly, socially and economically disadvantaged, young mothers and pregnant women are not alien to mental distress and often fall prey to psychological disorders. Mental distress has been a concerning health problem existing in Myanmar. However, people lack knowledge and awareness on mental health issues. They still believe that evil spirits and witchcraft could be the reason behind mental disorders and sicknesses. This social stigma has hindered the adoption of an efficient and effective strategy to cope with mental health problems.

There are various socio-demographic factors responsible for anxiety and depression among women in Myanmar. Broadly speaking, poor health status, family crisis, socially stigmatized subordinate nature of women under men’s domination while bearing all the household responsibilities without due recognition, lack of education and financial problems are some of the major circumstances accountable for mental distress among women in Myanmar. Mental distress is prevalent more among women who are the victims of domestic violence, divorced or widowed, effect of a trauma such as abortion and other maternal health problems, also due to ignorance and less or no diagnosis of mental health problems. In many instances, the stereotyped notion of male dominance in the society of Myanmar affects the mental health status of women to a large extent. For example, the inability to make their own decisions on family planning culminates various unwanted and preventable health issues among women. In a male dominated family where women are subjugated, women are seldom granted the freedom to make decision on matters of frequency of childbirth or desired family size. Overly large family size aggravates the burden and responsibility of women in management and maintenance of nurturing a well-organised family which may ultimately lead to mental health disturbances. It would be intriguing to elucidate on domestic violence and women in the society of Myanmar. Domestic violence, for example, wife beating, physical assault, intimate-partner abuse and violence, etc., are regarded as normal and not acknowledged as illegal. Again, in many cases, women also conceal their mental health problems either because they ignore it as something not so significant to attend to or are ashamed to address the mental illness they are facing.

Perinatal depression is one of the significant universal maternal health concerns, with a higher prevalence in the low-and-middle income countries (LMIC). Perinatal depression is a common ailment every women experiences during pregnancy or, after childbirth. It is considered as one of the seminal contributor of maternal mortality and morbidity across the globe. Untreated perinatal depression has been accepted as the repercussion of significant adverse outcomes including negative health behaviours in pregnancy, subsequent chronic and recurrent depression, impaired ability to work and care, poor social development, insecure attachments, relationship breakdown, and suicide- an important contributor to maternal deaths globally (Fellmath, et al. 2020). Socio-cultural and economic problems such as, dependence of women on men in various aspects of life, inability of women to decide on one’s own concerns, financial difficulties, family conflicts and lack of understanding and support, domestic violence, and women having history of mental distress are some of the relevant factors responsible for perinatal depression among women in Myanmar.

Mental health remains a neglected health problem in Myanmar. Mental distress among women which even lead to committing suicide in some cases are not given due importance despite its noticeable contribution in maternal health problems. Mental health status is not up to par in Myanmar and, thus, requires an appropriate mental health policy.

Furthermore, it would be unjust if we overlook the problem of perinatal depression faced by migrant women in Myanmar. Taking into consideration the challenges they have been facing in their lives before, during and after displacement, the migrant women have a much higher risk of suffering from perinatal depression. In addition to unaccustomed culture and society, socio-economic inequality, lack of social support and inadequate healthcare facilities aggravates the chances of perinatal depression and other maternal health problems among the migrant women in Myanmar. Improving the recognition and management of perinatal depression requires long-term collaborative and cross-sectional working- a hard task in low-income, migrant situations where political tensions and instability are the norm (Fellmath, et al. 2020). Efforts to better manage perinatal depression must be accompanied by preventative measures to promote mental health and address the wider, social determinants of health. It is only by tackling the complex array of factors impacting upon women’s mental health- from experiences of trauma through generalised poverty and unemployment to abusive relationships- that the plight these communities might be improved (Fellmath, et al.2020).

Intervention on Maternal Health in Myanmar

Generally, public health sector at different levels – public hospitals, urban and rural health centres, and the auxiliary midwives which are the voluntary community-based workers have been providing reproductive health (RH) services. However, due to inadequate funding and poor quality services on health sector, women in Myanmar prefer to access essential and effective reproductive and maternal health services provided by the private health sector which, on the other hand, increases out-of-pocket expenditure for healthcare. Improved modern family planning methods like contraception facilities are provided in private healthcare sectors that includes private hospitals or clinics, pharmaceutical dealers, private general practitioners (GPs). This implies the significance of private sector healthcare system in rendering essential and effective healthcare services including maternal and reproductive health services in Myanmar. However, long-term family planning methods such as intrauterine devices (IUDs), implant, and permanent methods like male and female sterilization are mainly provided in public health sectors.

Like other developing countries, Myanmar has also begun to undertake the maternal healthcare guidelines of the essential services as per the recommendation of World Health Organization (WHO) published in 2003. Community-based maternal health services have been enforced. Government sponsored birth-spacing projects are also launched by the government on some regions in Myanmar with a plan to further expand these services to cover all the country’s townships. The Myanmar Maternal and Child Welfare Association, a non-governmental organisation, began providing contraceptive services in 1991 as an affiliate of the International Planned Parenthood Federation (Katherine Ba-Thike, 1997).

There are also non-governmental organisations (NGOs) which provides reproductive and maternal healthcare services under the aegis of private healthcare sectors through the clinical social franchise program, an intervention for quality improvement of healthcare. Clinical social franchising has become a medium where limitations in service provided and shortages of products in healthcare systems are made up to some extent. Clinical social franchise program has become a prominent and highly influential strategy for rendering an efficient and effective health products and services through the private health sectors all over the globe, particularly in low-and-middle income countries. It is a program which collaborate different private health service providers to ensure that people, especially, low-and-middle income groups could access a better quality, uniform and standardized health services and products at a subsidized rate in a formally organised manner.

Social franchises typically include the following characteristics- outlets are operator-owned, outlets provide clinical services with or without franchise-branded commodities, and payments to outlets are based on services provided (Naomi Beyeler et al. 2013). The health services provided by clinical social franchise broadly includes sexual and reproductive health services, child health, tuberculosis (TB) and malaria testing and treatment and HIV care. Introduction of clinical social franchise program has brought about awareness among women the practice of family planning relatively, and a discernable improvement in the accessibility and availability of family planning facilities including different contraception methods. This further alleviates the inconveniences of women in accessing the facilities provided for family planning and other reproductive health program and services. It is also evident that social franchise clinics increased monthly reproductive health client volume in Myanmar, the number of family planning brands available, and had somewhat higher client satisfaction (Ting Aung, et al. 2017). The franchised clinics in Myanmar are making efforts to reach out to the vulnerable population in rural areas. A liaison between clinical social franchise programs and women health sector in modern day Myanmar has brought about a paradigm shift in maternal health issue.

Population Services International/Myanmar (PSI/M) is one such important non-governmental organisation which provides better quality and standardized healthcare products and services to people in private healthcare sectors through clinical social franchise program. PSI/M was founded in 1995 with a focus on prevention from HIV/AIDS, and now, ensuring a proper reproductive and maternal healthcare services have become its one of the most important objective. PSI/M provides counselling and awareness programs on reproductive health (RH), utilisation and regulation of modern methods of family planning such as IUDs, short-term hormonal methods like hormonal pills, injections, female sterilization, etc. At the same time, it makes effort to provide improved and better quality maternal health services and products at an affordable price, in a more uniform and formally organised manner.

Population Services International/Myanmar (PSI/M) also engages general practitioners (GPs) through a network of private medical doctors known as Sun Quality Health (SQH) that provides referral cards to eligible women to consult the SQH clinic for family planning and other maternal health services. PSI/M de facto educates and directs the members of SQH on reproductive health, sexually transmitted diseases including HIV, and other health problems like tuberculosis, pneumonia, diarrhoea and malaria. Population Services International/Myanmar (PSI/M) has also established a second tier called as Sun Primary Health (SPH) which engages rural village health workers in order to ensure that the franchise’s health services and facilities provided reach out to the geographically remotest rural areas. Literally, Population Services International /Myanmar (PSI/M) is one such organisation playing pivotal role in instigating reproductive and maternal health care services in private health sectors in almost all the townships in Myanmar, at the same time, providing effective and efficient healthcare products and services in Myanmar through clinical social franchise program. Further, it can be inferred that, an efficient access to contraception facilities by women in Myanmar is much influenced by the condition of geographical terrains and transportation facility to a larger extent as it causes disparity in intervention. It will be more convenient for women living in healthcare program townships and in areas having proper transportation facility to avail the existing services on reproductive and maternal healthcare, family planning program and contraception schemes, and appropriate knowledge of the service providers.

The Maternal and Child Health Voucher Scheme (MCHVS) have also been introduced in Myanmar with an objective to improve the health status of pregnant women and their babies while providing better accessibility to and utilisation of maternal and child health services by skilled birth attendants. Literally, pregnant women in rural areas in Myanmar benefit just a minimum antenatal care, and maximum delivery is carried out at homes. The major factors that have been hampering the women from optimising the maternal and child health services are, to no surprise, geographical barriers and lack of proper transportation facility and, financial hardships they are facing.

In an attempt to alleviate the financial difficulties the beneficiaries are encountering in the run of accessing the maternal and child health services, the demand-side financing programme has been adopted by the Ministry of Health (MoH), Myanmar. Maternal and Child Health Voucher Scheme (MCHVS) is one such demand-side financing programme undertaken to increase maternal and child health services, namely, antenatal care (ANC), delivery, postnatal care (PNC) and infant immunization for pregnant women, particularly low-income women, and newborns. Antenatal care is provided only at health centres, while the remaining three can be received at both home and health centres through skilled birth attendants (SBAs). This scheme also provides reimbursement facilities to the pregnant women if these services were received at health centres. Apart from the midwives, local authorities, community health volunteers and even shopkeepers and school teachers (Songyot Pilasant, et al. 2016) were engaged for distributing the vouchers to the beneficiaries.

Considering the fragility and intricacy of maternal health, it is imperative to contemplate the significance of skilled birth attendants (SBAs) in assuring a better maternal health condition. According to World Health Organisation (WHO), skilled birth attendants are defined as “an accredited health professional such as a midwife, doctor or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns”. As described by World Health Organization, the major causes of maternal death related to pregnancy and childbirth are severe bleeding after birth, high blood pressure during pregnancy, obstructed labour, and unsafe abortion and delivery. It is worth mentioning that, antenatal care (ANC), safe delivery, essential obstetric care, and family planning are the fundamental requirements for alleviating the maternal deaths which are rendered mainly by the skilled birth attendants. It is reported as most of the maternal and neonatal deaths occur at the time of delivery or immediately during the postpartum period and are preventable. They can be prevented through proper availability and accessibility of maternal and child healthcare services.

It appears that the factors responsible for utilization of skilled birth attendants by eligible women in Myanmar are multifaceted. The socio-demographic factors such as education, income, order of birth, frequency of antenatal care visits, and predisposing factors like knowledge of maternal and child health services the women could avail, an insight of the utility and efficiency of skilled birth attendants and attitude towards them influence the engagement of skilled birth attendants by the eligible women. Further, the convenience and reachability in accessing the maternal and child health services by the women is another enabling factor that determines the utilization of skilled birth attendants. The attitude and perception of the beneficiaries towards the skilled birth attendants, their extent of knowledge and awareness about maternal and child health services as well as accessibility to the services provided commensurate the utilization of skilled birth attendants. As such, an appropriate programme for an efficacious management to increase the utilization rate of SBA should be given importance.

In rural areas of Myanmar where it is hard to access the service of skilled birth attendants, auxiliary midwives (AMWs) contribute essential assistance during the time of pregnancy and childbirth. They are assigned the task for identification and screening of pregnant women and their health status, at the same time to impart knowledge on diet supplements and other childbirth consciousness. In addition to executing normal deliveries, auxiliary midwives also assist the midwives in undertaking immunisation services. As it appears that the auxiliary midwives already have the potential to engage in maternal interventions, it would be indispensable to professionalise them through proper education and instructions on medical essentialities and systematic monitoring and supervision of their tasks. As a matter of fact, the services rendered by the auxiliary midwives have been able to mitigate, to some extent, the difficulties facing women in accessing reproductive and maternal health services in rural areas. They are able to widen the reach of family planning facilities and improvised maternal and child health services.

Women’s Empowerment and Maternal Health in Myanmar

A glimpse at the status of maternal health in Myanmar as regards to the significance and the changing scenario of maternal health and its relation with empowerment of women over the globe entails the importance to germinate the sense of women’s empowerment in Myanmar. Women’s empowerment promotes and encourages women to be self-reliant and stand on their own feet. For its realisation, education of women is very much essential. Literacy of women enhances employability, social consciousness and empowerment of women. Evidently, women with lack of formal education and low income are more liable to confront the predicaments of maternal health problems in Myanmar. Providing education and empowering women in Myanmar could influence their decision-making ability on various aspects of life, especially, on the matter of her health.

Women’s empowerment have a significant impact in the context of reproductive and maternal health sector enabling women to decide on accessing healthcare facilities like family planning which includes contraceptive usage, birth intervals, fertility, etc. without any external interference from family, social stigma or peer groups. Women should be empowered in such a manner that stereotyped socio-cultural barriers and the domination of men over women, as is also seen in the society of Myanmar, cannot hinder or to interfere women on leading a virtuous, self-reliant, inner-directed life. The stereotyped notion of women as inferior to men in social construct is accountable for induced inequality in control and competence, as well as resource allocation between men and women, particularly within the realm of marriage. By resource allocation, it refers to the distribution of material, economic and social resources which are considered as the “preconditions” of empowerment (Stephanie Spaid Miedema, et al. 2016). This gender discrimination exposes women to higher risk of intimate partner violence. Intimate partner violence (IPV) has been understood as “any behaviour within an intimate relationship that causes physical, psychological or sexual harm” (Stephanie Spaid Miedema, et al. 2016). This subjugation of women by men impacts considerably on the decision-making ability of a woman on various aspects of her life, including her reproductive health.

The essence of women’s empowerment is not well inculcated among women in Myanmar. The people of Myanmar seldom recognize the relevance of women’s empowerment and its influence on utilisation of healthcare services by women including reproductive, maternal and child health services. Further, empowerment of women is essential to overcome various hindrances encountered by women in accessing health care services, which also manifest gender-based inequality in health care access on some occasions. It is said that women barely attain rights and attention on par with men. It is worth noting that health status of women, to a larger extent, indicates their manner of orientation towards women’s empowerment.

Conclusion

Taking into account the vulnerabilities and resilience of women’s health and poor infrastructure of health sector in Myanmar, it is indispensable to make a comprehensive effort to rectify and improvise maternal health status in the country. Reduced maternal morbidity and mortality serves as the indicator of betterment in maternal health. In order to ensure improvement in reproductive and maternal health status among women in Myanmar, at the same time, alleviating maternal morbidity and mortality, it is mandatory to disseminate proper knowledge and awareness on family planning. It is required to culminate a positive insight and attitude towards family planning in the minds of women in Myanmar. In addition to keeping population growth rate in check, effective and efficient use of family planning methods should be ensured to reduce reproductive health problems and maternal morbidity and mortality rate in Myanmar. Abortion is a serious problem responsible for elevating maternal morbidity and deaths. At the same time, narrow birth intervals, lack of education, socio-economic disadvantages, improper and inadequate healthcare services and facilities, and insufficient healthcare visits before and after birth are the major factors responsible for maternal health problems and rise in maternal morbidity and mortality.

Thus, a proper awareness, identification, understanding and appropriate treatment of women’s health problem associated with pregnancy and postpartum period is mandatory. Over and above the various programmes and schemes taken up by the government and other NGOs and private health care sectors for alleviating the maternal health problems in Myanmar, spreading awareness and educating on maternal health and its associated problems among women in Myanmar is substantial. Providing formal education to empower women and overcoming gender inequalities and its impact should be given utmost attention. More engagement of skilled birth attendants and further training of auxiliary midwives should be promoted. Par excellence, the disparities, inefficiencies, disproportionate access and shortages of health services and products needs to be redressed to eliminate the maternal health problems in Myanmar.

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