Early postnatal care contact within 24 hours by skilled providers and its determinants among home deliveries in Myanmar: Further analysis of the Myanmar Demographic and Health Survey 2015-16.

BACKGROUND: Access and use of early postnatal care (PNC) by skilled providers are crucial for reducing maternal and newborn deaths. However, use of PNC among the deliveries by skilled providers in some developing countries remains unsatisfactory. Furthermore, literature concerning PNC among home deliveries remains limited, particularly in resource-limited countries such as Myanmar. This study aimed to estimate the prevalence of having early PNC contact by skilled providers and its determinants among home deliveries in Myanmar. METHODS: This cross-sectional study used secondary data from the Myanmar Demographic and Health Survey 2015-16. We included information on all home deliveries in the interviewed mothers aged 15-49 years in the 2 years preceding the survey. Early PNC attendance and its determinants were assessed (using modified Poisson regression with robust variance estimates). All analyses were performed using STATA, Version 15. A p-value <0.05 was considered statistically significant. RESULTS: Of a total of 2,129 home deliveries, 36.1% (95%CI: 32.4%, 39.9%) did not receive PNC from any providers. Among all home deliveries included in this study, 468 (22.0%, 95%CI: 19.1%, 25.1%) received early postnatal checkup within 24 hours by skilled providers (doctors/nurses/midwives/Lady Health Visitors). Factors associated with early PNC contact among home deliveries by skilled providers included possessing higher education (adjusted Prevalence Ratio (aPR: 1.40, 95%CI: 1.01, 1.94), resident from coastal regions (aPR:1.37, 95%CI: 1.04, 1.80), currently married (aPR: 1.87, 95%CI: 1.01, 3.49), attaining antenatal care (ANC) at least four times (aPR:1.47, 95%CI: 1.22, 1.77), giving birth by a skilled birth attendant (aPR:8.80, 95%CI: 6.67, 11.61), and having access to mass media at least once weekly (aPR:1.23, 95%CI: 1.03, 1.46). CONCLUSION: A high percentage of home deliveries (78%) were not receiving early PNC by skilled providers. To facilitate early and safe PNC, expanding the coverage of skilled birth attendants and promoting the utilization of ANC should be strengthened. Targeted health education should be delivered through mass media especially for those with low education levels residing in delta, lowland, hills and plains.

Interventions to increase the uptake of cervical cancer screening in low- and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: To identify effective interventions to increase the uptake of cervical cancer screening (CCS) for low-and middle-income countries (LMICs). METHODS: We searched PubMed, CENTRAL, ISI Web of Sciences, Scopus, OVID (Medline), CINAHL, LILACS, CNKI and OpenGrey for randomized controlled trials (RCTs) and cluster RCTs conducted in LMICs from January 2000 to September 2021. Two reviewers independently screened studies, extracted data, assessed risk of bias and certainty of evidence. Meta-analyses with random-effects models were conducted for data synthesis. RESULTS: We included 38 reports of 24 studies involving 318,423 participants from 15 RCTs and nine cluster RCTs. Single interventions may increase uptake of CCS when compared with control (RR 1.47, 95% CI 1.19 to 1.82). Self-sampling of Human Papillomavirus (HPV) testing may increase uptake of CCS relative to routine Visual Inspection with Acetic Acid (RR 1.93, 95% CI 1.66 to 2.25). Reminding with phone call may increase uptake of CCS than letter (RR 1.72, 95% CI 1.27 to 2.32) and SMS (RR 1.59, 95% CI 1.19 to 2.13). Sending 15 health messages may increase uptake of CCS relative to one SMS (RR 2.75, 95% CI 1.46 to 5.19). Free subsidized cost may increase uptake of CCS slightly than $0.66 subsidized cost (RR 1.60, 95% CI 1.10 to 2.33). Community based HPV test may increase uptake of CCS slightly in compared to hospital collected HPV (RR 1.67, 95% CI 1.53 to 1.82). The evidence is very uncertain about the effect of combined interventions on CCS uptake relative to single intervention (RR 2.20, 95% CI 1.54 to 3.14). CONCLUSIONS: Single interventions including reminding with phone call, SMS, community self-sampling of HPV test, and free subsidized services may enhance CCS uptake. Combined interventions, including health education interventions and SMS plus e-voucher, may be better than single intervention. Due to low-certainty evidences, these findings should be applied cautiously.

Feasibility and readiness to implement Robson classification to monitor caesarean sections in public hospitals in Myanmar: Formative research.

Recent years have demonstrated an increase in caesarean section (CS) in most countries worldwide with considerable concern for the potential consequences. In 2015, WHO proposed the use of Robson classification as a global standard for assessing, monitoring and comparing CS rates. Currently, there is no standardized method to assess CS in Myanmar. The aim of this study was to explore health provider's perceptions about the feasibility, acceptability and readiness to implement the Robson classification in public hospitals across Myanmar. Ten maternities were purposively chosen, including all five teaching hospitals (tertiary referral hospital-level) affiliated to each medical university in Myanmar, which provide maternal and newborn care services, and district/township hospitals. Face-to-face in-depth interviews (IDI) with healthcare providers and facility administrators were conducted using semi-structured discussion guides. Facility and medical records systems were also assessed. We used the thematic analysis approach and Atlas.ti qualitative analysis software. A total of 67 IDIs were conducted. Most participants had willingness to implement Robson classification if there were sufficient human resources and training. Limited human resources, heavy workloads, and infrastructure resources were the major challenges described that may hinder implementation. The focal person for data entry, analysis, or reporting could be differed according to the level of facility, availability of human resources, and ability to understand medical terms and statistics. The respondents mentioned the important role of policy enforcement for the sustainability of data collection, interpretation and feedback. The optimal review interval period could therefore differ according to the availability of responsible persons, and the number of births. However, setting a fixed schedule according to the specific hospital for continuous monitoring of CS rate is required. In Myanmar, implementation of Robson classification is feasible while key barriers mainly related to human resource and training must be addressed to sustain.

Introducing misoprostol for treatment of incomplete abortion: A feasibility and acceptability study in secondary-level health facilities in Myanmar.

OBJECTIVE: To assess the feasibility and acceptability of misoprostol as a treatment option for incomplete abortion in secondary hospitals in Yangon and Mandalay, Myanmar. METHODS: An explanatory sequential mixed methods study was conducted. Women seeking treatment for an incomplete abortion with a uterine size <12 weeks were eligible to participate in the prospective cohort including sublingual administration of 400 µg misoprostol, clinical assessment 7-10 days after administration, and patient interview. Treatment efficacy was assessed, defined as proportion of participants with complete uterine evacuation with misoprostol alone. After the cohort, provider interviews were conducted to understand how their experiences with misoprostol may have influenced cohort findings. Study sites included seventeen secondary health facilities in four townships in Yangon and Mandalay, Myanmar. RESULTS: A total of 110 women were enrolled from July 2018 to January 2019; 96 completed follow-up. In 75 % of cases, incomplete abortion was successfully treated with misoprostol. Treatment efficacy varied significantly by region (Yangon 85 %, Mandalay 67 %; p = 0.048), driven by providers' variable comfort with misoprostol and proclivity to intervene with additional treatment. With experience, all were willing to incorporate the protocol into practice by study end. Patient acceptability and satisfaction were high. CONCLUSION: Misoprostol is an acceptable and feasible treatment option for women seeking postabortion care at secondary facilities in Myanmar. Extensive health provider training and support systems and continued implementation experience are crucial to effectively translate clinical PAC guidelines into practice in Myanmar.

International virtual confidential reviews of infection-related maternal deaths and near-miss in 11 low- and middle-income countries - case report series and suggested actions.

BACKGROUND: Obstetric infections are the third most common cause of maternal mortality, with the largest burden in low and middle-income countries (LMICs). We analyzed causes of infection-related maternal deaths and near-miss identified contributing factors and generated suggested actions for quality of care improvement. METHOD: An international, virtual confidential enquiry was conducted for maternal deaths and near-miss cases that occurred in 15 health facilities in 11 LMICs reporting at least one death within the GLOSS study. Facility medical records and local review committee documents containing information on maternal characteristics, timing and chain of events, case management, outcomes, and facility characteristics were summarized into a case report for each woman and reviewed by an international external review committee. Modifiable factors were identified and suggested actions were organized using the three delays framework. RESULTS: Thirteen infection-related maternal deaths and 19 near-miss cases were reviewed in 20 virtual meetings by an international external review committee. Of 151 modifiable factors identified during the review, delays in receiving care contributed to 71/85 modifiable factors in maternal deaths and 55/66 modifiable factors in near-miss cases. Delays in reaching a GLOSS facility contributed to 5/85 and 1/66 modifiable factors for maternal deaths and near-miss cases, respectively. Two modifiable factors in maternal deaths were related to delays in the decision to seek care compared to three modifiable factors in near-miss cases. Suboptimal use of antibiotics, missing microbiological culture and other laboratory results, incorrect working diagnosis, and infrequent monitoring during admission were the main contributors to care delays among both maternal deaths and near-miss cases. Local facility audits were conducted for 2/13 maternal deaths and 0/19 near-miss cases. Based on the review findings, the external review committee recommended actions to improve the prevention and management of maternal infections. CONCLUSION: Prompt recognition and treatment of the infection remain critical addressable gaps in the provision of high-quality care to prevent and manage infection-related severe maternal outcomes in LMICs. Poor uptake of maternal death and near-miss reviews suggests missed learning opportunities by facility teams. Virtual platforms offer a feasible solution to improve routine adoption of confidential maternal death and near-miss reviews locally.

Factors that affect the discontinuation of family planning methods in Myanmar: analysis of the 2015-16 Myanmar Demographic and Health Survey.

BACKGROUND: Access to family planning contributes up to a 44% reduction in maternal deaths. Since the majority of unplanned pregnancies and abortions occur in women who were either not using contraception or not using it consistently, greater access to contraception and more consistent use of contraception are crucial in the reduction of unplanned pregnancies and abortions. This study aims to determine which types of contraceptives are most often discontinued, the reasons for discontinuation, and the factors that influence contraceptive discontinuation for women in Myanmar. METHODS: This study is a secondary data analysis of calendar data from the 2015-16 Myanmar Demographic Health Survey. The dependent variable is discontinuation of contraception within 12 months among episodes of contraceptive use in the 5 years before the survey among women age 15-49. Multivariable logistic regression was used to identify the predictors of contraceptive discontinuation. RESULTS: The 12-month discontinuation rate for all contraceptive methods was 39%. The discontinuation rates for short-term methods were remarkably high (43% for pills and 42% for injectables), while the rate for long-term methods was very low (7% for intrauterine devices and 0.2% for implants). Discontinuation while still in need of contraception was high (55%) although 28% of those women switched to other modern methods. Multivariable logistic regression showed the factors associated with contraceptive discontinuation were a woman's age, location (state/region), wealth, and number of births within the past 5 years. CONCLUSIONS: The high rate of discontinuation while in need is very alarming given goals to reduce the unmet need for family planning in Myanmar. Family planning programs must ensure timely, informed method-switching by women who discontinue contraception, especially among women for whom discontinuation is the highest (age 45-49, middle and richest wealth quintile, regions where high discontinuation and multiparity); increase the availability of long-term contraceptive methods, and improve counseling that ensures clients' informed and voluntary choice of family planning services.

The salt between the beans: a qualitative study of the role of auxiliary midwives in a hard-to-reach area of Myanmar.

BACKGROUND: Auxiliary Midwives (AMWs) are unpaid volunteer health workers assisting qualified paid midwives in maternal and child health care mainly in hard-to-reach areas of Myanmar. This paper describes the relationship between AMWs and the health system in providing maternal and child services as perceived by the community, AMWs themselves and health care providers in one remote township of Myanmar. METHOD: A qualitative study was conducted in Ngape Township, Myanmar. A total of 15 focus group discussions with midwives, AMWs, community members and mothers were conducted. Ten key informant interviews were performed with national, district and township level health planners and implementers of maternal and child health services. Thematic analysis was done using the ATLAS.ti software. RESULTS: AMWs occupy a unique position between the community and the health sector in the study township. The relationship and trust with the community is built upon prolonged presence providing health care, skill building and fulfilling community expectations. Health care providers' expectations to provide only preventive care, health promotion and education and childbirth care are often exceeded in reality when emergencies occur in hard-to-reach areas. This challenge to handle emergency situations with no support and limited skills and training is considered as most difficult by the AMWs. This mismatch of service provision expectations by both the community and other health care providers has put AMWs in a position which they describe as being the "salt between the beans" an essential ingredient but often invisible between the beans. CONCLUSION: The trust and relationship developed by AMWs over four decades of community practice serving as the mediator role is an untapped resource that can facilitate future community-based maternal and child health interventions in Myanmar.

Women's knowledge on common non-communicable diseases and nutritional need during pregnancy in three townships of Ayeyarwaddy region, Myanmar: a cross-sectional study.

BACKGROUND: Health systems in many countries do not adequately address non-communicable diseases (NCDs) during pregnancy, especially in low- and middle-income countries. In Myanmar, most studies on NCDs have investigated risk factors and prevalence of NCDs in the general population. This study aimed to assess the level of knowledge of common NCDs and nutritional need during pregnancy and to identify the factors associated with such knowledge, in three townships of Ayeyarwaddy region in Myanmar. METHODS: A cross-sectional study was conducted among pregnant women aged between 18 and 49 years. We interviewed 630 pregnant women by using a pretested structured questionnaire. Knowledge questionnaire had five categories: general knowledge in NCDs, hypertension, diabetes, anemia, and nutritional need during pregnancy. Knowledge scores ranged from 0 to 56. We used Bloom's cut-off point to classify the knowledge into three levels: low level as 59% or below (0-33 scores), moderate level as 60-80% (34-49 scores), and high level as 80-100% (50-56 scores). We conducted multiple linear regression analyses to find the association between different exposure variables (behavioral risk factors, pre-existing NCDs in pregnant women, and family history of NCDs) and knowledge on common NCDs and nutritional need during pregnancy adjusted for socioeconomic factors. RESULTS: Among pregnant women, 64.8% had moderate level of knowledge, 22.7% had low level, and only 12.5% had high level. The mean knowledge scores were 39.6 (standard deviation 10.2). Pregnant women with the following factors were more likely to have higher knowledge: their belonging to the second, middle, and fourth quintiles of wealth index and their family members' status of having some kind of NCDs. CONCLUSIONS: Majority of pregnant women had low to moderate level of knowledge on common NCDs and nutritional need during pregnancy. Wealth and family history of NCDs were significantly associated with their knowledge. Prevention and promotion of NCDs should be integrated in maternal and child health programs and should emphasize for the pregnant women who are in the poorest or richest wealth quintiles and who do not have family history of NCDs.

The potential of task shifting selected maternal interventions to auxiliary midwives in Myanmar: a mixed-method study.

BACKGROUND: An estimated 282 women die for every 100,000 live births in Myanmar, most due to preventable causes. Auxiliary Midwives (AMWs) in Myanmar are responsible for providing a package of care during pregnancy and childbirth to women in rural hard to reach areas where skilled birth attendants (Midwives) are not accessible. This study aims to examine the role of AMWs in Myanmar and to assess the current practices of three proposed essential maternal interventions (oral supplement distribution to pregnant women; administration of misoprostol to prevent postpartum haemorrhage; management of puerperal sepsis with oral antibiotics) in order to facilitate a formal integration of these tasks to AMWs in Myanmar. METHODS: A mixed methods study was conducted in Magwe Region, Myanmar involving a survey of 262 AMWs, complemented by 15 focus group discussions with midwives (MWs), AMWs, mothers and community members, and 10 key informant interviews with health care providers at different levels within the health care system. RESULTS: According to current government policy, AMWs are responsible for identifying pregnant women, screening for danger signs and facilitating early referral, provision of counselling on nutrition and birth preparedness for women in hard-to-reach areas. AMWs also assist at normal deliveries and help MWs provide immunization services. In practice, they also provide oral supplements to pregnant women (84%), provide antibiotics to mothers during the puerperium (43%), and provide misoprostol to prevent postpartum haemorrhage (41%). The current practices of AMWs demonstrate the potential for task shifting on selected essential maternal interventions. However, to integrate these interventions into formal practice they must be complemented with appropriate training, clear guidelines on drug use, systematic recording and reporting, supportive monitoring and supervision and a clear political commitment towards task shifting. CONCLUSION: With the current national government's commitment towards one AMW in one village, this study highlights the potential for shifting specific maternal lifesaving tasks to AMWs.