Dynamics of contraceptive use among married women in North and South Yangon, Myanmar: findings from a cross-sectional household survey.

OBJECTIVE: The objective was to explore the sociodemographic factors associated with contraceptive use, the variation in prevalence and duration of contraceptive use across the age groups and parity among 18-49-year-old married women in North and South Yangon. STUDY DESIGN: We conducted a cross-sectional study regarding contraceptive use among married women aged 18-49 in North and South Yangon from September to November 2016. We used a questionnaire based on the Demographic and Health Surveys Program, with additional questions on the duration of contraception along the life-course. Associations between contraceptive prevalence and sociodemographic factors were tested by χ 2. We describe the percentages of contraceptive use and nonuse across the age and parity subgroups, and the mean duration of contraception. We compared the contraceptive prevalence ratios across the parity using logistic regression. RESULTS: The contraceptive prevalence of modern methods was 66% (95% confidence interval: 61.5%-69.9%) with better coverage in rural (69.6%) than in urban women (61.5%). Contraceptive use varied by age and parity, demonstrating lower prevalence in the oldest age group (45-49) and high parity (parity five and above). The mean duration of contraceptive use rose with increased age and parity, except in the oldest-age and high-parity groups. CONCLUSIONS: The findings called for greater attention to improve the contraceptive coverage of married women living in urban areas around Yangon city (periurban women). IMPLICATIONS: The study identified the pockets of low contraceptive coverage in a region with the highest contraceptive prevalence in Myanmar. Women above the age of 40 and women who had high parity had low contraceptive prevalence. Women living near the city showed lower contraceptive coverage compared to their rural counterparts.

Unmet Need for Family Planning among Urban and Rural Married Women in Yangon Region, Myanmar-a Cross-Sectional Study.

Despite increasing contraceptive use and prevalence, many women who want to avoid or delay pregnancy are not using contraceptives. This results in unintended pregnancies, which increases the risk of unsafe abortions. This study aimed to explore the extent of the unmet need for family planning (FP) among urban and rural married women in Myanmar and their demand for and satisfaction with FP. A cross-sectional survey using adapted Demographic and Health surveys questions was conducted in south and north Yangon from September 2016 to November 2016. A total of 1100 currently married women of 18-49 years participated. The contraceptive prevalence was 67.2% in total, 63% urban, and 70% rural. About 19.4% (95% CI: 16.7%-22.4%) of the studied women had an unmet need for FP, significantly higher in urban than rural women (22.6% versus 16.6%). Rural women also showed significant lesser odds (adjusted OR: 0.63; 95% CI: 0.461-0.849) of unmet need than the urban counterparts. About 86% of the women had demand for contraception and 77% of them satisfied their demand. The study population revealed a fairly good contraceptive coverage; however, a considerable proportion of women had an unmet need for FP, especially the urban women. The demand for contraception is increasing, and contraceptive services need to expand coverage to marginalized groups in order to reduce the risk of unsafe abortions.

Impoverishment and catastrophic expenditures due to out-of-pocket payments for antenatal and delivery care in Yangon Region, Myanmar: a cross-sectional study.

OBJECTIVES: (1) To assess the levels of impoverishment and catastrophic expenditure due to out-of-pocket (OOP) payments for antenatal care (ANC) and delivery care in Yangon Region, Myanmar; and (2) to explore the determinants of impoverishment and catastrophic expenditure. DESIGN, SETTING AND PARTICIPANTS: A community-based cross-sectional survey among women giving birth within the past 12 months in Yangon, Myanmar, was conducted during October to November 2016 using three-stage cluster sampling procedure. OUTCOME MEASURES: Poverty headcount ratio, normalised poverty gap and catastrophic expenditure incidence due to OOP payments in the utilisation of ANC and delivery care as well as the determinants of impoverishment and catastrophic expenditure. RESULTS: Of 759 women, OOP payments were made by 75% of the women for ANC and 99.6% for delivery care. The poverty headcount ratios after payments increased to 4.3% among women using the ANC services, to 1.3% among those using delivery care and to 6.1% among those using both ANC and delivery care. The incidences of catastrophic expenditure after payments were found to be 12% for ANC, 9.1% for delivery care and 20.9% for both ANC and delivery care. The determinants of impoverishment and catastrophic expenditure were women's occupation, number of household members, number of ANC visits and utilisation of skilled health personnel and health facilities. The associations of the outcomes with these variables bear both negative and positive signs. CONCLUSIONS: OOP payments for all ANC and delivery care services are a challenge to women, as one of fifteen women become impoverished and a further one-fifth incur catastrophic expenditures after visiting facilities that offer these services.

Inequity in the utilization of antenatal and delivery care in Yangon region, Myanmar: a cross-sectional study.

BACKGROUND: Equity of access to and utilization of healthcare across socio-economic groups is important to achieve universal health coverage. Although the utilization of antenatal and delivery care has been increasing in low- and middle-income countries, inequities in the utilization of antenatal and delivery care have been reported in many countries, but have not yet been studied in Myanmar. This study aimed to determine whether inequities in the utilization of antenatal and delivery care existed in Yangon region, Myanmar. METHODS: A community-based cross-sectional survey using multistage sampling was conducted from October to November 2016. A wealth index was selected as the main socioeconomic parameter for measuring inequities with respect to early initiation of antenatal care (ANC), number of antenatal care visits, delivery by a skilled birth attendant (SBA) and delivery by cesarean section (CS). Inequities were evaluated using concentration curves and concentration indexes. RESULTS: Of the 762 women who gave birth within the 12-month survey period, there was no evidence of inequity in utilization of ANC; however, inequity of at least one antenatal visit among women aged less than 20 years was found with a concentration index of 0.04. The concentration indexes for delivery by SBA and CS were 0.05 and 0.14, respectively. Delivery by CS was disproportionately higher in adolescents and women with higher education than middle school. CONCLUSION: There was no overall inequity in the utilization of ANC but substantial inequities in delivery by CS and SBA were shown. Social determinants of health, particularly age and education, were associated with inequities in the utilization of delivery care. Adolescent pregnant women were found to be particularly vulnerable, and thus should be a target group for strategic plans to reduce inequities in utilization of delivery care.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study.

BACKGROUND: International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries. METHODS: Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated. FINDINGS: Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations. INTERPRETATION: We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems. FUNDING: The Lowitja Institute.

Maternal, neonatal, and child health in southeast Asia: towards greater regional collaboration.

Although maternal and child mortality are on the decline in southeast Asia, there are still major disparities, and greater equity is key to achieve the Millennium Development Goals. We used comparable cross-national data sources to document mortality trends from 1990 to 2008 and to assess major causes of maternal and child deaths. We present inequalities in intervention coverage by two common measures of wealth quintiles and rural or urban status. Case studies of reduction in mortality in Thailand and Indonesia indicate the varying extents of success and point to some factors that accelerate progress. We developed a Lives Saved Tool analysis for the region and for country subgroups to estimate deaths averted by cause and intervention. We identified three major patterns of maternal and child mortality reduction: early, rapid downward trends (Brunei, Singapore, Malaysia, and Thailand); initially high declines (sustained by Vietnam but faltering in the Philippines and Indonesia); and high initial rates with a downward trend (Laos, Cambodia, and Myanmar). Economic development seems to provide an important context that should be coupled with broader health-system interventions. Increasing coverage and consideration of the health-system context is needed, and regional support from the Association of Southeast Asian Nations can provide increased policy support to achieve maternal, neonatal, and child health goals.

An approach to health system strengthening in the Union of Myanmar.

OBJECTIVES: In 2007 and 2008, Myanmar developed a health system strengthening (HSS) strategy and proposal through funding support from the Global Alliance for Vaccines and Immunization (GAVI). The aim of this paper is to identify critical success factors in the development of the HSS strategy in Myanmar. METHODS: The main source of information for this review includes international and national literature, and participant observation by the authors in the health systems analysis and HSS strategy development in Myanmar between 2007 and 2009. RESULTS: Critical success factors in the development of the HSS strategy included evidence-based development of the strategy through a sector analysis, and a long-term approach to strategy development with wide stakeholder participation. This contributed to important strategy breakthroughs in the areas of health planning, health financing, human resource management and civil society partnerships. CONCLUSION: Implementation of the HSS strategy in Myanmar should position the MOH and partners well to implement challenging system reforms in the areas of health planning, financing and human resource management in the coming years, as well as support more coordinated efforts for relief and recovery effort following the Nargis natural disaster in 2008. These innovations in Myanmar, with evidence of similar breakthroughs in other countries of the Asian region including North Korea, Cambodia, Nepal and Sri Lanka, provides promising evidence of the potential of the HSS approach as an emerging health development paradigm, particularly in relation to responding to the issue of "within country" inequities in access to health care.

Assessment of left ventricular function during upright treadmill exercise with tantalum 178 and multiwire gamma camera.

BACKGROUND: Prior studies with first-pass radionuclide angiography (RNA) during treadmill exercise used a single-crystal (Anger) or multicrystal gamma camera and technetium 99m tracers. Motion correction, when done, used point sources, which limited correction to only plane movement. METHODS AND RESULTS: We examined the performance of a multiwire gamma camera (MWGC), generator-produced tantalum 178, and a novel method of motion correction during treadmill exercise testing. We studied 100 patients in whom rest and stress gated tomographic myocardial perfusion images were obtained. Eight patients were excluded because of incomplete data. There were 53 men and 39 women aged 52 +/- 12 years. The resting left ventricular (LV) ejection fraction (EF) was 61% +/- 12% by gated single photon emission computed tomography. Stress myocardial perfusion was normal in 83 patients and abnormal in 9 patients. The resting RNA EF in the upright position was 57% +/- 12% (r = 0.52, P = .0001 vs gated EF). At peak exercise, the EF by MWGC was 60% +/- 26% if uncorrected and 69% +/- 13% after motion correction. Among the 80 patients with normal perfusion and normal resting EF by gated single photon emission computed tomography, a normal response to exercise was seen in 52 (63%) without motion correction and 74 (89%) with motion correction (P < .05). CONCLUSION: Assessment of LV function is feasible with MWGC. The motion-corrected images significantly improved the results.

Right ventricular pressure-volume loops using simultaneous radionuclide angiography with a multiwire gamma camera and right heart catheterization.

BACKGROUND: The purpose of this study was to generate right ventricular (RV) pressure-volume loops (PVLs) from time-activity curves obtained by first-pass radionuclide angiography (RNA) and RV pressures obtained by right heart catheterization. METHODS AND RESULTS: Short-lived tantalum 178 was used to obtain first-pass RNA at baseline (n = 31), after nitroglycerin (n = 5), or after the conclusion of cardiac catheterization (n = 13). From the radionuclide-derived RV ejection fraction and thermodilution stroke volume, the RV end-diastolic volume and end-systolic volume were measured. Special proprietary software was developed and used to integrate the pressure and the RNA data. The mean heart rate was 80 +/- 17 beats/min; RV ejection fraction, 39% +/- 12%; RV end-diastolic volume, 217 +/- 79 mL; RV end-systolic volume, 142 +/- 74 mL; and RV end-diastolic pressure, 10 +/- 7 mm Hg. The RV PVLs were of high quality and reproducible. CONCLUSIONS: This study provides proof of concept of the feasibility of generating RV PVL; the short half-life (10 minutes) and low energy (59 keV) of Ta-178 allow the generation of multiple loops at low radiation exposure. Such studies could be performed at the bedside and provide a wealth of information that may have clinical and research merits.

Left ventricular function in patients with type 2 diabetes mellitus.

This study showed that the mean left ventricular ejection fraction, end-diastolic volume, end-systolic volume, and muscle mass are comparable in patients with type 2 diabetes mellitus to gender-matched patients who do not have diabetes mellitus, but abnormal ejection fraction is more common in men, although not in women, with diabetes mellitus than without. The ejection fraction was higher and the volumes and muscle mass were lower in women than men in the presence or absence of diabetes mellitus.

Relation between effects of adenosine on brachial artery reactivity and perfusion pattern in patients with known or suspected coronary artery disease.

This study examined the changes in brachial artery diameter and flow velocity in response to intravenous adenosine and compared the results to cuff occlusion and single-photon emission computed tomographic (SPECT) images. The change in diameter was less with adenosine than with cuff occlusion. There was no correlation between the presence of abnormal SPECT images and the responses to adenosine or cuff occlusion in either diameter or flow velocity.

Drug-eluting stent: a review and update.

The development of stent has been a major advance in the treatment of obstructive coronary artery disease since the introduction of balloon angioplasty. However, neointimal hyperplasia occurring within the stent leading to in-stent restenosis is a main obstacle in the long-term success of percutaneous coronary intervention (PCI). The recent introduction of drug-eluting stents (DES) contributes a major breakthrough to interventional cardiology. Many large randomized clinical trials using DES have shown a remarkable reduction in angiographic restenosis and target vessel revascularization when compared with bare metal stents. The results of these trials also appear to be supported by evidence from everyday practice and non-controlled clinical trials. However, the expanded applications of DES, especially in treating complex lesions such as left main trunk, bifurcation, saphenous vein graft lesions, or in-stent restenosis, are still under evaluation with ongoing studies. With the availability of different types of DES in the market, the issue of cost should not be a deterrent and DES will eventually be an economically viable option for all patients. The adoption of DES in all percutaneous coronary intervention may become a reality in the near future. In this review article, we summarize the recent development and progress of DES as well as compare and update the results of clinical trials.

Transpharyngeal ultrasound detection of carotid body paraganglioma.

We report a patient in whom a right carotid body paraganglioma was delineated using a transpharyngeal approach during a transesophageal echocardiographic (TEE) study. Color Doppler-guided pulsed-Doppler interrogation of the right internal carotid artery in the tumor region, revealed high maximum systolic and maximum diastolic velocities of 1.5 m/s and 1.0 m/s, respectively, suggestive of tumor compression.

Transesophageal echocardiographic identification of normal and stenosed posterior intercostal arteries.

We describe our experience in using transesophageal echocardiography to identify both right and left posterior intercostal arteries and assessing them for stenosis.

Live three-dimensional transthoracic echocardiographic identification of discrete subaortic membranous stenosis.

We describe an adult patient in whom live three-dimensional transthoracic echocardiography illustrated the exact site and full extent of the subaortic membrane as well as the narrow opening within the membrane, indicative of severe stenosis. To our knowledge this has not been reported previously.