Ownership and use of insecticide-treated nets in Myanmar: insights from a nationally representative demographic and health survey.

BACKGROUND: Malaria poses a substantial public health threat in Myanmar, indicating the need for rigorous efforts to achieve elimination of the disease nationwide by 2030. The use of insecticide-treated nets (ITNs) forms part of a pivotal strategy for preventing transmission. This study explored the ownership and use of ITNs in Myanmar and identified factors associated with non-use of ITNs. METHODS: Household datasets from the 2015-2016 Myanmar Demographic and Health Survey were utilised, which encompassed all household members except children under the age of five. Descriptive statistics and inferential tests, including simple and multiple logistics regression models and Pearson correlations, were employed for analysis. All analyses, taking the two-stage stratified cluster sampling design into account, used weighting factors and the "svyset" command in STATA. The ownership and use of bed nets were also visualised in QGIS maps. RESULTS: Among the 46,507 participants, 22.3% (95% CI 20.0%, 24.5%) had access to ITNs, with only 15.3% (95% CI 13.7, 17.1%) sleeping under an ITN the night before the survey. Factors associated with the non-use of ITNs included age category (15-34 years-aOR: 1.17, 95% CI 1.01, 1.30; 50+ years-aOR: 1.19, 95% CI 1.06, 1.33), location (delta or lowland-aOR: 5.39, 95% CI 3.94, 7.38; hills-aOR: 1.80, 95% CI 1.20, 2.71; plains-aOR: 3.89, 95% CI 2.51, 6.03), urban residency (aOR: 1.63, 95% CI 1.22, 2.17), and wealth quintile (third-aOR: 1.38, 95% CI 1.08, 1.75; fourth-aOR: 1.65, 95% CI 1.23, 2.23; fifth-aOR: 1.47, 95% CI 1.02, 2.13). A coherent distribution of the ownership and use of ITNs was seen across all states/regions, and a strong correlation existed between the ownership and use of ITNs (r: 0.9795, 95% CI 0.9377, 0.9933, alpha < 0.001). CONCLUSIONS: This study identified relatively low percentages of ITN ownership and use, indicating the need to increase the distribution of ITNs to achieve the target of at least one ITN per every two people. Strengthening the use of ITNs requires targeted health promotion interventions, especially among relatively affluent individuals residing in delta or lowland areas, hills, and plains.

Socioeconomic inequalities in skilled attendance at birth and caesarean section rates in Myanmar 2015-2016: a cross-sectional study.

OBJECTIVES: This study aims to assess inequalities in skilled birth attendance and utilisation of caesarean section (CS) in Myanmar. STUDY DESIGN: Cross-sectional study design. SETTING AND POPULATION: We used secondary data from the Myanmar Demographic and Health Survey (2015-2016). Our outcome measures of skilled birth attendance and utilisation of CS were taken from the most recent birth of interviewed women. Absolute and relative inequalities across several sociodemographic characteristics were assessed and evaluated by calculating rate differences, rate ratio and concentration indexes. RESULTS: More than one-third (36%, 95% CI 32.5% to 39.4%) of women gave birth without a skilled birth attendant present at their most recent birth. 40.7% (95% CI 37.8% to 43.7%) gave birth in healthcare facilities, and the CS rate was 19.7% (95% CI 17.9% to 21.8%) for their most recent birth. The highest proportion of birth without a skilled provider was found in the hilly regions and rural residents, poorest and less educated women, and those with less than four antenatal care visits. Inequalities in birth without a skilled provider were observed across regions, place of residence, wealth quintile, education level and number of antenatal care taken. The highest rate of CS was found among plain regions and urban residents, richest women, more than secondary education, those with more than four antenatal care visits and in private health facilities. Inequalities in CS utilisation were observed across place of residence, wealth quintiles, education level, number of antenatal care taken and type of health facilities. CONCLUSION: This study provides evidence regarding inequalities in maternal health service utilisation in Myanmar. Increasing maternal health service availability and accessibility, promoting quality of care and health education campaigns to increase maternal health services utilisation are recommended.

School-based comprehensive sexuality education for prevention of adolescent pregnancy: a scoping review.

BACKGROUND: Adolescent pregnancy is a global public health problem. Numerous approaches for Comprehensive Sexuality Education (CSE) delivery in schools have been implemented around the world. Previous reviews on CSE did not follow the International Technical Guidance on Sexuality Education (ITGSE) because CSE is very diverse in terms of population, interventions, settings and outcomes. We conducted this scoping review to identify and map the evidence of school-based CSE for prevention of adolescent pregnancy with emphasis on adolescents' contraceptive use, unintended pregnancy and abortion. METHODS: We searched PubMed, CENTRAL, Scopus, ISI Web of Science, CINAHL, and WHO ICTRP to identify potential eligible studies from their inception to 4th Nov 2023.We included randomized controlled trials (RCTs) and non-RCTs of CSE implemented in public or private schools for adolescents. CSE was defined as a multi-session intervention in school that covered topics including contraception, pregnancy, abortion, and HIV/STI. School-based interventions were the main intervention that may be either stand-alone or multicomponent. There was no limitation on study's geographical area, but only English-language studies were considered. Two reviewers selected and extracted data independently, discussed for consensus or consulted the third reviewer if there were discrepancies for final conclusion. Data were presented using figures, map and table. RESULTS: Out of 5897 records, 79 studies (101 reports) were included in this review. Most studies were conducted in the United States and other high-income countries in secondary or high schools with cluster RCTs. All studies included participatory methods. Almost all studies included Sexual and Reproductive Health which is the eighth concept of CSE. Very few studies reported the prespecified primary outcomes of contraceptive use during last sex, unintended pregnancy and abortion and hence this highlighted the gaps of available evidence for these outcomes. The number of concepts, components, duration and providers of CSE varied across the included studies. However, none of the interventions identified in this scoping review adhered to the ITGSE recommended approach. CONCLUSIONS: Our scoping review shows gaps in school-based CSE implementation in terms of completeness of concepts, components, providers, duration and outcomes recommended by ITGSE.

Determinants of correct knowledge on tuberculosis transmission and self-reported tuberculosis prevalence among general population aged 15-49 years in Myanmar.

INTRODUCTION: Myanmar has been identified as one of the tuberculosis (TB) high-burden countries and having an understanding of TB transmission is vital for personal infection prevention as well as preventing transmission to others. This study aimed to identify the determinants of correct knowledge on TB transmission and self-reported TB prevalence among general population in Myanmar. METHODS: This is a cross-sectional study using secondary data from Myanmar demographic and health survey 2015-16. The determinants of correct knowledge on TB transmission mode and self-reported prevalence of TB were assessed using multivariable logistic regression models. Weighted estimates were provided in all analyses to account for the multistage sampling design used in the survey. RESULTS: Among the respondents, less than half (44.6%, 95% CI: 43.9, 45.4) had the overall correct knowledge about TB transmission and misconceptions. Older age group, female gender, those with higher education and higher socioeconomic status, and exposed to mass media at least once a week, residents from the delta and lowland region or plain areas were more likely to have correct knowledge about TB transmission. The overall prevalence rate of self-reported TB was 2.6% (95%CI: 2.4, 2.9) and the prevalence was higher among older age group and males. CONCLUSION: Our study highlights the need for targeted efforts to improve awareness and understanding of TB transmission among general population in Myanmar. The study suggests the implementation of appropriate, innovative, and comprehensive targeted TB education and communication strategies.

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.

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.

Fentanyl for labour pain management: a scoping review.

BACKGROUND: Labour pain has been identified as an important reason for women to prefer caesarean section (CS). Fentanyl is one of the short acting opioids recommended by World Health Organization for pain relief during labour. This study aimed to identify and describe the available evidence on the use of fentanyl (monotherapy) for labour pain management by any routes of administration or regime. METHODS: We included the records published until 31 December 2021 which reported administration of fentanyl to women with normal labour for labour pain relief. Data were extracted by one reviewer and checked by another reviewer using a standardised agreement form. We mapped and presented data descriptively in figure and tabular format. RESULTS: We included 51 records from 49 studies in our scoping review. The studies were conducted in 12 countries, mostly high-income countries. The study designs of the 51 included records were varied as follows: 38 (74.5%) experimental studies (35 randomised controlled trials and three quasi-experimental studies), and 12 (23.5%) observational studies (five retrospective cohort studies, four prospective cohort studies, two retrospective descriptive studies, and one descriptive study) and one qualitative study. Of the included records, six used intranasal fentanyl, five used subcutaneous fentanyl, 18 (35.3%) used intravenous fentanyl, 18 (35.3%) used intrathecal fentanyl, and nine used epidural fentanyl. Many records compared fentanyl with another analgesic agent while five records (9.8%) had no comparison group and seven records (13.7%) compared with no analgesia group. The doses of fentanyl varied by routes, study and the requirement depended on the women. Pain assessment was the most frequent outcome measure presented in the records (78.4%). Only nine records (17.6%) investigated women's satisfaction about labour pain relief using fentanyl and seven records (13.7%) reported the effect of fentanyl on breastfeeding. The most common reported neonatal outcomes were foetal heart rate (33 records, 64.7%) and Apgar score (32 records, 62.7%). CONCLUSION: There is limited primary evidence especially randomised controlled trials to evaluate the effectiveness and harms of different routes of fentanyl in low- or middle-income countries. There is a need for high-quality research to establish the most effective route of fentanyl and associated effects for evidence-based international guidelines.

Utilization of insecticide-treated bed nets among pregnant women in Myanmar-analysis of the 2015-2016 Demographic and Health Survey.

BACKGROUND: Due to the effectiveness of insecticide-treated nets (ITNs), most malaria-endemic countries resort to free distributions in the population with particular attention to pregnant women, a more vulnerable group. However, the mere issuance of ITNs does not usually translate to proper utilization. This study aimed to examine the utilization of ITNs and its associated factors among pregnant women in Myanmar. METHODS: The data analyzed in this cross-sectional study were extracted from available survey datasets of the 2015-16 Myanmar Demographic Health Survey. The secondary data were presented using a chart, descriptive statistics and inferential statistics including simple and multiple logistic regression models. All analyses were performed using STATA, Version 15. A p-value <0.05 was considered statistically significant. RESULTS: Of 466 currently pregnant women, the majority (96%) possessed bed nets for sleeping. Among them, 15.9% slept without a bed net the night before the survey, while 65.7% slept with untreated nets. Only about 1 in 5 (18.4%) slept under ITNs. In the multivariate logistic regression analysis, pregnant women residing in delta and lowland regions [adjusted odds ratio (aOR) = 7.70, 95% confidence interval (CI): 3.62, 16.38], plains (aOR = 7.09, 95%CI: 3.09, 16.25) or hilly areas (aOR = 4.26, 95%CI: 1.91, 9.52) were more likely to report non-utilization of ITNs than those residing in coastal regions. CONCLUSION: Relatively poor ITN utilization was observed among pregnant women in Myanmar. Health promotion activities for ITN utilization should be implemented especially for pregnant women residing in the delta, lowland, plain and hilly regions. Other social-behavioral factors including perceived susceptibility to malaria, knowledge of ITNs, and attitude towards ITN that might favor the non-utilization of ITNs need to be further explored.

A qualitative study on acceptability of the mistreatment of women during childbirth in Myanmar.

BACKGROUND: Improving the quality of maternal health care is critical to reduce mortality and improve women's experiences. Mistreatment during childbirth in health facilities can be an important barrier for women when considering facility-based childbirth. Therefore, this study attempted to explore the acceptability of mistreatment during childbirth in Myanmar according to women and healthcare providers, and to understand how gender power relations influence mistreatment during childbirth. METHODS: A qualitative study was conducted in two townships in Bago Region in September 2015, among women of reproductive age (18-49 years), healthcare providers and facility administrators. Semi-structured discussion guides were used to explore community norms, and experiences and perceptions regarding mistreatment. Coding was conducted using athematic analysis approach and Atlas.ti. Results were interpreted using a gender analysis approach to explore how power dynamics, hierarchies, and gender inequalities influence how women are treated during childbirth. RESULTS: Women and providers were mostly unaccepting of different types of mistreatment. However, some provided justification for slapping and shouting at women as encouragement during labour. Different access to resources, such as financial resources, information about pregnancy and childbirth, and support from family members during labor might impact how women are treated. Furthermore, social norms around pregnancy and childbirth and relationships between healthcare providers and women shape women's experiences. Both informal and formal rules govern different aspects of a woman's childbirth care, such as when she is allowed to see her family, whether she is considered "obedient", and what type of behaviors she is expected to have when interacting with providers. CONCLUSIONS: This is the first use of gender analysis to explore how gender dynamics and power relations contribute to women's experiences of mistreatment during childbirth. Both providers and women expected women to understand and "obey" the rules of the health facility and instructions from providers in order to have better experiences. In this way, deviation from following the rules and instructions puts the providers in a place where perpetrating acts of mistreatment were justifiable under certain conditions. Understanding how gender norms and power structures how women are treated during childbirth is critical to improve women's experiences.

HIV Testing among General Population with Sexually Transmitted Infection: Findings from Myanmar Demographic and Health Survey (2015-16).

BACKGROUND: Human Immunodeficiency Virus (HIV) testing and counseling is recommended for people with Sexually Transmitted Infections (STIs). In Myanmar, HIV testing and its predictors among those with STI in general population is unknown. METHODS: This is a cross-sectional study using secondary data from Myanmar demographic and health survey 2015-16. We included all women and men aged 15-49 years that reported having STI in the past 12 months. Self-reported HIV testing and its predictors were assessed (using modified Poisson regression with robust variance estimates). We have provided weighted estimates as the analyses were weighted for the multistage sampling design. RESULTS: Of 998 self-reported STIs, 96 [9.6%, 95% confidence interval (CI): 7.5, 12.1] had been tested for HIV in the past 12 months. Respondents who were residing in hilly regions [adjusted prevalence ratio (aPR): 2.28, 95% CI: 1.29, 4.04] were more likely to have taken the HIV test. However, people in the poorest quintile (aPR: 0.34, 95% CI: 0.12, 0.96) and those who were staying at the current residence for more than 12 months (aPR: 0.45, 95% CI: 0.25, 0.79) were less likely to have taken HIV test. CONCLUSION: There is a necessity to promote HIV literacy and HIV testing among those with STI with focus on the poorest populations.

Reported measles cases, measles-related deaths and measles vaccination coverage in Myanmar from 2014 to 2018.

BACKGROUND: There is a global resurgence of measles, consequent upon worldwide stagnating measles vaccination coverage. The study aim was to document trends and characteristics of reported cases of measles, measles-related deaths, and measles vaccination coverage (MCV1-first dose of measles-containing vaccine and MCV2-second dose of measles-containing vaccine) at national and sub-national level in Myanmar over a five year period between 2014 and 2018. METHODS: This was a descriptive study using routine data collected and submitted to the Expanded Programme on Immunization. RESULTS: Between 2014 and 2018, there were 2673 measles cases of which 2272 (85%) occurred in 2017 and 2018. Five adjacent regions in lower Myanmar were the most affected: in 2017 and 2018, these regions reported 1647 (73%) of the 2272 measles cases in the country. Overall, 73% of measles cases were laboratory confirmed, 21% were epidemiologically linked, and 6% were clinically compatible (clinical diagnosis only), with more laboratory confirmed cases in recent years. Annual measles-related deaths were either zero or one except in 2016 when there were 21 deaths, all occurring in one remote village. In the recent years, the most commonly affected age groups were 0-8 months, 9 months to 4 years, and ≥ 15 years. Among 1907 measles cases with known vaccination status, only 22% had been vaccinated and 70% of those had only received one dose of vaccine. Annual MCV1 coverage nationally varied from 83 to 93% while annual MCV2 coverage nationally varied from 78 to 87%, with no clear trends over the years. Between 2014 and 2018, a high proportion of the 330 townships had MCV coverage < 95%. Over 80% of measles cases were reported from townships that had MCV coverage < 95%. CONCLUSION: There have been a large number of measles cases in recent years associated with sub-optimal measles vaccine coverage. Myanmar has already conducted supplemental immunization activities in October and November, 2019. Myanmar also needs to improve routine immunization services and targeted responses to measles outbreaks.

Knowledge of potential risk of blood-borne viral infections and tattooing practice among adults in Mandalay Region, Myanmar.

INTRODUCTION: Tattooing especially gains popularity among both men and women in adulthood from the wide range of socioeconomic groups and is noted as a risk taking behaviour in adults. Especially when tattooing does not perform to the highest standards, it can potentially be the hazardous practice. Myanmar has a paucity of evidence-based information on the estimated prevalence of tattoos and awareness of potential disease transmission from tattooing under insanitary conditions as well as the infection risk. The present research was undertaken to help identify the self-reported prevalence of tattooing among adults (18-35 years) and their knowledge of transmission risk of blood-borne infections and its determinants. METHODS: A community-based cross-sectional study focused on residents aged 18-35 years was carried out in two urban and two rural areas in Mandalay district, Mandalay Region during 2015. Trained interviewers used a pre-tested structured questionnaire for face-to-face interviews with one eligible participant per selected household (n = 401). Bivariate analysis and multivariable analysis using binary logistic regression were done to ascertain the relevant explanatory variables. RESULTS: The overall self-reported prevalence of tattooing was 19.5% (78/401) (95% CI = 16-24). Nearly 80% of participants (318/401) knew at least one blood-borne viral infection that could be transmitted from tattooing. The persons who had high formal education, manual laborers and those who lived with their families were significantly more likely to cite at least one blood-borne viral infection. Their perceived possibility to remove tattoo independently influenced the practice of tattooing (aOR = 1.91, 95% CI = 1.06-3.45; p = 0.03) compared with participants who reported no perceived possibility. Tattooing was more common in male (aOR = 13.07, 95% CI = 6.25-27.33; p<0.001) compared to female which was independently significant. CONCLUSIONS: This study ascertained the tattoo prevalence as two in ten adults of working age especially among male in central part of Myanmar in the context of lack of registration system for tattoo parlours and the issuance of safety guidelines. Findings have suggested the target groups and risk factors to be included in future health promotion programs. Future research directions should focus on perspectives of tattooists to create and sustain the sanitary practices to reduce the chance of transmission of blood-borne viral infections.