Large families in the poorest regions suffer
poor health and nutrition, but access to contraception and maternal care is
limited
Ngun Bil
Sung has been helping women give birth for 32 years, ever since she had a dream
in which she was called by God to deliver babies.
Although
she has no formal training, the 67-year-old from Chin State, an isolated,
mountainous and devoutly Christian region of Myanmar, estimates she has safely
delivered 1,500 babies, including her own.
But now
she believes villagers in what is considered to be the poorest region of the
country need access to family planning advice and contraception. “For families
here to survive, both the mother and the father need to work on the farm. But
if they keep having babies constantly, women can’t work at all, and it’s very
difficult for the family to provide.”
Ngun Bil
Sung says that a third of the women she sees in the nine villages she visits
are not leaving enough space between births. Many women are old or very young,
making their pregnancies higher risk; and she’s witnessed the consequences of
some desperate and dangerous illegal abortions.
About 40%
of women in Myanmar use contraception, but in Chin State the figure is closer
to 3%. Meanwhile, Myanmar has the second highest maternal mortality rate in
south-east Asia, with 87% of those deaths occurring in rural areas. Unsafe
abortion is the third leading cause of maternal death. Abortion is illegal in
Myanmar, except to save a woman’s life.
Women in
Chin State have more babies than elsewhere in Myanmar, and evidence suggests
they struggle to support them: children in the state have the lowest health and
nutritional levels in the country. The region also has the lowest rate in the
country of births attended by a trained attendant and of births in a health
facility, at under 40% and under 5% respectively.
But
improving access to family planning services is an uphill battle. Many people
believe using contraception defies God’s wishes and promotes promiscuity. The
logistics of reaching people are also tough. Roads are frequently little more
than dirt paths, just wide enough for a motorcycle to navigate, and many of
those were washed away last summer during severe flooding and landslides. There
is almost no mobile phone reception outside the towns, and a myriad of
languages are spoken in the region, the local dialect changing from one
hillside to the next.
“To be
able to serve the Chin community, it’s clearly more expensive per head per
visit [than elsewhere],” says Dr Sid Naing, country director of Marie Stopes
International Myanmar, which opened seven branches in Chin as part of an
expansion into three remote regions in 2014.
Between
September 2014 and March 2016, Marie Stopes has seen 13,725 people in the
state.
Nun
Thiam, a 28-year-old government midwife working in a local village, regularly
encounters women who say they don’t want to have more children, but their
husbands won’t let them use contraception.
“Women
keep having babies so they can’t work any more,” she says. “It becomes their
duty to look after the children, while the husbands go to the farm and become
the sole provider of the family, so they are stuck in an inferior role. As they
keep having babies their role gets lower and lower, to the point where they
have to listen to everything their husband says.”
Dr Henri
Za Lal Lian, the MSI centre manager in Falam township, which is encouraging
more men to attend education sessions, says: “The husbands are still the key
players in their household, so male involvement is critical.”
Sex
before marriage is also a taboo in Chin State. Unmarried people who are
sexually active are often too afraid to buy contraceptives in pharmacies, where
other people might see them. MSI staff will discreetly deliver condoms and
emergency contraception to people in Falam who phone and ask for supplies or
advice.
Sex
education is not taught in Myanmar schools, so many people have little
knowledge of the options available and no concept of safe sex. Women, in
particular, are often just told by their parents to stay away from men once
they reach puberty.
“It’s
important for young women like me to have knowledge before they become sexually
active, so that they can protect themselves,” says Helen Leng Zun Rem, a
26-year-old staff member at MSI in Falam, who says some of her peers have
become pregnant unintentionally. “The things I have learned in my job will
really help me in the future.”
But
things are slowly improving.
Za Lal
Lian has been working with religious leaders to challenge attitudes to family
planning and says the organisation’s relationship with the church has improved
since the branch first opened. He says the number of clients visiting the Falam
office and attending outreach sessions in villages has risen significantly
since some pastors began letting Marie Stopes use their churches for
reproductive health education sessions, and some have actively encouraged
people to access services.
Improved
coordination with government health workers has enabled him to develop a
schedule that focuses on Falam in the rainy season and further afield when it
is drier.
There is a lack of
health and family planning awareness among people living in remote villages in
Chin. Photograph: Dave Stamboulis/Alamy
But
funding for family planning services is a problem.
MSI’s
offices in Chin are supported by the 3MDG fund, a pooled multi-donor fund
managed by the UN, but funding will end in December. Naing hopes the government
will be able to step in. It has vowed to prioritise healthcare, including
introducing a roadmap to universal health coverage by 2030.
But, he
says, “our health sector is in transition. We are not sure for the moment which
way the country is going.”
Za Lal
Lian adds: “While I have much respect for government health workers … [the
public sector is] still very much understaffed. If we stop being here it will
be a terrible loss for the villagers.”
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