Maung 3-9-15
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Transcript of Maung 3-9-15
Addressing Reproductive Health as a human right:
A multilevel approach
UCLA The Bixby Centeron
Population and Reproductive Health 09/March/2015
Dr Cynthia Maung, Mae Tao Clinc
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Overview
Eastern Burma/Border context Risks for reproductive health and barriers to care Community driven service provision
Safe delivery Access to family planning and safe abortion Gender based violence
Collaboration efforts with government and international partners Way forward
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Eastern Burma/Border Context
Successive military governments in Burma have left ethnic and rural areas without basic infrastructure or social services Roads are frequently impassable in the rainy season Communication infrastructure is weak, with those in border areas ‘catching’ signal from Thailand, China, and India to stay in touch.
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Burma’s maternal mortality rate is second worst in the region, next to Indonesia
Facilities are run‐down and under resourced
Travel restriction: access to health care, education, and training for health professional, and logistics and supplies
Informal payments are high, with 82% to 85% of healthcare expenditure out of pocket, compared to 14% in Thailand.
Eastern Burma4
Current Context
Temporary ceasefires
No political dialogue yet
Security – attacks and fighting continue in some areas
Community in conflict area have seen increased military presence
Increased economic activity and international investment
Investment leading to land confiscation and displacement
• Lessening of travel restrictions and some improvement in transport links
• Limited health services by Govin ethnic conflict affected areas
• Gov allows INGOs to provide some direct humanitarian assistance
• Gov does not formally recognize existing ethnic social structures
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Image: village protesting the damming of a river in Eastern Burma.
There are currently plans for six dams to be built on the Salween River in Shan, Karenni, and Karen States.
This is a growing driver of protest and unrest, undermining the peace process.
In October and September 2014, 2,000 people were displaced by renewed fighting in this area
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Cross border communities
Migration is driven by ongoing conflicts, militarization, environmental disasters, and human rights violations People also move between the two countries to access employment, health and social services There are an estimated 400,000 people from living in Tak province, Thailand, including refugees, migrants, and stateless persons The future of refugee camps is uncertain Migrant registration in Thailand has improved
2012: out of 3,314 babies born at the community clinic at Mae Tao clinic, only 9% had a mother or father with legal documents
2014: around 33% had a mother or father with legal documents
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• The costs of accessing care drives many people outside the country. In 2013, 57% of persons admitted to Mae Tao Clinic were living in Thailand, and 43% had travelled from Burma.
• Changes to the work permit system and improvements in access to health insurance for migrant workers have expanded access to care by particularly vulnerable groups in Thailand
• However, by the end of 2014, only 14.5% had health insurance in Tak Province
• In a survey of Mae Tao Clinic patients, 67.5% of patients living in Thailand said that they don’t know about Health Insurance or Social Security.
• 60.7% also said that they came to Mae Tao Clinic because they could not afford care in the official Thai or Burmese health systems.
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Access to Health Care
Risks for reproductive health and barriers to care
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Comparison of key indicators of reproductive health
Eastern Burma 2008
Eastern Burma 2013
Burma (National)
Thailand
Maternal Mortalityper 100,000 live births
721 n/a 200 26
Unmet need for family planning n/a 54.1% 19% 3.1%
Contraceptive prevalence 21.8% 26.7% 46% 79.6%
Antenatal careat least one visit
n/a 60.4% 83.1% 98.6%
HISWG. 2015. Long road to Recovery – Ethnic and community based health organisations lead the way to better health in Eastern Burma.www.hiswg.orgParmar PK et al. Health and human rights in eastern Myanmar prior to political transition. BMCMinistry of Health. 2013. Health in MyanmarWorld Health Observatory. Data Repository. http://apps.who.int/gho/data
Some indicators were not comparable.
The Millennium Development Goal of 130 deaths per 100,000 live births by 2015
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Barriers for accessing healthcareEastern Burma Thailand
Financial Ability to pay – informal fees, transportation Out of pocket payments 82%Lack of health insurance
Lack of health insurance, entitlement to public servicesAbility to pay – fees, transportation
Rights/Knowledge of rights
No birth certificate, health recordMilitarization and restrictions on movement
Fear of arrest/abuse of absent from workWork card retained by employer
Geography RemotenessLack of health and other infrastructure
Remoteness – seafarers, remote, highly mobile
Communication,cultural factors
Language barrierstraditional beliefs
Language barrierstraditional beliefs
Time Time to travel to care Unable to take time from work
Adapted from Chalermpol Chamchan, Kanya Apipornchaisakul. 2012. A situation Analysis on HSS for Migrants in Thailand. Institute for Population and social research, Mahidol University
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Community health network in Eastern Burma Ethnic and community groups have developed primary health services to ensure care for more than 500,000 people living in conflict affected and isolated communities. Services include control of common endemic disease, maternal and child health, environmental and school health programs. There are around 200 hundred primary health care clinics and mobile outreach teams, a handful of secondary care facilities, around a thousand primary health care workers, and several thousand village based auxiliary health care workers. While physically located in Thailand, Mae Tao Clinic is part of this network. It was founded in 1989 to address the health needs of Burmese vulnerable populations along the Thai‐Burma border in Tak province.
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Community Level Access to Safe Delivery
Local communities have developed a network of community health workers comprising maternal health workers, and traditional birth attendantsfocusing on ANC, Family Planning, Safe Delivery, and PNC. The program provides advanced training in management of basic emergency obstetric care and essential neonatal care for remote and difficult to access populations, including internally displaced communities. Mae Tao Clinic serves as a referral point for complex pregnancies, abortion complications, and obstetric emergencies. It also provides comprehensive reproductive health services for the migrant community.
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Achievements Every year we have over 3,000 safe deliveries at MTC and through field, outreach and village services, community and ethnic health providers deliver more than 10,000 babies per year in Burma.
84 % of deliveries attended by trained ethnic health workers in Eastern Burma (EBRMS 2013).
The result has been improvements in safe delivery, access in obstetric emergencies and access to birth registration, family planning, post abortion care, and referral pathways to safe abortion.
The network has gained recognition from Thai health services and, more recently, from the public hospitals in Myawaddy, Burma
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Access to family planning and safe abortion
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Access to family planning
Legal barriers: abortion is restricted Technical barriers: Human resources: providers knowledge; some methods (eg IUD) are restricted to specialist Supply chain: availability is limited in remote and conflict affected communities Social & Culture barriers: Stigmatization: particularly for young people, traditional misbelief, Fear of side effects
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Safe abortion is not provided by the Burmese health system Permanent family planning methods are limited
Safe abortion is available in Thailand, with some restrictions under Thai law Barriers for Burmese women: Cost, language, fear, lack of knowledge and beliefs, legal status
Resulting in 500‐600 women treated at MTC for complications from unsafe abortions
Number of PAC Clients2006‐2012 at Mae Tao Clinic
0
100
200
300
400
500
600
700
2006 2007 2008 2009 2010 2011 2012 2013 2014
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Ratio of post abortion care per 100 deliveries (2005‐2011) at Mae Tao Clinic
2005 2007 2009 2011 2013
Deliveries admission 1,520 2,158 2,962 3,240 3,314
Abortion admission 433 451 456 527 658
% abortion in 100 deliveries 28 21 21 16 20
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Direct Obstetric Complications (2012) at Mae Tao Clinic
71%
63956%
474%
18416%
25923%
APH/PPH
Pre-Eclampsia/Eclampsia
Prolonged Labor
PAC
Ectopic pregnancy
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Mae Tao Clinic’s Approach
MTC identified 3 priority areas to help reduce complications and unsafe abortions :
Increase access to high quality comprehensive post abortion care services
Increase awareness and knowledge of the community
Increase access to safe abortion services
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1. Increase access to high quality comprehensive post abortion care services
Upgrading facilities and Staff Skills: PAC integrated to all EmOCtraining Clinical management ( MVA within 24hrs ) Treat sepsis/hemorrhage cases with blood transfusion and IV antibiotics PAC family planning counseling and supplies before discharge from clinic STI/HIV risk assessment and VCT referral Increase access to long term family planning method Referral to Mae Sot hospital for serious complications
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2. Increased Knowledge and Awareness
Incorporate counselling on unsafe abortion for high risk client in RH department All PAC patients receive family planning counselling Outreach work through partnerships with other local organizations to provide training on family planning methods, unsafe abortion risks
Result99% of PAC Clients receiving family planning method Overall family planning method patients has increased from 3723 in 2001 to 9610 in 2011 3 successful referral cases to Mae Sot Hospital for safe abortion Efforts are being made to increase Long‐term methods
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Acceptance of long term Family Planning method (2008‐2012)
109
50
25
4
94
19
2523
69
40
33
14
108
46
41
51
96
45
36
90
0
20
40
60
80
100
120
Tubal ligation Implant Vasectomy IUD
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3. Increase Access to Safe Abortion
Developed referral system with Mae Sot Hospital for patients meeting 5 criteria Maternal factors
Physical health concern Maternal age > 35years due to increase risk of abnormality
Fetal factors Fetal abnormally or chromosomal abnormalities
Psychosocial factors Mental health evaluate by psychologist and psychiatrists
Rape (documented by police report) women under 15years who has consensual sex with her boyfriend Contraceptive failure ( Tubal ligation and IUD is eligible, must be evaluated by hospital committee )
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Gender based violenceLeadership, empowerment and protection
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Background Displacement and conflict increase the risk of women and girls to gender based violence
Many women across Burma experience sexual violence and torture, including rape, in conjunction with other civil and political violations, such as arbitrary arrest, forced labour, and detention.
Stigma and access to legal and health services are barriers to care and justice in these settings
During the more than sixty years of civil war in Burma, sexual violence by military actors has been documented in Kachin, Karen, Mon, Chin, Shan and Karenni States and condemned in UN reports
Since 2010 election, there were 100 new cases of rape by Burmese soldiers have been documented by the Women League of Burma
Most cases are linked to the military offensives in Kachin and Northern Shan States.
Trafficking and sexual slavery in migrant destination is also a threat to women and girls
Sexual violence increases the risk of unwanted pregnancy, unsafe abortion, and sexually transmitted infections.
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Community Protection
A network of women’s organizations have built a movement of solidarity to end violence against women in Burma. Activities include Protection: providing information, support and safe houses to survivors Training: community members on rights and issues relating to GBV Documentation: of state sponsored violence Advocacy: for justice for individuals, for domestic law change, and international pressure on the national government International justice: advocacy to UN and other international bodies
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Community Protection continued
Civil Society’s involvement from conflict to recovery needs to include women’s empowerment and the protection of women as part of human security. To achieve this women need to be encouraged to participate in all levels of administration. Young people have the potential with the right guidance and opportunity invested in them to bring about long lasting positive change, we need to foster this and empower them to be leaders and to move forward to achieve their goals.
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Ongoing challenges
Community health workers operating in the border areas continue to provide vital services despite lack of recognition and accreditation.
Maternal health is not limited to child birth but also includes unwanted pregnancy and unsafe abortion. Women also suffer from obstetric emergencies as a result of dangerous pregnancies. Mae Tao clinic is now integrating post abortion care to all EmOC trainings.
We are also working with community groups to improve referral of post abortion care clients to Mae Tao Clinic, and post abortion care services in selected sites in Burma.
Decades of civil conflict have resulted in thousands of children born without citizenship in either Burma or Thailand and therefore without the protections that citizenship entails.
Despite donor funding to advance Burma’s healthcare system, more work is needed for family planning services, including broad engagement with community health providers.
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Recommendations
If political reforms in 2015 are to include the expansion of public health services to previously politically and geographically isolated areas of Burma, they will require Investment and empowerment of the existing community infrastructure and human resources of Eastern Burma Recognition of the community health system and workforce Decentralisation as part of democratization process and health policy reform
Continuing cooperation between the international community, Thailand and community health system in border areas for comprehensive primary health care
Further development of cross border coordination with community health system and Thailand and Burmese health services
Support for civil society initiatives for family planning and gender based violence for vulnerable and undocumented women and girls both in Thailand and Burma
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Thank you
Further reading
Apple, B., & Martin, V: No Safe place: Burma’s Army and the Rape of Ethnic Women. Washington, D.C.: Refugees International; 2013. http://www.burmalibrary.org/docs09/No_safe_place_Burmas_army.pdf
Batley R, Mcloughlin C. Engagement with non‐state service providers in fragile states: reconciling state building and service delivery. Dev Pol Rev 2010; 28: 131
Chalermpol Chamchan, Kanya Apipornchaisakul. 2012. A situation Analysis on HSS for Migrants in Thailand. Institute for Population and social research, Mahidol University
IHRC at Harvard Law School: War Crimes and Crimes against Humanity in Eastern Myanmar. Cambridge, MA; 2014. http://hrp.law.harvard.edu/wp‐content/uploads/2014/11/2014.11.05‐IHRC‐Legal‐Memorandum.pdf
Karen Rivers Watch. 2014. Afraid to go home: Recent violent conflict and human rights abuses in Karen State Low, S et al. Human resources for health: task shifting to promote basic health service delivery amongst IDPs in ethnic
health program service areas in eastern Burma/Myanmar. Global Health Action, North America, 7, sep. 2014. Available at: http://www.globalhealthaction.net/index.php/gha/article/view/24937
MoH. 2012. Health in Myanmar. Government of Myanmar. Risso‐Gill, Isabelle et al. Health system strengthening in Myanmar during political reforms: perspectives from international
agencies. Health Policy Planning. doi:10.1093/heapol/czt0 Sollom R, Richards AK, Parmar P, Mullany LC, Lian SB: Health and Human Rights in Chin State, Western Burma. PLoS
Med 2011, 8(2):e1001007. TBC: Protection & Security Concerns in South East Burma/Myanmar (p. 17). Yangon, Myanmar 2014.
http://www.theborderconsortium.org/media/54376/report‐2014‐idp‐en.pdf Ward J, If Not Now, When? Addressing Gender‐based Violence in Refugee, Internally Displaced, and Post‐Conflict Settings.
A Global Overview, RHRC Consortium, 2002. WHO (2008). Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and
guidelines. Geneva, Switzerland: WHO.
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