Bixby Center Lecture held on March 9, 2015 by Dr. Cynthia Maung, Mae Tao Clinic

1. Addressing Reproductive Health
as a human right:
A multilevel approach
UCLA The Bixby Center
on
Population and Reproductive Health
09/March/2015
Dr Cynthia Maung, Mae Tao Clinc
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2. 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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3. 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.
3
 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.

4. Eastern Burma
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5. 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 Gov
in ethnic conflict affected areas
• Gov allows INGOs to provide
some direct humanitarian
assistance
• Gov does not formally recognize
existing ethnic social structures
5

6. 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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7. 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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8. • 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

9. Risks for reproductive health and
barriers to care
9

10. Comparison of key indicators of reproductive health
Eastern Burma
2008
Eastern Burma
2013
Burma
(National)
Thailand
Maternal Mortality
per 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 care
at 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.org
Parmar PK et al. Health and human rights in eastern Myanmar prior to political transition. BMC
Ministry of Health. 2013. Health in Myanmar
World 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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11. Barriers for accessing healthcare
Eastern 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 services
Ability to pay – fees, transportation
Rights/
Knowledge of rights
No birth certificate, health record
Militarization and restrictions on
movement
Fear of arrest/abuse of absent from
work
Work card retained by employer
Geography Remoteness
Lack of health and other
infrastructure
Remoteness – seafarers, remote,
highly mobile
Communication,
cultural factors
Language barriers
traditional beliefs
Language barriers
traditional 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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12. 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.
12

13. 13

14. Community Level Access to Safe Delivery
 Local communities have developed a
network of community health workers
comprising maternal health workers,
and traditional birth attendants
focusing 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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15. 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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16. Access to family planning and
safe abortion
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17. 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

18. Number of PAC Clients
2006‐2012 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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19. 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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20. Direct Obstetric Complications (2012)
at Mae Tao Clinic
7
1%
639
56%
47
4%
184
16%
259
23%
APH/PPH
Pre-Eclampsia/Eclampsia
Prolonged Labor
PAC
Ectopic pregnancy
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21. 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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22. 1. Increase access to high quality
comprehensive post abortion care services
 Upgrading facilities and Staff Skills: PAC integrated to all EmOC
training
 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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23. 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
Result
99% 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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24. Acceptance of long term Family Planning
method (2008‐2012)
109
50
25
4
94
19
25
23
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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25. 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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26. Gender based violence
Leadership, empowerment and protection
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27. 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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28. 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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29. 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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30. 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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31. 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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32. 32
Thank you

33. 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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