Legalizing Male Sterilization for Reducing

Maternal Mortality in Myanmar

HLA MYAT TUN

Institute of Strategic Planning Policy Studies, College of Public Affairs

University of the Philippines Los Baños

I. INTRODUCTION

Myanmar is one of the United Nations member countries and the government has

committed to achieve the objective of Millennium Development Goals (MDGs) by 2015.

The MDGs were set by United Nations International Conference on Population and

Development (ICPD) in 1994. Among these MDGs, goals No. 5: Reduce maternal

mortality is needed to pay focus attention to meet the target by 2015. The total population

of Myanmar is estimated at 55.4 millions with annual growth rate of 2.02 percent in

2006.1 Population growth is not a serious problem and population control is not prior in

the health sector but there is a high incidence of Maternal Mortality Ratio (MMR)

because of inadequate birth spacing programmes especially for married population.

The government provides birth spacing services in health centers since 1991. The

contraceptive prevalence rate (modern methods) among married women in reproductive

age (15-49) is only 32.8 percent in 2001.2 However, male’s access to contraception and

roles or participation has not been stipulated in existing policies. The high-level decision

makers have not considered the participation of male in birth spacing activities or

programmes to reduce MMR. Men are not conscious of their shared in responsibility on

women’s health and birth spacing programmes. The general perception and knowledge

among men on the need for reproductive health is primarily for the prevention of

HIV/AIDS and Sexually Transmitted Infections (STIs). Very low appreciation on the use

of condom for birth spacing purpose and men are unconsciously ignored and

unconsciously being unequalled for birth spacing. Generally, men have yet to be

1
Statistical Year Book 2006, Central Statistical Organization, Ministry of National Planning and economic
Development, The Government of the Union of Myanmar
2
UNFPA Statistics < http://www.unfpa.org/worldwide/indicator.do?filter=getIndicatorValues>
informed, educated and provided on sexuality, reproduction, and use of contraceptive

methods. They also need the adequate information and services programmes for their

needs in birth spacing specifically for married population. Political commitment,

supportive policy and programmes are needed to enhance male participation and birth

spacing programmes particularly with the use of male sterilization among married

population. Supportive men’s role in birth spacing programmes must be emphasized to

meet the targeted aim within 6 years. Public policy decision makers, development,

population and health agencies have largely ignored men’s participation in birth spacing

even though there has no significant barriers regarding to cultural and religion within the

country.

II. Statement of the Problem

In Myanmar, abortion is illegal but the rate of occurrence of this practice is significant.

This tends to be the leading cause of maternal mortality because of unintended

pregnancies. At least 50 percent of maternal death and 20% of all hospital admission

have resulted from complication of unsafe abortion. The lack of access to contraceptive

methods and the insufficient male support in birth spacing are the major factors of

increasing abortion rate across the country3. The use of illegal and unsafe abortion

methods are in large part the result of unmet contraceptive need among women.

Maternal mortality rate is significantly high that must be reduced if not totally eliminated.

It is estimated that one in three deaths related to pregnancy and childbirth could be

avoided if all the people in the community had access to contraceptive services. The

3
Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and
Population, Yangon 2003
unmet need for contraception is estimated at 16.8 per cent among married population. 4

The government set the target at 56 per 1000 live births on MMR by 2015 based on 2001

data. The MMR was 316 per 100,000 live births in 20055 and reducing MMR within 6

years is challenging task.

One study found that the smaller the health institution in an area, the higher the abortion

rate in the surrounding area due to lack of access to contraceptive methods. The Fertility

and Reproductive Health Survey (FRHS) found out that 20% of women did not want to

get pregnant but were not using any contraceptive methods because they are not

accessible to services. The government has been promoting several contraceptive

methods to women such as pills, injectables, Intra Uterine Devices (IUDs) for temporary

contraception and female sterilization for permanent contraception with a set of criteria.

But women have some difficulties to access the services especially for the women who

are living in rural and remote areas and married population lack affordable and effective

long-term methods of contraception especially the concern of men in long-term methods

of contraception for married population have to be considered. Male involvement

programmes in reproductive health have been introduced in 2004. The use of female

sterilization is low due to a lengthy and difficult approval process. Female sterilization is

only available after approval by a sterilization board. Male sterilization is restricted by

law to those men whose wives have been approved but are unable to undergo sterilization

for medical reasons. Thus, men has the policy barrier to undergo voluntary sterilization

even though they realize that they have a significant role in saving women’s life by

4
Nationwide Cause Specific Maternal Mortality Survey 2004-2005
5
Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and
Population, Yangon 2003
taking responsibility in birth spacing among married population and to improve women

health. By providing policy, programmes and services long term contraception for men,

male sterilization, they will have lessened problems and barriers for the accessibility on

long-term contraception. However, men’s needs for birth spacing has been neglecting

even though birth spacing methods for women have been available to the public since

1991 and male involvement programmes in reproductive health have been initiated since

2004. Nevertheless, there is high demand on long term contraceptive services for married

population. Limited access to birth spacing services to women and men lead to increase

the risk of unsafe abortion and maternal death.

III. Objectives of the Study

The study carries the following objectives:

1. To analyze contraceptive use in Myanmar

2. To compare and contrast male and female contraceptive use

3. To review and analyze existing policies and programmes on contraceptive use

particularly male sterilization

4. To generate policy recommendation towards improving male participation on the

birth spacing programmes that would ultimately improve maternal health and

reduce maternal mortality in the country

IV. METHODOLOGY

This study mainly used secondary data on contraceptive use of married population in

Myanmar, maternal mortality, population of women in reproductive age and Myanmar

reproductive health policy etc. These secondary data were collected through surveys,

publications, annual reports, project reports, country reports and internet sources of

Ministry of Health, Ministry of Immigration and Population, United Nations Population

Fund (UNFPA), World Health Organization (WHO) and Population Reference Bureau.

This study used descriptive analysis. Finding and results were presented and summarized

in tabular and figure form where applicable.

V. RESULTS AND DISCUSSION

According to Family and Reproductive Health Survey 2001, the contraceptive use of

married population is shown in figure 1.

Condom
63 Male Sterilization
Injections
1.2 Pills
Female Sterilization
1.8 Any traditiional methods
4.2 IUD
0.3
8.6 Other modern methods
4.6 14.8 1.5 Not using any methods

Source: Family and Reproductive Health Survey 2001

Figure 1. Contraceptive use by married population in Myanmar (in %)

Contraceptive are mostly rely on female methods. The most popular method is injections

14.8%, followed by pills 8.6%. It shows that the demand on longer term contraception

because, probably, married population has another social concerns and they do not want

to get bothered with short-term methods. The percentage of not using any methods is the

highest 63% because of inadequate information and services among users. The

government has to provide information and services which are affordable and efficient to

married population both male and female methods. For male methods, condom

promotion programmes are the only one widely implemented led by the government but

condoms use by married men is low 0.3%, because condoms were perceived as a

preventative material for the HIV and STIs. Besides, the accessibility and acceptance of

condoms in rural areas is challenging because of several factors for instance, strong

traditional norms, lack of knowledge, transportation and distribution barriers for regular

supply of some INGOs and unaffordable price for population in the areas etc,. Male

sterilization is five times higher than condoms among the couples even though it has

restrictions by law. It shows that the government need consider the male sterilization one

of the options for contraceptive methods among married population.

According to the surveys of the Ministry of Health in 1991, 1997 and 2001, trends in

contraceptive methods use in shown in figure 2. Any modern methods of contraceptive

used are increasing more than two times, 13.6% in 1991 to 32.8% in 2001. It shows that

people are aware of contraceptive use and the programmes are effectively implementing

within the country. However, condom use was always lower than male sterilization

among married population since the government has started birth spacing programme
1991. It shows that the government has to consider male sterilization as the need for long-

term contraception among married population.

PFCS 1991 FRHS, 1997 FRHS, 2001

35

32.8
28.3
30

25

20
%

14.9

13.6
15
11.7

10
8.6
7.4

5.5

4.7

4.4

4.2
5
3.7

3.2
3.1

4
2.3
1.8

1.8
1.3
1.3

0.9
0.3
0.1

Condoms 0.1

0
Female Sterilization

Any traditiional methods

Any modern methods

Male Sterilization

IUD
Injections

Pills

Methods Used

Source: Population Changes and Family Health Survey (PFCS) 1991, Family and

Reproductive Health Survey (FRHS) 1997, Family and Reproductive Health

Survey (FRHS) 2001

Figure.2 Trends in contraceptive methods used by married population

According to the ‘‘Nationwide Cause- specific Maternal Mortality Survey” carried out by

the Department of Health in 2004-2005, maternal mortality ratio was estimated at 316 per

100,000 live births at the national level and 89 per cent of all maternal deaths were

reported from rural areas. Maternal mortality ration (MMR) by age is shown in table 1.

MMR is the highest 921.66 at the age group of 45-49 which is three to four times higher
compare with other age groups. The women in that age group 45-49 can be assumed as

they have completed desired children for the family but have inadequate services for

long-term or permanent contraception and they are in need for such methods.

Table 1. Maternal Mortality Ration (MMR) by Age (2004-2005)

No. Age Live Births MMR per 100,000 LB

1 15-19 1007 297.91
2 20-24 5091 196.43
3 25-29 6414 202.68
4 30-34 5267 265.81
5 45-49 217 921.66
Total 22478 315.86
Source: Nationwide Cause-Specific Maternal Mortality Survey 2004-2005, Ministry of

Health

Maternal mortality ration in Myanmar were presented in Health in Myanmar 2009 by

Ministry of Health is shown in table 2. MMR is higher in rural areas than urban because

of insufficient services and health personnel. Insufficient contraceptive methods in rural

and remote areas are one of the factors contributing high incidence of maternal mortality

in the country. They lack effective and affordable long-term contraception specifically

female sterilization because of the barriers in the cost and accessibility such as for

traveling, hospitalization, and proposing for sterilization approval etc.

Table 2. Maternal Mortality Ratio by Year

1988 1999 2001 2002 2003 2004 2005 2006

Maternal Mortality
Ratio
(per 1,000 live births)
Urban 1 1.8 1 1.1 0.98 0.98 0.96 0.96
Rural 1.9 2.8 1.8 1.9 1.52 1.45 1.43 1.41
Source: Health in Myanmar 2009, Ministry of Health
Men’s role in reproductive health is growing and their participation specifically in birth

spacing for reducing MMR is becoming an important agenda for the country. On World

Population Day 2008, the Minister of Immigration and Population stated “In our country,

each and every family has the right to decide their family size based on the choices of

each individual and couple.” According to his statement, having the right to decide the

desired family size, there have to be provided with choices for both male and female

contraceptive methods including male sterilization which is the only one option for long-

term or permanent methods for married men. Men sterilization has less expense,

complication and process compare to female sterilization. Lack of men long-term

contraception contributes high unwanted pregnancies among married population.

Unwanted pregnancies cause high unsafe abortion which is the leading cause of high

MMR.

Besides, for reducing MMR, the women’s health movement has to be supported by men’s

effective reproductive responsibility. However, access to male contraception was not

mentioned in existing reproductive health policies (Annex. I).

VI. CONCLUSION

Male contraception in contraceptive programmes is the important need for the country

health improvement but high-level decision makers have not considered yet the access of

male birth spacing activities in existing policies to reduce MMR. Male sterilization was

highly preferred among married population despite it is being illegal. Thus, political

commitment, programmes and services are needed to be addressed to provide male birth

spacing specifically male sterilization as one of the contraceptive methods for married

population with the aim of reducing targeted MMR by 2015. Data on men contraception

should also be collected and for further policies and programmes for male participation in

contraception.

Men’s sharing responsibility in contraception can contribute to reduce maternal death by

preventing unsafe abortion which is the leading cause of maternal mortality among

married population especially who are living in rural and remote areas. There is high

demand on long-term contraception among married population who already have finished

child bearing. Accessibility of men’s contraception should be considered and included in

existing policy and programmes which would effectively contribute in reducing

unwanted pregnancies, unsafe abortions, and maternal mortality. By fulfilling the need of

men in contraception, there are multi effects for families and country.

Reducing MMR in 6 years ahead and it is the time for the government should make

special efforts to emphasize men’s shared responsibility and promote their effective

involvement in responsible parenthood particularly in family planning, maternal health,

prevention of unwanted pregnancies and unsafe abortion.

VII. REFERENCES

Books

1. Population Changes and Family Health Survey (PFCS) 1991, Ministry of

Immigration and Population, Union of Myanmar

2. Family and Reproductive Health Survey (FRHS) 1997. Ministry of Immigration

and Population, Union of Myanmar

3. Family and Reproductive Health Survey (FRHS) 2001. Preliminary Report,

Ministry of Immigration and Population, Union of Myanmar

4. Nationwide Cause-Specific Maternal and Mortality Survey 2004-2005, Ministry

of Health, Union of Myanmar

5. Statistical Year Book 2006, Central Statistical Organization, Ministry of National

Planning and Economic Development, the Government of the Union of Myanmar

6. Responses to the list of issues and question with regard to the consideration of the

combined second and third periodic report by Convention on Elimination of All

Forms of Discrimination against Women (CEDAW), 14 October 2008

7. Myanmar Reproductive Health Policy, Maternal and Child Health Department,

Ministry of Health, the Government of the Union of Myanmar

8. Family Planning Fact Sheets: Myanmar and Birth Spacing: An Overview, World

Health Organization South-East Asia Regional Office (WHO/SEARO)

9. Contraceptive Sterilization: Global Issues and Trends, 2002. (Chapter 7, Male

Sterilization, p.161)

10. Vasectomy: Reaching Out to New Users, Population Report June 2008, Johns

Hopkins, Bloomberg, School of Public Health

11. Methods for Costing Family Planning Services, Barbara Janowitz & John H.

Bratt, United Nations Population Fund (UNFPA) & Family Health International

(FHI) 1994

12. Male Involvement in Reproductive Health, Including Family Planning and Sexual

Health, UNFPA Technical Report, No. 28

13. Contraception: An Investment in Lives, Health and Development, 2008 Series,

No.5. United Nations Population Fund

14. Men: Key Partners in Reproductive Health, Bryant Robey, Elizabeth Thomas,
Soulimane Baro, Sidki Kone, and Guy Kpakpo 1998
15. Absent and Problematic Men: Demographic Accounts of Male Reproductive
Roles, Margaret E. Greene & Ann E. Biddlecom, 1997 No. 103, Population
Council
Electronics

1. United Nations Population Fund

www.unfpa.org

2. United Nations Population Fund, Myanmar Country Office

http://myanmar.unfpa.org/

3. United Nations Population Division

http://www.un.org/esa/population/unpop.htm

4. Population Reference Bureau

http://www.prb.org/
Annex. I

Birth spacing policies in Myanmar Reproductive Health Policy

 Daily combined contraceptives, progesterone-only-pills, three-monthly injectable

contraceptives, Intra-uterine devices and condoms will be available and accessible

to all individuals of reproductive age and provided with informed choice.

 Other contraceptive methods such as monthly injectable and implants may be

introduced to broaden choice and to improve quality of birth spacing services

after considering evidenced based information, the needs of the community and

the cost effectiveness.

 Easy access to sterilization will be encouraged for those women requiring

permanent contraception on medical ground.

 Introduction of emergency contraceptive methods into the existing birth spacing

services will be considered.

 Service providers in public and private sectors will be trained in the provision of

quality birth spacing services.

 Mechanism will be sought to review and revise the existing rules and regulations

periodically, impacting the availability of commodities to ensure that safe and

effective birth spacing methods are easily available.

Men’s role in reproductive health in Myanmar Reproductive Health Policy:

 Awareness of critical reproductive health needs and the importance of

enhancement of men’s reproductive health status in improving the reproductive

health of the family will be raised.

 Men’s role in promotion of birth spacing service, prevention of transmissions of

RTI/STI and in supporting reproductive health service for the family and the

community will be strengthened.