One recent Monday morning, dozens of young women crowd into the waiting room of a sexual health clinic run by Marie Stopes International (MSI) in Thingangyun district, in east Yangon, Myanmar’s largest city. Many have traveled long distances by bus with their young children to get here; others were accompanied by their husbands, who are now gathered in groups outside, chewing on betel nuts.
One of the patients, May Thu Mon, 24, had an IUD inserted four months ago. She already has two children: a three-year-old son and a nine-month-old baby, who was unplanned. Now she doesn’t want any more. “I only want two children,” she says. “It’s my decision.”
So, following the nurse’s suggestion, May Thu Mon has opted for a long-term injectable implant. It lasts for three to five years, is reversible, and, for the first time, is being offered free to women who can’t afford the $100 price tag. “I see other families struggling with too many children, and they get into trouble,” says May Thu Mon. “So no more babies for me.”
For many women in Myanmar, choosing how many children to have and when to have them is an impossible luxury. Across the country, one in four women of reproductive age cannot access the modern contraceptives they need to avoid or delay pregnancy, according to the latest figures from the United Nations Population Fund (UNFPA).
Abortion is illegal in Myanmar, unless the woman’s life is in danger. But the lack of access to birth control means deaths resulting from unsafe abortion make up a large percentage of the maternal mortality statistic, which is about 200 per 100,000 live births – one of the worst rates in the region.
Hoping to bring down those numbers and fulfil the goals of Family Planning 2020, the Myanmar government has pledged to increase its contraception prevalence rate from 41 percent to above 60 percent in the next four years, and to improve contraception method mix by increasing the use of long-acting methods and decentralizing the distribution of contraceptives to the country’s districts. “We have to improve family planning services,” says Dr. Hla Mya Thway Einda, director of the maternal health and reproductive division at the Department of Public Health. “Women’s knowledge is OK; it’s accessibility that’s a problem.”
As part of the plan, the government, working with UNFPA and other NGOs, including MSI and Population Services International, has made the country’s first long-acting reversible contraceptive available through the public-health system. By expanding the availability of different types of contraception to the women who need it most – the peri-urban poor, ethnic minorities and those living in remote areas – the government hopes to reduce unsafe abortions, which, according to Dr. Hla Mya Thway Einda, account for between “20 to 35 percent of maternal deaths.”
But making different methods of contraception available is only part of the challenge. Perhaps more difficult is getting that contraception to the people who need it. About two-thirds of Myanmar’s population live in remote and rural areas with little or no access to family planning. The country suffers a lack of qualified healthcare workers and midwives and regularly runs out of medical supplies, including birth-control devices and medications. On top of that, security concerns in conflict-affected areas along the Thai-Myanmar border make it harder to get family-planning personnel and supplies to every part of the country. “The commodities are coming, but the supply chain is not there,” says Dr. Hla Hla Aye, Myanmar assistant representative at UNFPA.
But Dr. Hla Hla Aye says things are slowly changing for the better. For example, in the 1990s, those who worked in the field couldn’t even use the phrase “family planning,” as it was considered taboo; they had to say “birth spacing.” That changed in 2011, when the government began seriously investing in family planning before signing on to the global health initiative Family Planning 2020 in 2013.
Dr. Hla Hla Aye says she wants Myanmar to follow the leads of Sri Lanka and Malaysia, both of which have drastically reduced their maternal mortality ratios over the past three decades. “Every maternal death [in Myanmar] needs to be reviewed, analyzed and responded to,” she says. “This can lead to action to prevent further deaths.”
At the health clinic in Thingangyun, Dr. Lei Yee Win, who has been working there for just over three years, says she is seeing a positive shift in women and girls’ contraceptive preferences: “Most women used to like short-term contraception, but now prefer IUD or implants. They previously didn’t know the advantage of long-term contraceptives and they weren’t accessible. Now that we give long-term contraceptives, women prefer them.”
But there are still plenty of women who are wary of trying something new, despite the benefits. Mother-of-one Su Su, 25, currently uses Depo-Provera, a popular injectable birth control method that lasts three months, and is not ready to switch. “I would prefer to use a longer-term contraceptive like the implant, but I’ve never used it before, so I would rather choose short-term,” she says.
With her three-month-old baby, nicknamed Potato, sitting on her lap, Su Su says she has no plans for any more children. “There are many siblings in my family and we’re all together in the same house,” she says. “It’s too many people, so just one child for me.”
Health experts agree that women in Myanmar understand the benefits of having fewer children – now the government has to help them act on that knowledge. “No one wants to bear children every year,” says Dr. Hla Mya Thway Einda. “When we talk about quality of life, it becomes apparent a smaller family is better.”