Cer Lui had to make a split decision — to either drive herself to the hospital more than six hours away by motorbike, or stay in her home with her seven children — and deliver her baby.
When her husband found her, she had bled to death due to post-delivery bleeding.
She’s just one of 2,800 women in Burma who die every year from preventable causes related to pregnancy and childbirth.
Every year in Chin State, 357 deaths per 100,000 live births are due to pregnancy-related causes, the highest maternal mortality rate in the country. This is nearly 10 times higher than that of neighbouring Thailand. Burma’s national mortality rate is 282.
Looking at the numbers, what’s gut-wrenching is that many of these deaths could have been prevented through quality antenatal, obstetric and perinatal care, says Janet Jackson, the United Nations Population Fund’s (UNFPA) representative in Burma.
Probing into the figures reveals that most deaths occur postnatally. Jackson expands on what some of these cases may look like: “In the afterbirth, if the placenta has not come away fully, and a tiny bit is left, that can become septic. Or you may have a situation when a woman is bleeding more than she should be, [or] the uterus doesn’t contract quickly and is open to an infection that could be life threatening.”
Improving the training of midwives is a key part of the solution, she adds.
Digging deeper into the numbers
Burma’s maternal mortality rate is the second-highest in ASEAN. To investigate the causes of this, the UNFPA and World Health Organization are supporting the government’s introduction of a maternal death survey.
For the first time, data analysis workshops are also being held across the country to plan services and a community response to census data on maternal and infant mortality that was collected in 2014.
On a misty morning in the mountain-perched town of Falam, community members gathered in the town hall and discussed the high maternal mortality rate in Chin State.
“Discussing women dying during childbirth is still very sensitive,” explains Aye Thazin Aung, who has worked as a midwife for 15 years in Chin State.
Many are hesitant to talk about the subject because they see it as bringing shame upon the community or family.
But indications that these sensitive issues are now being talked about more openly might best be represented by the image of police and military officers delivering their thoughts on the causes of maternal mortality to a packed public hall in Falam last month.
Police Commander Ye Win Tat Kyaw lists low health education, transport issues and induced abortions as some of the contributing factors to the high maternal mortality rate. To tackle these causes, he said “we should do health education and clinics in every region” as a start.
Roads are slowly being upgraded in Chin State, which will improve transport struggles, particularly during the rainy season, but building clinics in every village is not feasible.
As well as being one of Burma’s poorest regions, Chin State’s terrain is rugged and mountainous, its road network is threadbare and settlements are diffuse.
“Ideally you have health facilities in reasonably accessible areas for everyone in the whole country and those should be fully equipped and have well trained staff, but because of those challenges it’s not going to happen in a year or even five,” said Marie Stopes country director Dr Sid Naing.
So what now? In the meantime, outreach and mobile clinics are potential quick fixes.
Broadly speaking, the reasons for the high maternal mortality rate are clear: Bleeding and infection are the leading medical causes of death among women during pregnancy and childbirth. Unsafe abortion is the third most common cause of maternal death in Burma.
But the obstacles to improving the situation are less clear. Challenges surround the distribution of medical information, and ensuring a supply of trained staff and clinics with sufficient medical supplies.
Retaining staff in isolated rural regions is also challenging due to cultural differences and language barriers. For nurse May Thu Toe, one problem she experiences is the language barrier. Most nurses are assigned by the government to their outposts and many often only speak Burmese and not the local tribal languages.
So information sessions in isolated villages aren’t always a clear exchange of information. “Some women wouldn’t understand the messages and will still look for an abortion.” In such cases May Thu Toe can only try to provide information about how best to deliver the child in a clinic, rather than homebirth, to protect the health of the mother and newborn child. What’s at the heart of experiences like this is also the need for more education about contraceptives, she believes. Abortion is illegal in Burma.
Saving lives through contraception
Last year $1.6 million was invested in contraceptives by the UNFPA, to tackle access issues, as only just over 50 percent of married women practice family planning.
In Christian-majority Chin State, many pressures are put on women around their choices to access contraceptives. To raise the question of family planning is still controversial.
Mother of five Nuam Lang explains, “I don’t want to have any more children but I am Roman Catholic and cannot use contraceptives.” Her husband can’t find regular work and she is worried that she will not be able to support her children’s clothing, food and education needs if she has any more children.
“I know need to do family planning but I have no money, I also need to take vitamins first and contraceptive drugs will only make me feel dizzy,” she states, while her youngest baby sleeps contently in a sling wrapped around her body. Here lies one of the biggest challenges when it comes to encouraging women to consider choosing contraceptive use: myths and misconceptions.
Like Nuam Lang, another mother, 20-year-old Hrang Hlen Cer, said she didn’t want to use contraceptives such as the birth control pill, as she believed there would be health repercussions like feelings of dizziness, heavier menstruation and pain.
Although midwife Aye Thazin Aung has tried to dispel myths surrounding contraceptives, she says it is very difficult to change many women’s minds.
Retired district lawyer Sui Thluai says cultural barriers play a part as well: “Men’s attitudes also need to change, as although some women may want to access family planning, their husbands will forbid and threaten to divorce the women.”
To break down some of these cultural barriers, health workers are also running outreach information sessions in hard-to-reach villages as well as information services in churches and youth hotspots.
When D’ Sai Lyan Mawi isn’t delivering babies, she visits towns and villages on her trusty motorbike to deliver education sessions about women’s health. She hopes education programs will continue to be scaled up in her region, in light of the alarming census data: “If the health department spreads their outreach, awareness trainings to different villages, then child and maternal mortality rates will be reduced.”
What’s been encouraging is groups of women making the decision to use new contraceptive technology. After a community consultation was held in her village, Ly Ly Par discussed contraceptives with her friends and together with seven of her friends they journeyed to Falam to get an intrauterine device (IUD) at the MSI clinic there. “I didn’t know these things existed before, so after I got information I discussed with my husband and decided to get one.”
When asked if she thinks more women in her village are using family planning, she states, “I hope so, but I’m not sure.”
*Some names in this article were changed due to the privacy preferences of some of those interviewed.