Family planning awareness and service accessibility among women living with HIV in Myanmar

Study setting

General setting. The Republic of the Union of Myanmar is a low-income country located in South-East Asia. It is bordered by Bangladesh, India to the west side, China, Laos and Thailand towards the north and eastern sides, and 1760 miles of the coast line by the Bay of Bengal and the Andaman Sea in the south and south-west. There are 14 states/regions and one Nay Pyi Taw Union Territory. Myanmar consists of 74 districts, 330 townships, 398 towns, 3065 wards, 13,619 village tracts and 64,134 villages. Myanmar is actively engaged in building a new, modern, peaceful, developed and democratic nation. In 2014, the total population was 51.4 million with an average population density of 80 people/km²⁴.

HIV/AIDS situation in Myanmar. Myanmar is one of the 35 UNAIDS fast track priority countries that account for 90% of new HIV infections globally. The country has a concentrated HIV epidemic among urban areas and key populations. There has been good progress towards reducing the burden of disease evidence by a decline in prevalence among the general adult population from 0.9% in 2000 to 0.6% in 2016. A significant decline also has been seen in HIV-related mortality^5,6.

The National AIDS Programme (NAP), under Department of Public Health, Ministry of Health and Sports, is taking the leading role to fight against HIV/AIDS in the country. NAP antiretroviral therapy (ART) services are currently delivered through 127 ART centres, and 174 decentralized sites which may be at the township level, sub-township level and station health units or rural health centre, as indicated by burden of disease⁵.

Maternal and Reproductive Health Division (MRH). With the goal “To attain a better quality of life and ensure universal accessibility of reproductive health and rights by contributing quality reproductive health care services for women, men, adolescents and youth”, the MRH is leading for maternal and reproductive health care services in the country in collaboration with international and national partners. Maternal deaths in Myanmar has been declined from 453/100,000 live births in 1990 to 178/100,000 live births according to UN Interagency Estimates 2015⁷. Contraceptive prevalence rate (modern methods) and unmet need for contraception were 51% and 16%, respectively as revealed by the Myanmar Demographic Health Survey, 2015–2016⁸. In line with the Myanmar National Health Plan (2017–2021), and National Strategic Plan for Reproductive Health (2014–2018), Myanmar MRH is providing quality care services for women in Myanmar to achieve Myanmar UN Sustainable Development Goal targets by 2030.

Study population

For quantitative portion, this study included reproductive age women (15–49 years) living with HIV. They were on ART from two selected ART centers at two districts with the high burden of HIV in Myanmar. For qualitative portion, this study included reproductive age women (15–49 years) living with HIV, and service providers.

Sampling and sample size

For the quantitative portion of the study, included were HIV positive women of reproductive age who were receiving care from the selected ART centers. A sample size was calculated using OpenEpi. A cross-sectional single proportion method was used setting proportion of service accessibility as 79%⁹, precision as 0.06%, and alpha at 0.05%. Thus, the minimal required sample size was 177. From the lists of ART registers from selected ART sites, HIV positive women of reproductive age were pre-identified, and randomly selected before the day their visits to ART centers. At the day of data collection, those identified HIV positive women were recruited for this study after obtaining their consent. A total of 184 women with HIV were included in this study.

For qualitative portion, 19 women living with HIV were purposively selected to include in this study based on their ability to cooperate and discuss. Their ability of cooperation and discussion was assessed during a face-to-face interview, and also discussion of service providers who knew about their clients very well. Two key informant interviews with two service providers were also done. The interview guide is available as Extended data¹⁰. One service provider was from maternal and reproductive health teams whose role was to provide overall supervision and monitoring of the MRH services to the communities in the district. Another service provider was a team leader from ART team at the district who managed the care for HIV positive people.

Data collection methods and tools

For the quantitative portion, face-to-face interviews were done using semi-structured questionnaires by six trained data collectors from Department of Medical Research. Semi-structured questionnaires was developed and pretested based on the tools used in previous study in Myanmar⁹. The questionnaires are available as Extended data¹⁰. Perceived geographical accessibility to family planning services among women living with HIV was measured in this study. High geographical accessibility was defined as those who lived within a 30-minute travel and within a one-mile distance from the nearest health facility which provides family planning services, and those who were aware that the service existed⁹.

For qualitative portion, one focus group discussions (FGD) with women living with HIV from each ART center was done with 9 to 10 participants in each FGD using FGD guideline. Each FGD included both married and unmarried women with different ages to get information from different dimensions. This study included total two FGDs. Both FGDs were moderated by the principle investigator (H.H.L.) who had enough experiences for qualitative data collection, and note takings were done by trained note takers from Department of Medical Research. The FGD was conducted at a place of convenience to the participants. Both FGDs were conducted in rooms located near ART teams in the same compound, but away from the influence of health staff. Audio-recording was done with the permission from the participants. Each FGD took approximately one hour. Key informant interviews with service providers were done by K.T.S. using KII guideline. Each KII took approximately 45 min. No repeated discussion was needed for FGDs/KIIs. Information was regarded as saturated from the completed FGDs and KIIs.

Data analysis

For the quantitative portion, data from face to face interviews was entered using EpidataVer3.2 software and analyzed using SPSS v20. Descriptive analysis was done, and frequency and proportion of variables of interests were presented in text and tables.

For the qualitative portion, transcripts from FGDs and KIIs were made in Myanmar language the same day based on the verbatim notes of the interview and audio recordings. All the transcripts obtained were combined and the principal investigator (H.H.L.) read the transcript to become familiar with the data. Manual descriptive thematic analysis was used by the principal investigator to analyze the transcripts. It was reviewed by a second investigator (K.T.S.) to reduce bias and subjectivity in interpretation. The decision of coding rules and theme generation was done in consensus among investigators. Any difference between the two was resolved by discussion. The study findings were reported according to consolidated guidelines for reporting qualitative research (COREQ)¹¹.

Ethical issues

Approval to conduct this study was obtained from Department of Public Health, Ministry of Health and Sports, Myanmar [105/Oct/2017/DOPH/MOHS]. Participants were informed about the study through participant information sheet. Those who gave the written informed consent were recruited in this study. Participants had the right to withdrawal from this study at any time. Data confidentiality and anonymity of study participants were maintained strictly throughout the study.

Demographic information

This study included 184 women living with HIV. The mean (SD) of them was 38(9) years, 121 (66%) were from rural areas, and 118 (62%) had primary and secondary education. Of them, 135 (73%) were working for a living at the time of survey. The average income of them was 150000MMKs (150USD) per month. In total, 90 women (49%) were married, 10 (5%) were single (Table 1). The results of the quantitative aspect of the study are available as Underlying data¹².

Family planning education

Among the respondents, 124 (67%) have never received health education on family planning, and 64 (35%) didn’t know any source of information for family planning services. Among married women, 16 (29%) intended to have child. One-fourth of women with HIV responded that transmission of HIV from mother to child cannot be preventable; “preventing by taking ART” was the most mentioned answer. However, a majority (97%) of them had heard of any type of modern contraceptive methods. Oral contraceptive pills and injection methods were the most mentioned method by the respondents (Table 2 and Figure 1).

Figure 1. Awareness on different types of modern contraception (n=184).

EC, emergency contraceptive; IUCD, intrauterine contraceptive device; OC, oral contraceptive.

In the last six months, 55 (30%) of respondents have used any type of contraception, and more percentage of women used contraceptive methods from private services (Table 3).

Access to family planning services

Perceived geographical accessibility to family planning services among women living with HIV was measured in this study. High geographical accessibility was defined as those who lived within 30 minutes travel and within a one-mile distance from the nearest health facility that provides family planning services, and those who were aware that the service existed. This study showed only 7% of respondents had high perceived geographical accessibility to family services (Table 4).

Results of qualitative assessment

The main challenges to accessing family planning information and services among women living with HIV were also explored from qualitative data collection methods. Most of participants responded that they had poor knowledge and received not enough information on the family planning services Some of them mentioned they had financial constraints to access modern contraceptive methods. Key informant interviews with public service providers revealed that there was the lack of referral system, and poor linkage between Maternal and Reproductive Health Teams, and ART centers for women living with HIV to provide the quality family planning services (Table 5).

Extended data

Figshare: FP PLHIV MM Questionnaires and Guidelines. https://doi.org/10.6084/m9.figshare.8275076.v1¹⁰.

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).