Keywords
Family Planning, monitoring, Myanmar
This article is included in the International Conference on Family Planning gateway.
Family Planning, monitoring, Myanmar
According to UN interagency estimates, the Myanmar maternal mortality ratio (MMR) has reduced from 453 per 100,000 live births in 1990 to 178 per 100,000 live births in 2015; however, this figure was the second highest among ASEAN countries and did not meet the 2015 Millennium Development Goal1. As of the 2014 census, the MMR in Myanmar was 282 deaths per 100,000 live births2.
Aiming to reduce maternal, newborn and child morbidity and mortality according to the Sustainable Development Goals: Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH), care has been accorded as a priority issue in the action plan of National Health Plan (2017–21)3. In addition, Myanmar has also committed to the ICPD goals, United Nations Secretary General’s Global Strategy for Women’s and Children’s Health, as well as Family Planning 2020 commitment to improve women and children’s health4,5.
As family planning is an evidence-based intervention for improving the maternal and newborn health, as well as a cost-effective powerful tool for development, Myanmar has been endeavoring to increase access to quality family planning services through strong coordinated efforts among public private, UN and donor agencies, INGOs and NGOs. The family planning program was implemented under the guidance of Reproductive Health policy (2002), Five years Reproductive Health Strategic Plans (RHSP) and Costed Implementation Plan for FP 20204,5.
Myanmar’s family planning programme started in 1991 as a public sector pilot in one township, and then progressively extended to 163 out of 330 townships in 2014. Before 2011, the government had no specific financial allocation for reproductive health commodities, including contraception, and heavily relied on UNFPA supplies. From 2011, the government increased the health budget, allocated a budget for contraceptive commodities and invested more in the family planning program, to allow it to provide more contraceptives, both short- and long-term, free of charge in all public facilities since 20125.
Although various inputs have been used in the Myanmar Family Planning program and the contraceptive prevalence rate (CPR) has increased from 41% in 2007 to 52.2% in 20166, it is estimated to be slightly lower than the target of 60% by 20205. At the same time, an unmet need for family planning has been reduced from 19% in 2007 to 16% in 20166, still falling short of the 2020 target of an unmet need of less than 10%6.
According to the Myanmar Demographic and Health Survey (DHS) (2015–16), contraceptive use is growing nationally, but there are disparities in use among different states and regions, from the lowest prevalence in Chin State (25%) up to 60% in Yangon and Bago region6. Given the wide variability in contraceptive use and the performance of the FP program by state/region, there is a strong need for valid information about contraceptive use for better annual tracking. Currently, there is limited information on contraceptive use available for the regular monitoring and evaluation as Myanmar has had limited surveys, data quality and methodology issues exist in the Health Management Information System (HMIS), and slow and scattered rollout of the Logistic Management Information System (LMIS) means these service statistics data have limited application for state/regional routine monitoring. The national estimates of mCPR for same period, 2016, are quite different among DHS survey (51.3%)6, result from the Family Planning Estimation Tool (FPET); a web application developed by Track 20 project/Avenir Health that uses all available survey data to produce annual estimates for key family planning indicators, (50.8%)7 and HMIS (61.3%)8 (Figure 1). This discrepancy between the different data sources led the program to consider the which were most reliable data source for both national and subnational annual monitoring on family planning.
In order to understand what data may best serve annual monitoring of the performance of the family planning program in Myanmar, both at the national and state/regional level, four data sources of modern contraceptive use were compared:
1. Modelled mCPR estimates (and confidence intervals) from Track20’s FPET tool (requires free registration), based on nationally and state/regionally representative surveys7.
2. Method-specific prevalence from the 2015–16 Myanmar DHS6.
3. mCPR estimates and contraceptive method prevalence from Myanmar’s HMIS system8, based on local annual census conducted by midwives on contraceptive use among married women in their catchment area, and
4. Estimates of modern method use (EMU) based on contraceptive commodity consumption data from Myanmar’s LMIS system9 were compared (Table 1).
Source | mCPR | Years | Method use | Year |
---|---|---|---|---|
FPET | X | 2015–2017 | ||
HMIS | X | 2015–2017 | X | 2016 |
LMIS | Limited regional and time trend availability | |||
DHS | X | 2016 |
While DHS data is the gold standard for monitoring of FP indicators, it does not provide information for annual monitoring. Between the years of surveys, only FPET can be used to test the reliability of service statistic data, since FPET uses all available survey data and gives almost the same result as the DHS (Figure 1). Therefore, it is the most reliable data source for annual estimates so far.
These four data sources, along with the confidence intervals from FPET, were compared for three consecutive years from 2015 to 2017. If the specific data were within the 95% of confidence interval of FPET, it was considered as the accurate data in this study to be used for annual monitoring of family planning. Firstly, estimates of mCPR from the HMIS at both the national and state/regional level were tested for accuracy based on whether they fell within the 95% confidence interval of mCPR estimates of FPET for the corresponding years. The consistency between two sources was matched for each three years. Then, the method-specific prevalence data for both national and state/regional level from HMIS were compared with DHS data for 2016 only. As the FPET could not provide the method mix data, this data could be compared with DHS. Finally, the estimates of method use (EMU) was also tested. EMU data was extracted by converting the inputs of commodity consumption data from LMIS using the EMU excel tool; a tool developed by Track 20 team. It was tested for those years and in states/regions where the LMIS was available. This tool was developed by the Track 20 team, by converting the inputs data of commodity consumption data from LMIS; it was also tested for those years and in states/regions where the LMIS system was available.
This paper is a secondary analysis of the four different sources of data: contraceptive prevalence rate from Family Planning Estimation Tool of Track 20, 2015–16 Myanmar Demographic and Health Survey (MDHS), Health Management Information System (HMIS) data of Department of Public Health and Logistic Management Information System (LMIS) data of RH commodities from Maternal Reproductive Health Unit of Department of Public Health. Ethics approval for Myanmar DHS was obtained from the Ethics Review Committee of the Department of Medical Research, Ministry of Health and Sports, Myanmar and the secondary data analysis for this study was done after obtaining the permission from the Department of Public Health, Ministry of Health and Sports, Myanmar.
In comparing HMIS estimates to the estimates and confidence intervals from FPET, among the total 17 State and Region, only two States (Chin and Kayin) produced HMIS-based estimates consistent with FPET results for three consecutive years (e.g. fell within the 95% CI of FPET estimates). Another two (Ayeyarwaddy and Kayah) were consistent with FPET for two of the three years of available HMIS data. Only one year of matching HMIS and FPET results were found in Mandalay, Sagaing, Tanintharyi and Yangon regions (Figure 2). In the other ten states/regions, estimates of mCPR from HMIS were not within the CI of FPET results for any of the years available (Figure 3). In general, the HMIS results were most consistent with FPET results in 2015, with six of 17 regions falling within the CI; this dropped to five in 2016 and three in 2017.
At the national level, only 2015 estimates from HMIS fell within the CI of the FPET mCPR estimates. In general, as at the national level, the HMIS estimates of mCPR appear to over-estimate prevalence when compared to FPET and DHS (Figure 4).
In comparing method prevalence, HMIS data were compared with the DHS. Although the HMIS data showed consistently higher prevalence compared to the DHS, the same pattern in method mix is observed between the two, with the exception of female sterilization, which appears to be under-reported in the HMIS system. Across both data sources, injectables were indicated as the most common method in use, making up more than half of all use, followed by pills, used by about a quarter of all married users of modern contraception (Figure 5).
It was observed that there were similar patterns of method mixes at the national level and most of the 17 states/regions, except Chin and Kayin State. In Chin, rates of use of the long-term methods IUD implants, and sterilization were considerably higher than the other areas in DHS data. In HMIS data, only IUD and implant were found as higher proportion than that of other State/Regions. Also in Kayin, the higher use of pills than injections was found only in the DHS, while the injection method was the highest proportion in national and other areas in both DHS and HMIS data.
Regarding estimates of modern method use (EMU, comparable to mCPR) from LMIS commodity consumption data, the LMIS data were found to be quite low in comparison to the HMIS and FPET estimates, except in Southern Shan State. For 2017, in Southern Shan State, while there was a >90% reporting rate, EMU from LMIS data were nearly identical to the mCPR of HMIS (63% vs 64%); however, both values are not within 95% CI of FPET estimates.
DHS is the gold standard method of tracking the family planning program; however, annually tracking the national and subnational progress level for equitable access to family planning services is required. When it was considered the data source for the annual tracking of mCPR, either estimates from FPET or routine service statistics, direct estimates of HMIS were needed to consider carefully to use as it is much higher than the DHS survey and not matched with FPET results except in Chin and Kayin states. It might be due to data quality issue and related with performance of data collectors. Therefore, it should be explored in detail why HMIS shows a high result with 5% annual growth, through reviewing the methodology and validating the data quality.
For the monitoring of the methods mix, as the series of HMIS data are similar pattern with DHS at both national and state/regional level, except Chin and Kayin. Therefore, HMIS data can be used for monitoring of the method mix, except in Chin and Kayin. The LMIS data could be used for annual tracking when there are high reporting rates and valid information of consumption. Thus, LMIS should be strengthened in data validity as well as area coverage.
The Demographic and Health Surveys dataset analyzed during the current study (Myanmar 2015–16) is available in the MEASURE DHS repository (http://www.measuredhs.com). Access to the dataset requires registration, and is granted to those that wish to use the data for legitimate research purposes. A guide for how to apply for dataset access is available at: https://dhsprogram.com/data/Access-Instructions.cfm.
The HMIS data were requested from the HMIS unit of Department of Public Health, Ministry of Health and Sports, Myanmar, available at https://mm.dhis2.net/hmis/dhis-web-commons/security/login.action. Access to this data is restricted to protect the identities of the subjects; researchers wishing to apply for access should send an email to the Deputy Director General of HMIS, Dr Thet Thet Mu at thetthetmu@mohs.gov.mm, including justification for why access should be granted.
The contraceptive commodity consumption data for LMIS for RH commodities were requested from the Maternal and Reproductive Health Unit of Department of Public Health, Ministry of Health and Sports, Myanmar and John Snow International (JSI); an international organization that are providing technical support for LMIS, also supported in accessing the data. Data can be visualized here. To protect the identities of the subjects, those wishing to gain access to the data should submit an official request to the Director of Maternal and Reproductive Health Division of Ministry of Health and Sports, Myanmar, via ayechum_yi@mm.jsi.com or khaingnwetin@gmail.com, including justification for why access should be granted.
I would like to express my sincere gratitude to the Track20 project, including facilitators, for giving the opportunity to conduct this analysis and kind support throughout the analysis and report writing. I also thanks to the Ministry of Health and Sports, Myanmar, for approval to carry out this study and to use the data of HMIS and LMIS.
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Is the work clearly and accurately presented and does it cite the current literature?
No
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
No
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
References
1. Chetty V: Pooling of Time Series and Cross Section Data. Econometrica. 1968; 36 (2). Publisher Full TextCompeting Interests: No competing interests were disclosed.
Reviewer Expertise: Demography and health systems research
Is the work clearly and accurately presented and does it cite the current literature?
Partly
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Monitoring and evaluation in global health programs; family planning
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Invited Reviewers | ||
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