Large families in the poorest regions suffer poor health and nutrition, but access to contraception and maternal care is limited.
Ngun Bil Sung has been helping women give birth for 32 years, ever since she had a dream in which she was called by God to deliver babies.
Although she has no formal training, the 67-year-old from Chin State, an isolated, mountainous and devoutly Christian region of Myanmar, estimates she has safely delivered 1,500 babies, including her own.
But now she believes villagers, in what is considered to be the poorest region of the country, need access to family planning advice and contraception. “For families here to survive, both the mother and the father need to work on the farm. But if they keep having babies constantly, women can’t work at all, and it’s very difficult for the family to provide.”
Ngun Bil Sung says that a third of the women she sees in the nine villages she visits are not leaving enough space between births. Many women are old or very young, making their pregnancies higher risk; and she’s witnessed the consequences of some desperate and dangerous illegal abortions.
A Chin family living in their bamboo home in the hills of Mindat, Myanmar. Photograph: Eric Lafforgue/Alamy
About 40% of women in Myanmar use contraception, but in Chin State the figure is closer to 3%. Meanwhile, Myanmar has the second highest maternal mortality rate in south-east Asia, with 87% of those deaths occurring in rural areas. Unsafe abortion is the third leading cause of maternal death. Abortion is illegal in Myanmar, except to save a woman’s life.
Women in Chin State have more babies than elsewhere in Myanmar, and evidence suggests they struggle to support them: children in the state have the lowest health and nutritional levels in the country. The region also has the lowest rate in the country of births attended by a trained attendant and of births in a health facility, at under 40% and under 5% respectively.
Improving access to family planning services is an uphill battle. Many people believe using contraception defies God’s wishes and promotes promiscuity. The logistics of reaching people are also tough. Roads are frequently little more than dirt paths, just wide enough for a motorcycle to navigate, and many of those have been washed during severe flooding and landslides. There is almost no mobile phone reception outside the towns, and a myriad of languages are spoken in the region, the local dialect changing from one hillside to the next.
“To be able to serve the Chin community, it’s clearly more expensive per head per visit [than elsewhere],” says Dr Sid Naing, Country Director of Marie Stopes Myanmar, which opened seven branches in Chin as part of an expansion into three remote regions in 2014.
Between September 2014 and March 2016, Marie Stopes has seen 13,725 people in the state.
Nun Thiam, a 28-year-old government midwife working in a local village, regularly encounters women who say they don’t want to have more children, but their husbands won’t let them use contraception.
“Women keep having babies so they can’t work anymore,” she says. “It becomes their duty to look after the children, while the husbands go to the farm and become the sole provider of the family, so they are stuck in an inferior role. As they keep having babies their role gets lower and lower, to the point where they have to listen to everything their husband says.”
Dr Henri Za Lal Lian, the MSI centre manager in Falam township, which is encouraging more men to attend education sessions, says: “The husbands are still the key players in their household, so male involvement is critical.”
Sex before marriage is also a taboo in Chin State. Unmarried people who are sexually active are often too afraid to buy contraceptives in pharmacies, where other people might see them. MSI staff will discreetly deliver condoms and emergency contraception to people in Falam who phone and ask for supplies or advice.
Sex education is not taught in Myanmar schools, so many people have little knowledge of the options available and no concept of safe sex. Women, in particular, are often just told by their parents to stay away from men once they reach puberty.
“It’s important for young women like me to have knowledge before they become sexually active, so that they can protect themselves,” says Helen Leng Zun Rem, a 26-year-old staff member at MSI in Falam, who says some of her peers have become pregnant unintentionally. “The things I have learned in my job will really help me in the future.”
But things are slowly improving.
Za Lal Lian has been working with religious leaders to challenge attitudes to family planning and says the organisation’s relationship with the church has improved since the branch first opened. He says the number of clients visiting the Falam office and attending outreach sessions in villages has risen significantly since some pastors began letting Marie Stopes use their churches for reproductive health education sessions, and some have actively encouraged people to access services.
Improved coordination with government health workers has enabled him to develop a schedule that focuses on Falam in the rainy season and further afield when it is drier.
There is a lack of health and family planning awareness among people living in remote villages in Chin. Photograph: Dave Stamboulis/Alamy
But funding for family planning services is a problem.
MSI’s offices in Chin are supported by the 3MDG fund, a pooled multi-donor fund managed by the UN, but funding will end in June 2017. Naing hopes the government will be able to step in. It has vowed to prioritise healthcare, including introducing a roadmap to universal health coverage by 2030.
But, he says, “our health sector is in transition. We are not sure for the moment which way the country is going.”
Za Lal Lian adds: “While I have much respect for government health workers … [the public sector is] still very much understaffed. If we stop being here it will be a terrible loss for the villagers.”
To learn more about Marie Stopes Myanmar, watch the video and discover family planning in Myanmar.