Transforming Maternal & Child Health in Myanmar

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Norman Robbins
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Transforming Maternal & Child Health in Myanmar Health and Hope Society is an indigenous-led NGO founded by a local doctor, Dr Sasa, working in a remote region of Chin

Health and Hope s work started in 2007 when Dr Sasa garnered international support for medical work and crossborder food aid to respond to the plight of thousands of

Since 2009, he, along with a committed team, established the first ever primary healthcare service for the region and by 2017, had trained 834 Community Health Workers

In addition to running a health programme, Health and Hope supports students to continue their studies beyond high school and runs projects focused on food security and

1 Transforming Maternal & Child Health in Myanmar Health and Hope Society is an indigenous-led NGO founded by a local doctor, Dr Sasa, working in a remote region of Chin State, western Myanmar. Health and Hope s work started in 2007 when Dr Sasa garnered international support for medical work and crossborder food aid to respond to the plight of thousands of people affected by a regional famine. Since 2009, he, along with a committed team, established the first ever primary healthcare service for the region and by 2017, had trained 834 Community Health Workers (CHWs) and 112 Traditional Birth Attendants (TBAs) from 551 partner villages. In addition to running a health programme, Health and Hope supports students to continue their studies beyond high school and runs projects focused on food security and community development. One of the key outcomes that we have been working towards through our health programme is a reduction in the rate of neonatal and maternal mortality along with a reduction in the incidence of infant and maternal morbidity. Since 2013, we have had the privilege of working alongside Birthlink UK who have devised a bespoke training course for local midwives and TBAs. This proposal provides the background and budget for our ongoing work in transforming maternal and child health across Chin and Rakhine State, Myanmar.

The context of our work Chin State is a mountainous region, with average elevations of between 5,000-8,000 feet.

Traditional livelihoods are rooted in small holder farms; usually paddy rice, upland shifting cultivation, or mobile farming raising fowl and livestock.

As such, since the year 2000, food consumption has declined and food insecurity and hunger are common in rural areas for several months of the year.

2 The context of our work Chin State is a mountainous region, with average elevations of between 5,000-8,000 feet. The mountains are steep with narrow valley floors providing little land for food production. Traditional livelihoods are rooted in small holder farms; usually paddy rice, upland shifting cultivation, or mobile farming raising fowl and livestock. However, deforestation and changes in rainfall and climate pose threats to productivity. Safe water supplies and irrigable water sources are also not meeting demand. As such, since the year 2000, food consumption has declined and food insecurity and hunger are common in rural areas for several months of the year. This has resulted in a child stunting rate of 58%, the highest in Myanmar, and widespread recognition of Chin State as being the most impoverished, with the highest rate (73%) of poverty against the Myanmar National Poverty Headcount index (average 32%). Villages in Chin State are scattered across the mountainous landscape and population ranges from seven to 800 households per village. The majority of the population is Christian, whereas Buddhists and Animists are also found in the southern part of Chin State. The rugged geography and scattered population make it difficult to provide education and health services. and there are significant challenges in retaining both teachers and medical staff. These factors have led to high dropout rates in schools and a high incidence of common and preventable diseases. Chin State has the highest incidence of malaria and enteric diseases. The primary cause of death is from infectious diseases including pneumonia, diarrhoea and malaria most of which are preventable and treatable. Medicines are scarce and expensive and there is no fully functioning hospital in the region. The estimated under five mortality rate is 66 per 1,000 live births, more than twice that for the country as a whole. The principle causes of death among children under-five are treatable causes of diarrhoea, acute respiratory infections and malaria, exacerbated by underlying malnutrition. It is in this context of desperate poverty, that Health and Hope work to bring basic healthcare, education and food security to local communities. Health and Hope is represented internationally by Health and Hope UK, a charity registered in the United Kingdom (charity no ) and in Myanmar by Health and Hope Myanmar (NGO registration no 0337). We are grateful for the ongoing commitment and support of HRH Prince of Wales, the patron of our work.

3 Map of Chin State, Myanmar showing our partner villages (Note: The only means of travel from e.g. Paletwa to Lailenpi is by foot & motorbike taking 3-4 days due to the mountainous terrain.)

Health Programme Our overall programme for healthcare in Chin State consists of six projects with Traditional Birth Attendant (TBA) and Community Health

Six-month training course covering education and prevention practices to address the most common types of sickness and illhealth in rural areas.

and their mothers. H3 Clinic Ongoing provision of clinical services to the local community and clinical training centre for CHWs and TBAs.

in-situ, a 5-10 day training course covering advanced topics in health including maternal and child health and an opportunity for self-reflective learning

Village-level support from Area Coordinators to 300 CHWs providing: mentoring support, peer learning opportunities, one-toone health training, access to

4 Health Programme Our overall programme for healthcare in Chin State consists of six projects with Traditional Birth Attendant (TBA) and Community Health Worker (CHW ) training now forming a key part of our ongoing work: Project Short Description 2017 H1 Community Health Worker (CHW) - Basic Training Six-month training course covering education and prevention practices to address the most common types of sickness and illhealth in rural areas. - H2 Traditional Birth Attendant Two, one week long training sessions for 90 TBAs covering ante- (TBA) Training natal, birth and post-natal care of babies and their mothers. H3 Clinic Ongoing provision of clinical services to the local community and clinical training centre for CHWs and TBAs. H4 H5 H6 CHW Refresher and Advanced Training CHW / TBA Village-Level Support Community Health Financing Initiative Held at either our base in Lailenpi or in-situ, a 5-10 day training course covering advanced topics in health including maternal and child health and an opportunity for self-reflective learning for CHWs. Village-level support from Area Coordinators to 300 CHWs providing: mentoring support, peer learning opportunities, one-toone health training, access to medicines, a newsletter and medical journal, health education campaign material and monitoring of health statistics across partner villages. New for this year, a revolving fund of seed, plants and livestock which provides a capital investment to enable the local community to pay for the ongoing cost of healthcare to their village after a five year period.

Traditional Birth Attendants (TBA) are usually older women who hold status and respect within their communities.

TBAs are involved both at the birth itself and may also assist during early pregnancy and in the early post-birth period.

and stages of labour Care of the baby during birth Care of the cord, delivery of the placenta Management of obstetric emergencies Care of the newborn baby & mothers Breastfeeding Birth

To date, through our partnership with Birthlink UK, 112 TBAs have attended training sessions from specialist midwives and a paediatric nurse.

5 Traditional Birth Attendants (TBA) are usually older women who hold status and respect within their communities. They usually have their own children and have gained knowledge of the birthing process through practical experience and oral tradition, rather than formal learning. TBAs are involved both at the birth itself and may also assist during early pregnancy and in the early post-birth period. Poor traditional hygiene practices, as well as myths and superstitions surrounding childbirth, can be radically reversed through education, leading to a significant reduction in maternal and perinatal mortality and morbidity. TBA Training Curriculum The menstrual period & signs of pregnancy Key stages of pregnancy Healthy pregnancy & minor problems Clinical observations Prenatal care & preparation for birth Signs and stages of labour Care of the baby during birth Care of the cord, delivery of the placenta Management of obstetric emergencies Care of the newborn baby & mothers Breastfeeding Birth control & hand washing Training cycle Training for TBAs is cyclical with the majority of TBAs attending two, one week long training courses run twice a year. To date, through our partnership with Birthlink UK, 112 TBAs have attended training sessions from specialist midwives and a paediatric nurse. During one week of training up to 60 TBAs are in attendance. Thirty TBAs undergo basic training and 30 returning TBAs undertake lessons in advanced practical skills, revisit key topics and focus on reflective learning and field visits to gain further hands on experience. A small selection of TBAs who show leadership skills, understanding of good practice and who are adept at the practical work are invited back to form a core group of locally based trainers. After three years, we hope these women will be able to run the TBA training into the future with our ongoing support and regular monitoring.

Impact of TBA Training Since the initial training of TBAs in 2013, there have been many success stories, both in the lives of the TBAs and in the women and children whom they care for.

This was particularly evident when the team had an opportunity to witness a birth in the village in the middle of a training session.

Heavy postpartum bleeding experienced by the mother in previous deliveries was minimal due to proper third stage management.

6 Impact of TBA Training Since the initial training of TBAs in 2013, there have been many success stories, both in the lives of the TBAs and in the women and children whom they care for. On a practical level, the skills imparted have been successfully used by TBAs in their daily practice. This was particularly evident when the team had an opportunity to witness a birth in the village in the middle of a training session. The midwife and TBA, without prompting, successfully used best practice for both hand washing and third stage delivery, abandoning the traditional practice of pulling the cord prematurely. Heavy postpartum bleeding experienced by the mother in previous deliveries was minimal due to proper third stage management. In a review and discussion of experiences during the last training session, one TBA reported successfully using mouth to mouth infant resuscitation to save a baby s life. A skill previously unknown. On another occasion, a mother came with bleeding for an antenatal check. A pinard horn given to TBAs was used, but no heartbeat was heard and no foetal movements felt. The TBA realised the baby had died, but also that the baby s arm had dropped down as the mother had walked. Because she had learned the manoeuvre for shoulder dystocia, she felt confident enough to deliver the baby and the procedure saved the mother s life. One key finding from the initial visit in 2013, was that women were discouraged from feeding colostrum to their newborns having been traditionally taught that it was not proper milk. The TBAs were informed of the wide ranging benefits of colostrum to immunity, growth and nutrition and the importance of immediate breast feeding to assist the process of third stage involution of the uterus. We were delighted that all the TBAs were, six months later, encouraging skin to skin contact, and advising mothers to give colostrum. One TBA reported how putting the baby on the breast had helped with the successful delivery of the placenta. Above all, through the training, the TBAs felt encouraged and valued. They clearly relished the opportunity to receive education and be recognised for the skills they bring for the benefit of the wider community. One TBA reported having had courage, confidence and dignity for the first time in her life and it was evident as time progressed that the TBAs had greater confidence in their knowledge and ability to perform key practical tasks. All of the participants that came to the first training, bar two who were affected by ill health, returned for the followup training, despite the fact that several had to walk for five days to reach the training centre.

In-situ training and community clinic CHWs at our training centre in Lailenpi village Community Health Workers (CHWs) Many of the local government funded health care initiatives in ethnic minority

CHWs, in contrast, are known to deliver life-saving services in rural areas through simple health interventions, right at the point where they are most needed.

7 In-situ training and community clinic CHWs at our training centre in Lailenpi village Community Health Workers (CHWs) Many of the local government funded health care initiatives in ethnic minority states in Myanmar do not stretch beyond the large towns and cities. CHWs, in contrast, are known to deliver life-saving services in rural areas through simple health interventions, right at the point where they are most needed. CHWs are trusted members of the local community. Village leaders are invited to select one man and one woman who have completed high school and are between the ages of 16 and 30 for our six-month training programme. Once the CHWs have graduated, they return home where they serve their local community. CHWs are able to address the vast majority of types of sickness and ill-health in rural areas through education and preventative practices. They work to promote the use of clean boiled water, hand washing and better waste disposal, improving breast-feeding practices, teach about nutrition and combat deadly superstitions about health. Many of these simple and effective techniques are often overlooked, but have a significant impact in reducing morbidity and averting mortality, particularly in newborns, children and their mothers. CHW Story: Khi-Hla Ying I am from Seing Seing, in Paletwa Township. If we are sick, we must go one full day walking to reach Paletwa to get to the nearest clinic. We can also go by boat but only if the river is full. My younger sister passed away in 2011 due to diarrhoea. There was no one to help us. She could not make the journey to hospital. She was only three years old. One of my younger brothers also died when he was two years old. He had a very high fever and did not recover. My youngest brother died as soon as he was born. We didn t even name him. Our village school only reaches Grade 7. I had to live in a rented house to finish my studies for two years with my friends with no-one to care for us. A village leader told my dad about the CHW training. I had never heard of the village and was scared to come. We are a different tribe and speak a different dialect. But thinking of the helplessness of my sister and brothers, I had to have courage. We travelled five days by foot and boat to get here. We had no map and I had never climbed a mountain. I had heard bad stories about the hill people, but I had nothing to fear! I have been so surprised by their kindness and hospitality. It is so peaceful and like living with a very big family. I have learnt so much here, not only about health and medicine, but about life, love, hope and peace. I cannot wait to go home to share what I have learnt. I want to pass on this knowledge of health. I want to help build toilets and tell people about boiling water and good hygiene, so that we don t lose any more of our children to diarrhoea.

Written examinations during CHW training The training centre in Lailenpi village, Chin State CHW Training Curriculum Health, culture and popular beliefs Common sicknesses and their causes Hygiene,

diseases Dental problems and eye diseases Parasites and infectious diseases Cardio-vascular diseases Haematological and endocrine diseases Gastro-intestinal infections Respiratory tract infections

lectures, focus group exercises and hands-on practical sessions. At the end of the training, CHWs take written and practical exams and attend a formal graduation ceremony.

In order to stimulate ongoing and reflective learning, Area Coordinators visit CHWs in their villages every four months and provide ongoing opportunities for: Peer to peer learning Access to health

8 Written examinations during CHW training The training centre in Lailenpi village, Chin State CHW Training Curriculum Health, culture and popular beliefs Common sicknesses and their causes Hygiene, sanitation and preventative strategies Nutrition Basic first aid Family planning and obstetrics Drug and alcohol abuse Gender based violence Mental health Bacterial and viral infections Skin diseases Dental problems and eye diseases Parasites and infectious diseases Cardio-vascular diseases Haematological and endocrine diseases Gastro-intestinal infections Respiratory tract infections Formation of health committees Our training course provides CHWs with a comprehensive curriculum taught over a period of six months using a variety of teaching methods including classroom based lectures, focus group exercises and hands-on practical sessions. At the end of the training, CHWs take written and practical exams and attend a formal graduation ceremony. On returning to their communities they take with them a copy of their course material, including the textbook Where there is no Doctor, four months supply of basic medicines and a simple medical kit. In order to stimulate ongoing and reflective learning, Area Coordinators visit CHWs in their villages every four months and provide ongoing opportunities for: Peer to peer learning Access to health education materials In-situ health training Access to a regular supply of medicines Mentoring, coaching and encouragement Regular monitoring and impact reporting Practical training for CHWs at our base in Lailenpi In-situ training for CHWs

9 Budget Training sessions for TBAs and CHWs are run throughout the year around the monsoon season, either at our training centre in Lailenpi or in-situ, within the villages where the CHWs are based. On average, a TBA will assist 25 women in pregnancy each year and together with the one or two CHWs in her village, will provide the only local healthcare service for an average of 400 people. The multiplying effect of their combined knowledge, passed on through future generations, has an ongoing impact in the region far beyond the initial investment. The below budget provides a breakdown of the local cost of training 45 TBAs and 75 CHWs. Funding for technical advice and specialist trainers from Birthlink UK has already been secured during the 2017 calendar year. Traditional Birth Attendant Training (45 TBAs) GBP Living Allowance Transport Allowance for TBAs (per diem rate travel to training) 703 Living Allowance for TBAs (per diem rate during training) 624 Medicines & Medical Equipment Birthing Kits (45 kits including soap, towel, umbilical cord ties, blades for cord cutting, pinard stethoscope for foetal heart monitoring, thermometer, stethoscope, blood pressure cuff, ambubag, mask for infant resuscitation, sterile gloves etc ) 2,498 Painkillers, anti-biotics, multi-vitamins, folic acid, iron etc 404 Training Materials Exercise books and stationary 44 Printing for training materials 145 Staffing & Operational Costs Salary cost during training 370 Logistics, comms, financial management, fund-raising, monitoring & reporting 880 Accommodation Expenses Misc supplies for training (cleaning supplies, crockery etc ) 158 Bedding, towels, linen and accommodation expenses for 45 participants 583 Food 372 Transportation Vehicle hire for transportation of medical equipment, medicines & supplies 376 Total 7,157

In-Situ Training for (75 CHWs) GBP Living Allowance Living Allowance for CHWs (per diem rate during training) 1,172 Training Materials Exercise books, stationary and printing 577 Health worker

5 months salary costs) 2,750 Living allowance during outreach 656 Logistics, comms, financial management, fund-raising, monitoring & reporting 988 Accommodation & Training Camping equipment 189 Food

10 In-Situ Training for (75 CHWs) GBP Living Allowance Living Allowance for CHWs (per diem rate during training) 1,172 Training Materials Exercise books, stationary and printing 577 Health worker guidebook and treatment guidelines 352 Staffing & Operational Costs Salary cost during outreach (5 staff * 2.5 months salary costs) 2,750 Living allowance during outreach 656 Logistics, comms, financial management, fund-raising, monitoring & reporting 988 Accommodation & Training Camping equipment 189 Food for training 819 Transportation Fuel and vehicle maintenance 1,219 Total 8,722 Thank you for considering partnering with us to transform maternal and child health in western Myanmar. Please contact: Christopher Jones, Executive Director - Health and Hope UK if you have any further questions: chris.jones@healthandhope.org Health&Hope International Office: Health and Hope UK, 62 Heronsgate Road, Herts, WD3 5NX, UK National Office: Health and Hope Myanmar, Lailenpi, Matupi Township, Chin State, Myanmar info@healthandhope.org Website: Tel: +44 (0)

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