More people are on the move than ever before. People migrate from one place to another for the purpose of getting better opportunity for jobs and lifestyles across the world. The global level of migration is estimated to be about one billion: 250 million internationally and 763 million internally. That number represents about 1 in 7 people in the total population around the world (World Health Organization [WHO], 2017b).
Asia has the largest number of migrant workers of any region (United Nations [UN], 2017) and migration flows are experiencing increasing feminisation with 42% of migrants (Lasimbang et al, 2016). Thailand is the main destination country for international migration in the Greater Mekong Subregion (GMS) due to significant differences in economic development with neighbouring Cambodia, Lao People's Democratic Republic (Lao PDR), and Myanmar (Huguet, 2016). Regarding international migration in Thailand, the number of migrants totalled about 1.2 million in 2000 and rose to 3.5 million in 2017 (UN, 2017).
The majority of these migrants (over 80%) are within the reproductive ages of 15–49 years, with a relatively even gender split according to the data of the Thai National Economic and Social Development Board in 2013 (Huguet, 2016). Over the decades, Myanmar migrants have crossed the border either officially or illegally to work in Thailand as regular-skilled and low-skilled workers and as well as irregular low-skilled workers, because of dissatisfaction with the socio-economic and political situation in their home country (Chantavanich and Vungsiriphisal, 2012). Low-skilled migrant workers in Thailand are mostly hired to perform the ‘3D’ jobs (‘dirty’, ‘dangerous’ and ‘demanding’) which Thais increasingly shun (Chantavanich and Vungsiriphisal, 2012; Huguet, 2016).
These jobs are mostly in agriculture, manufacturing, construction and fisheries (Chantavanich and Vungsiriphisal, 2012; Huguet, 2016). Myanmar migrants account for about three-fourths of low-wage labour migration to Thailand (Department of Population and Ministry of Immigration and Population, 2015).
During the temporary migration, the migrants encounter reproductive health concerns such as unmet need for family planning, incorrect use of contraception, unwanted and adolescent pregnancy, poor maternal and child health, high prevalence of sexually transmitted infections (STIs), HIV infection and gender-based violence (Huguet, 2016). Family planning allows people to attain their desired number of children and determine the spacing of pregnancies (WHO, 2017a). The growing use of contraceptive methods has resulted in not only improvements in health-related outcomes, such as reduced maternal and infant mortality by preventing unplanned pregnancy, but also improvements in schooling and economic outcomes, especially for girls and women (Diaz et al, 2017).
Even though there are many benefits from family planning, 64% of all married women use contraception, in which 9 out of 10 users rely on modern methods. That said, globally, 216 million women have an unmet need for modern contraception; the desire to delay a pregnancy without the means to do so leads to an unmet need for family planning (Biddlecom et al, 2015). Findings indicate elevated risks of mortality for children under the age of five whose mothers had an unmet need for spacing (hazard ratio [HR]: 1.60, confidence interval (CI) 1.37–1.86, p<0.001) and children whose mothers had an unmet need for limiting (HR: 1.78, CI 1.48-2.15, p<0.001) compared to children whose mothers had a met need (Adedini et al, 2015).
One study found a strong association between temporary migration and unintended pregnancies, unsafe abortion and exposure to STIs as a result of risky sexual behaviour (Yang et al, 2007). According to the WHO systematic analysis of data from 2003–2012, each year, between 4.7%–13.2% of maternal deaths can be attributed to unsafe abortion (Say et al, 2014). One of the measures of access to sexual reproductive health services is the magnitude of women who want to practice the modern contraceptive methods and can access them (Diaz et al, 2017). The unmet need for contraception is high, especially in adolescents, migrants, urban slum dwellers, refugees and postpartum women (WHO, 2017a).
Migrant workers might face some barriers to accessing health services because of difficult communication, social norms, financial or cultural obstacles, discrimination, irregular legal/work status, and not knowing their entitlement to health insurance (Huguet and Martin, 2015; Lasimbang et al, 2016; Koller et al, 2017). Even the national strategies and programmes are often hindered by large gaps in reaching the marginalised populations like refugees and migrants (Huguet, 2016). Although migrant health has received increasing clinical and research attention, there has been relatively little focus on sexual reproductive health, including fertility management and an unmet need for family planning.
Therefore, the unmet need for family planning is formed by a broader set of factors such as economic, societal, and organisational rules and regulations. The social-ecological model (SEM) is a theory-based framework for understanding, exploring, and addressing the social determinants of health at many levels (Bronfenbrenner, 1977). It encourages us to move beyond a focus on individual behaviour and toward an understanding of the wide range of factors that influence health outcomes (Sallis et al, 2015). Hence, the variables of the study include socio-demographic characteristics, intra-personal factors such as knowledge about family planning, Thai language skill, satisfaction of living in Thailand, and interpersonal factors such as availability and accessibility of family planning services, social and media support, and viable options for health insurance. This study explored the prevalence of an unmet need for family planning among Myanmar migrant women in Bangkok, Thailand and its determinants.
Methods
Study design
A cross-sectional, community based study was conducted targeting sexually active women of reproductive age 18–45 years living together with their husbands or partners in Bangkok.
Setting
Bangkok is the capital, and also the most crowded city, of Thailand. It is also one of most populated areas of international migration: most migrants are from the neighbouring countries of Myanmar, Cambodia and Lao PDR (Kantayaporn et al, 2015; Griffiths and Ito, 2016). The estimated number of Myanmar migrants in Bangkok is about 63 498 with an even gender split in 2013–2015 (National Statistical Office, 2016). This figure is surely an underestimate due to the large estimated population of unregistered migrants (Tangcharoensathien et al, 2017). Data was collected from March 2018 to April 2018.
Participants
Sexually active Myanmar migrant women living together with their husbands or partners, within age 15–49 years living in Bangkok and also residing in the study area (both registered and unregistered) for at least six months, whose country of origin is Myanmar were included.
The study excludes women who were first married five or more years ago, have not had a birth in the past five years, are not currently pregnant, and have never used any kind of family planning method; or were infecund, menopausal, have had a hysterectomy, or never menstruated.
Sample size and sampling
The minimum sample size of the study was calculated using the following parameters: the expected proportion of women with an unmet need for family planning and threshold of error at 5%. A total of 372 women of reproductive age were included in the study. Due to the fact that a majority of migrant workers are undocumented, it was not possible to obtain all the necessary information about the population of migrants in order to draw respondents from a sampling frame. Therefore, the snowball technique was used to recruit respondents. The field supervisor developed a worksheet and located ‘seeds’ (the starting cases).
From each seed, interviewers identified 10 additional respondents. The total number of seeds was calculated by dividing the target number of cases by 10. The data were gathered by five trained research assistants. When the protocol, the questionnaire, and informed consent form were developed, the data collection tools were pretested and validated. Upon identification of eligible participants, an informed consent form was administered to the participants. Those who agreed to participate in the study filled out a self-administered questionnaire to collect the data. Their socio-demographic characteristics, and intrapersonal and interpersonal factors were categorised as independent variables, while unmet need for family planning was the key dependent variable.
Dependent variable
Unmet need for family planning can be defined as ‘currently married women who are fecund and sexually active who are not using any modern method of contraception, and report that they do not want any more children (limiting) or want to delay the next pregnancy by at least two years (spacing)’ (Bradley, 2012; WHO, 2020).
Modern methods of contraception include the following:
These categories are adapted according to the WHO (2017a) classification.
Independent variables
There were three parts of the questionnaire used to collect information on the independent variables, including respondent age, ethnicity, education, working status, desired and total living number of children. Thai language skill, satisfaction with staying in Thailand, knowledge about family plant, social support, availability and accessibility of family plant services, media support and health insurance scheme.
Measurement
The variables were constructed based on a review of the related literature and confined to the SEM-model framework. Regarding the socio-demographic background of the respondents, nominal-level scale was used to measure respondents' ethnicity and occupation, ordinal-level scale was used to measure education status, ratio-level scale was used to measure the discrete variables (eg number of living children, number of desired children), and to measure the continuous variables (eg age of the respondent). For knowledge level and social support variables, there were 15 and 10 questions, respectively. Response was classified as ‘poor’ or ‘good’ using median plus QD.
The questionnaires for these two portions were adapted from the previous studies of Myanmar (Nyein et al, 2014; Jirapongsuwan et al, 2015). The Kuder-Richardson Formula 20 psychometric tool was applied to knowledge items, and scored 0.796, while Cronbach's alpha coefficient for social support items scored 0.729. For availability and accessibility of family planning services, there were six questions to determine convenience of family planning, cost, ways to travel to the service outlet, and satisfaction with family planning service. The last part of the questionnaire (four items) asked respondents about media support and health insurance schemes.
The outcome variable: the unmet need for family planning among reproductive-age Myanmar migrant women living together with their partner or husband within reproductive age, was measured using nine questions. The response was ‘yes’/‘no’ or multiple choice. The steps of calculation of the unmet need are shown in Figure 1 and the computations are based on Bradley et al's (2012) ‘Revising unmet need for family planning: DHS analytical studies no 25’.
Dependent (ie outcome) variable
There are five steps in computing the unmet need for family planning in this study:
Statistical analysis
After all the completed questionnaires were verified and validated, the data entry sheet was developed by using Epi Info version 4.2 software and then cleaned and analysed in SPSS version 21. Major analyses included descriptive statistics to determine median, quartile deviation, percentage, and minimum and maximum values of the variables. Factors associated with an unmet need for family planning were determined by calculating odds ratios (OR) at 95 % confidence interval [CI] (ie significance threshold level at p-value ≤0.05). The statistical test used during univariate analysis was obtained from simple logistic regression, and multiple logistic regression was used during multivariate analysis.
Ethical considerations
Written consent and confidentiality were ensured throughout the study period and questionnaires were coded with numbers only. The participants were well-informed and were given enough time to freely decide to participate or not. Before the start of the interview, the written consent of the respondent was obtained by the interviewer, and each respondent was informed that they could stop the process of interview at any time during the interviewing period if they felt uncomfortable.
Results
In this study, 372 respondents were recruited; however, only 360 respondents gave full responses to the questionnaire, giving a response rate of 96.7%. The median age of the respondents was 30±4.5 years, with 55.8% (201) between age 26–35 years (middle age group), 26.4% (95) between age 36–45 years (older age group), and 17.8% (64) between the age of 18–25 years (younger age group).
The status of the respondents' ethnicity was Myanmar (52.8%) followed by Karen (18.6%), Mon (13.1%), Dawei (9.4%) or other (6.1%). Only a few participants (1.7%) were illiterate. Half the respondents (55.3%) had attended secondary level education. The majority (95.8%) of the participants were working while very few (4.2%) were dependent. Most of the participants (85.8%) worked in factories; other types of occupation include vendor (4.6%), salesperson (3.2%), construction worker (2.9%) or housemaid (5%). Nearly half of the respondents (42.8%) desired to have two children in their family and only one-third of the participants (31.1%) already had two children at the time of the study.
Regarding the intrapersonal factors, one-fourth (25.6%) of participants responded that they can communicate well in Thai language, and two-fifths (40.8%) of respondents said they were ‘very satisfied’ living in Thailand. Regarding knowledge of family planning, all of the participants were aware about the effectiveness of family planning to prevent pregnancy.
The oral contraceptive pill was the most (84.7%) mentioned method followed by the injectable, sterilisation, condoms and LAM (see Figure 1). The majority (91.3%) of participants answered correctly about how to properly use short-term family planning methods however, only one-fourth answered correctly about how to use the emergency contraception pills, while just over one-third could explain how to use long-term methods. A minority of respondents knew about potential side effects by using the family planning methods including the effects of short-term, long-term, and permanent methods compared with the knowledge of how to use these methods appropriately.
Concerning the interpersonal information, 17.3% of the participants had good support for using family planning by their close network of acquaintances (eg like husbands/partners, neighbours, family members) and 15% of the respondents discussed family planning with healthcare personnel during the year prior to the survey. The pharmacy, or drug store, was well-known for its availability and accessibility to family planning methods, with 84.4% and 73.3%, respectively citing these sources. The second and third commonly cited places were government and private facilities. The way to go to the outlets were by foot (69.3%), bus or train (48%), taxi (28.9%) or other method. Over two-thirds (72.5%) of the participants were satisfied with the family planning service at their chosen outlet and most of the respondents also replied that using the family planning methods is not expensive.
Table 1 describes media support and health insurance schemes. Less than half of the participants heard information about family planning from at least one kind of media and, of these, approximately two-thirds were motivated by the media to use family planning methods. These kinds of media include the internet and/or social media (53.5%), TV/radio (42.0%), and pamphlets or posters (31.3%). Over half of the participants are enrolled in a health insurance scheme, including the social security scheme (34.5%) and 30-baht scheme (65.5%). Those who did not have health insurance coverage cited prohibitive cost (53.9%) or refusal of employer buy-in to social security (17.5%).
| Variables | n | % | |
|---|---|---|---|
| Socio-demographic factors | |||
| Age groups | ≤ 25 years | 95 | 26.4 |
| 26−35 years | 201 | 55.8 | |
| ≥ 36 years | 64 | 17.8 | |
| (Median = 30, QD = 4.5, min = 18, max = 45) | |||
| Ethnicity | Myanmar | 190 | 52.8 |
| Karen | 67 | 18.6 | |
| Mon | 47 | 13.1 | |
| Dawei | 34 | 9.4 | |
| Others | 22 | 6.1 | |
| Education | Illiterate | 6 | 1.7 |
| Primary education | 69 | 19.2 | |
| Secondary education | 199 | 55.3 | |
| Tertiary education and above | 86 | 23.8 | |
| Work status | Factory worker | 296 | 82.2 |
| Vendor | 16 | 4.4 | |
| Sale person | 11 | 3.0 | |
| Construction worker | 10 | 3.0 | |
| Others | 12 | 3.3 | |
| Not working | 15 | 4.1 | |
| Desired number of children | No child | 154 | 42.8 |
| 1 child | 112 | 31.1 | |
| 2 children | 58 | 16.1 | |
| 3−5 children | 36 | 10 | |
| (Median = 1, QD = 0.5, min = 1, max = 5) | |||
| Number of living children | No child | 1 | 0.3 |
| 1 child | 87 | 24.2 | |
| 2 children | 154 | 42.8 | |
| 3 children | 95 | 26.4 | |
| > 3 children | 23 | 6.4 | |
| (Median = 2, QD = 0.5, min = 0, max = 7) | |||
| Intrapersonal factors | |||
| Known methods | Oral contraceptive pill | 305 | 84.7 |
| Depot injection | 256 | 71.1 | |
| Sterilisation | 206 | 57.2 | |
| Condom | 142 | 39.4 | |
| Implant | 135 | 37.5 | |
| Vasectomy | 129 | 35.8 | |
| Intrauterine device | 81 | 22.5 | |
| Emergency contraceptive pill | 55 | 15.3 | |
| Lactational amenorrhea method | 42 | 11.7 | |
| How to use correctly | Short-term method | 328 | 91.3 |
| Long-term method | 139 | 38.6 | |
| Permanent method | 251 | 69.7 | |
| Emergency contraceptive pill | 87 | 24.2 | |
| Condom | 225 | 62.5 | |
| Side effect | Short-term method | 130 | 36.1 |
| Long-term method | 54 | 15.0 | |
| Permanent method | 108 | 30.0 | |
| Interpersonal factors | |||
| Social support | Poor | 298 | 82.7 |
| Good | 62 | 17.3 | |
| Discussion with healthcare worker within last year | Yes | 55 | 15.3 |
| No | 305 | 84.7 | |
| Available family planning | Multiple answers | 258 | 71.7 |
| Government facilities | 258 | 71.7 | |
| Private facilities | 199 | 55.3 | |
| Pharmacy shops | 304 | 84.4 | |
| Others | 65 | 18.1 | |
| Accessible family planning (multiple answers) | Government outlets | 101 | 28.1 |
| Private outlets | 116 | 32.2 | |
| Pharmacy shops | 264 | 73.3 | |
| Others | 9 | 2.5 | |
| Never been to these places | 18 | 5 | |
| Variables | n | % | |
| Intrapersonal factors | |||
| Thai language skill | Poor | 71 | 19.7 |
| Fair | 197 | 54.7 | |
| Good | 92 | 25.6 | |
| Satisfied living in Thailand | No | 213 | 59.2 |
| Yes | 147 | 40.8 | |
| Awareness of family planning | Yes | 360 | 100 |
| No | 0 | 0 | |
| Knowledge level of family planning | Poor | 234 | 65.0 |
| Good | 126 | 35.0 | |
| Any message from media | Yes | 144 | 40.0 |
| No | 216 | 60.0 | |
| Type of media (n=144) | TV/radio | 61 | 42.0 |
| Pamphlets/posters | 45 | 31.3 | |
| Internet/social media | 77 | 53.5 | |
| Others | 15 | 10.4 | |
| Accessible family planning | Government outlets | 101 | 28.1 |
| Private outlets | 116 | 32.2 | |
| Pharmacy shops | 264 | 73.3 | |
| Others | 9 | 2.5 | |
| Never been these places | 18 | 5.0 | |
| Ways to facilities (n=342) | Walking | 237 | 69.2 |
| Others | 105 | 30.8 | |
| Satisfaction to facilities (n=342) | Yes | 248 | 72.5 |
| No | 94 | 27.5 | |
| Cost of family planning | Expensive | 39 | 10.8 |
| Not expensive | 315 | 87.5 | |
| Free of charge | 6 | 1.7 | |
| Health insurance scheme | Social security scheme | 71 | 19.7 |
| 30-baht scheme | 135 | 37.5 | |
| Variables | n | % | |
| Intrapersonal factors | |||
| Health insurance scheme (cont) | No scheme | 154 | 42.8 |
| Reasons for not having (n=154) | I can't afford | 83 | 53.9 |
| Employers don't want to pay | 27 | 17.5 | |
| I don't have legal documents | 10 | 6.5 | |
| Awaiting the renewal process | 33 | 9.2 | |
| Others | 1 | 0.6 | |
Table 2 presents findings on the unmet need for family planning for the all target groups eg the pregnant, postpartum, non-pregnant, and non-postpartum groups. The unmet need for family planning among Myanmar migrant women who were living together with their husbands in Bangkok was 15.8% at the time of the survey. That means that nearly 1 out of 7 migrant women wanted to space or limit a pregnancy, but they were not using family planning. Among all respondents in this survey, 3.9% wanted to limit child birth while 11.9% wanted to space their next pregnancy.
| Analysis of unmet need among migrant women | Unmet need | Met need | ||
|---|---|---|---|---|
| n | % | n | % | |
| Pregnancy (Cat I) | 34 | 48.6 | 36 | 51.4 |
| Postpartum (Cat II) | 7 | 36.8 | 12 | 63.2 |
| Non-pregnant/postpartum (Cat III) | 16 | 15.8 | 303 | 84.2 |
| Prevalence of unmet need | = {(Cat I+II+III)/total number of women} * 100 | |||
| = (57/360) * 100 | ||||
| = 15.8% | ||||
| Unmet need for spacing | = 11.9% | |||
| Unmet need for limiting | = 3.9% | |||
| Prevalence of contraceptive use | = Currently use family planning/total number of women = 242/360 = 67.2% | |||
| Total demand of family planning | = 83% (unmet need + current used family planning) | |||
| Proportion of demand satisfied | = 80.9% [current contraceptive use/ (unmet need + current use)] | |||
This study found that the prevalence of contraceptive use is 67.2% and total demand for family planning is 83.0% (based on the sum of the unmet need and current use of family planning). The main reason for not using any method of family planning was that they want another child (58.6%) or fear side effects of family planning (28.6%), among other reasons (24.1%) (eg fear of infertility, low coital frequency, sub-fecund, health concerns).
Results of the univariate analysis are presented in Table 3 (Myanmar, 2017) and show association between respondents who were not satisfied to live in Thailand, had a poor knowledge level, had poor social support from their husband and/or neighbours, experienced some difficult accessing family planning, and dissatisfaction with family planning services with an unmet need for family planning. It was found that the older age group desired family size of more than two children, high parity, were not happy living in Thailand, had poor knowledge and social support from their close network, had poor accessibility (such as far distance, not by foot) to the family planning outlet, and general lack of satisfaction with the idea of using family planning were associated with having an unmet need for family planning.
| Determinants | Unmet need | Univariate analysis | Multivariate analysis | ||||
|---|---|---|---|---|---|---|---|
| Yes (%) | No (%) | COR (95% CI) | P value | AOR (95% CI) | P value | ||
| Socio-demographic factors | |||||||
| Age groups | 15−25 years | 6.3 | 93.7 | 1 | |||
| 26−35 years | 17.9 | 82.1 | 3.24 (1.31− 7.98) | 0.011 | 2.43 (0.84− 7.05) | 0.101 | |
| 36−45 years | 23.4 | 76.6 | 4.54 (1.66− 12.45) | 0.003 | 2.52 (0.73− 8.73) | 0.144 | |
| Desired number of children | 1−2 children | 12.4 | 87.6 | 1 | |||
| 3−7 children | 22.9 | 77.1 | 2.10 (1.18− 3.72) | 0.012 | 1.24 (0.52− 2.93) | 0.625 | |
| Total number of children | No children | 7.2 | 92.8 | 1 | |||
| 1−2 children | 19.3 | 80.7 | 3.13 (1.52− 6.44) | 0.002 | 2.29 (0.90− 5.75) | 0.081 | |
| 3−5 children | 36.1 | 63.9 | 7.35 (2.94− 18.36) | < 0.0005 | 4.45 (1.10− 18.06) | 0.037* | |
| Intrapersonal factors | |||||||
| Satisfaction to stay in Thailand | Yes | 9.5 | 90.5 | 1 | |||
| No | 20.2 | 79.8 | 2.40 (1.26− 4.58) | 0.008 | 1.36 (0.62− 2.99) | 0.441 | |
| Knowledge level | Poor | 20.5 | 79.5 | 1 | |||
| Good | 7.1 | 92.9 | 3.35 (1.59− 7.09) | 0.002 | 3.17 (1.30− 7.68) | 0.011* | |
| Interpersonal factors | |||||||
| Ways to facilities | Walking | 9.3 | 90.7 | 1 | |||
| Other ways | 28.6 | 71.4 | 3.90 (2.12− 7.19) | < 0.0005 | 2.05 (1.01− 4.17) | 0.048* | |
| Satisfaction of facilities | Yes | 10.1 | 89.9 | 1 | |||
| No | 28.7 | 71.3 | 3.60 (1.95− 6.60) | < 0.0005 | 4.17 (1.96− 8.86) | < 0.0005 | |
| Health insurance | Yes | 20.9 | 79.1 | 2.64 (1.39− 5.02) | 0.003 | 2.08 (0.90− 4.76) | 0.085 |
| No | 9.1 | 90.9 | 1 | ||||
| Support from husband | Poor | 20.3 | 79.7 | 3.00 (1.46− 6.16) | 0.003 | 1.01 (0.43− 2.56) | 0.906 |
| Good | 7.8 | 92.2 | 1 | ||||
| Support from neighbours | Poor | 17.8 | 82.2 | 2.7 (1.05− 7.12) | 0.040 | 1.41 (0.41− 4.88) | 0.585 |
| Good | 7.4 | 92.6 | 1 | ||||
These features were more common among the older women than their younger counterparts. The younger women had less desire to have children, preferred a lower completed parity, were satisfied with living in Thailand, had good knowledge and social support, were near to a family planning outlet and were satisfied with family planning services. These differences by age group were significant (p<0.05). By contrast, having health insurance was negatively associated with the unmet need for family planning.
In the multiple variate analysis, the predictors of the unmet need for family planning are presented in Table 3 as well the adjusted odds ratio (AOR). Those women in the age group 36–45 years had a higher unmet need for family planning than the women age 18–25 years and 26–35 years, with OR of 2.52 (AOR–252, CI=0.73–8.73, p<0.037). Those with poor knowledge about family planning were three times more likely to have unmet need for family planning than those with a good level of knowledge, with AOR=3.17 (CI=1.30–7.68, p<0.011). The AOR of having unmet need for family planning among those who were not satisfied was significantly higher than those who had good accessibility, with AOR=2.05 (95% CI=1.01-4.17, p<0.048) and AOR=4.17 for satisfaction with family planning use (95% CI=1.96-8.86, p<0.0005).
Discussion
This paper assessed the unmet need for family planning among Myanmar migrant women in Bangkok, identifying major determining factors for the unmet need for family planning in this population. The prevalence of an unmet need for family planning was 15.8%. Age of respondent had a statistically significant positive association with an unmet need (AOR=2.52 [0.73–8.73], p=0.0037), knowledge and accessibility to family planning had a highly statistically significant association with unmet need (AOR=3.17 [1.30–7.68], p=0.011) and (AOR=4.17 [1.96-8.86] p=<0.0005), respectively. The major reasons for non-use of contraception among women with an unmet need was the desire for having more children and the fear of side effects.
The unmet need for family planning among these women was still moderately high (15.8 %, with 11.9% for spacing and 3.9 % for limiting) with a potential demand for family planning among these women of 83% and only 80.9% of this demand was satisfied at the time of the survey. This means that 1 out of every 6 women had an unmet need for family planning. Similar results have been shown in two other studies such as the Myanmar demographic health survey (DHS) 2015–2016 where 16% of currently married women had an unmet need for family planning. However, the percentage need for spacing and limiting is different: 5% for spacing and 11% for limiting the pregnancy (Ministry of Health and Sport of Republic of Union of Myanmar, 2017).
The findings are also consistent with a study in Natmauk Township, Magway Region of Myanmar among married women, where 18.1% had an unmet need for family planning: 8.8% for spacing and 9.3% for limiting (Myint et al, 2018). Our results were very low compared to the study by China among young adolescent migrants where an unmet need for family planning was 36.8% and 51.2% in two provinces (Decat et al, 2011). The difference in the results could be explained by sample size and population variation, socio-cultural beliefs, availability and accessibility of family planning methods, different strategic health planning and implementation.
Among the migrant population, high potential demand for family planning and moderately-high unmet need might lead to increased unplanned pregnancy and unsafe abortion, resulting in maternal and child morbidity and mortality. The odds of unintended pregnancy were about 16-fold among women who reported facing unmet need for family planning compared to those who did not (95% CI=11.63–23.79) (Bishwajit et al, 2017). One of the studies in Thailand-Myanmar among refugees and migrants found high infant/child mortality (ie by more than 1 in 10 women in the migrant population) (Salisbury et al, 2016).
Family planning plays an important role in reproductive health and can prevent unintended pregnancy, reduce abortion, increase opportunity for higher education, and stimulate economic growth. The third sustainable development goal (SDG) aims to achieve the target of less than 70 maternal deaths per 100 000 live births and reducing premature deaths due to non-communicable diseases by a third by 2030 (UN, 2015). The unmet need for family planning is one of the major indicators for monitoring and evaluating family planning programmes and, thus, the value for this indicator must be kept as low as possible or even reduced to zero in order to reduce the subsequent adverse effects of unplanned pregnancy and help meet the SDG target.
Among the multiple factors evaluated, only age of women, knowledge about family planning, accessibility, and social support were found to be significantly associated with unmet need for family planning. The women who had three or more children were 4.5 times more likely to have unmet need than those who had no children or less than three children. That factor has been confirmed by many studies eg in rural Bangladesh, Sri Lanka and Kenya, to be significantly associated with unmet need for family planning (Callahan and Becker, 2014; Nyauchi and Omedi, 2014; DeGraff and Siddhisena, 2015).
The respondents having a poor level of family planning knowledge are three times more likely to have an unmet need than women having a good level of knowledge. Other studies in Pakistan and China found that knowledge was positively associated with an unmet need for family planning (Decat et al, 2011; Khan et al, 2018). Nearly one-fourth of the participants were in the ‘good knowledge’ group. Most of the participants had heard about the oral contraceptive pill, while there was least (11.7%) knowledge about LAM. Respondents did not have a clear understanding about family planning side effects or rumours of the methods. Most of the users in this study used short-term methods, especially the oral contraceptive pills.
There was very low prevalence of longer-term and permanent methods of family planning. Few couples used barrier methods (eg condoms) for family planning. These findings are similar to a study in Thailand which found that oral contraceptive pills were popular, but there was a problem with compliance with the regimen or aversion to long-term and permanent methods (Tangcharoensathien et al, 2015; Salisbury et al, 2016). This study points to the need for improved education about family planning side effects and false rumours to reduce unnecessary discontinuation. One meta-analysis of DHS data from 34 countries reported that women who had discontinued method use and subsequently had unmet need for family planning accounted for 38% of the total estimated unmet need (Jain et al, 2013).
Regarding accessibility to family planning, the women in this study who were not satisfied with service at the health outlet were four times more likely to have an unmet need for family planning than their satisfied counterparts. Also, having to travel a far distance for family planning resulted in twice the risk of an unmet need for family planning. Those factors were also found to be significant in many studies eg in Ghana, China and India (Machiyama and Cleland, 2014; Vohra et al, 2014; Achana et al, 2015).
Many of the migrants had limited choice for type of family planning since they relied on the local pharmacy as the most convenient and affordable outlet. Long-term and permanent family planning methods (eg IUD, subdermal implants and sterilisation) are only available in government and private hospitals or specialised clinics. However, the cost, time of travel, wait time, and illegal status or language barriers of the migrant women might discourage them from seeking those more-effective forms of family planning.
The findings of the univariate analysis show that older women (≥ 36 years) were 2.5 times more likely to have unmet need for family planning than younger women; women who had low support from their husband/partner or neighbours were expected to have one times more risk of unmet family planning need. Those two factors have been proven by many studies in rural Myanmar, India, Ethiopia (Jirapongsuwan et al, 2015; Prasad et al, 2016; Workie et al, 2017), in Botswana, rural Poland (Colleran and Mace, 2015; Jirapongsuwan et al, 2015; Letamo and Navaneetham, 2015) to be significant predictors of unmet family planning need. Therefore, one study suggested that designing family planning programmes with peers and family involvement could increase the practice of family planning (Jirapongsuwan et al, 2015). Male involvement in family planning programmes is important to support the woman's decision related to preventing undesired pregnancies.
Conclusions
Based on the findings of this study, we conclude that the prevalence of the unmet need for family planning in the study area is high (15.8 %) and women have more unmet need to space (11.9 %) than to limit (3.9 %) the next pregnancy. The main factors still keeping the unmet need high among Myanmar migrant women in Bangkok are poor knowledge and accessibility, and being older. The major reason for non-use of contraception among women with an unmet need for family planning is fear of side effects. Based on the study's findings, the women mostly relied on their personal network to obtain information on family planning, and the sources were mainly pharmacy shops and healthcare facilities.
The destination country should promote family planning awareness through integrated services such as: 1) STI testing and treatment, 2) attendance at prenatal and delivery services, and postnatal care, and 3) vaccination programmes in private and public hospitals. In addition, there should be added investment in social behaviour-change communication and community mobilisation, based on favourable outcomes of a previous volunteer health worker project in seven provinces, conducted in 2003. The project points to the need to strengthen or increase the demand for family planning by training the peer volunteers to help raise awareness, track behaviour change and report data to the local health staff.
Regarding the most popular methods (oral contraceptive pills) among migrant women, there should be a hotline service in the Burmese language for oral contraceptive-related information, prescription of oral contraceptives, and how to correct for mistakes, such as forgetting to take the pill. The country of origin should provide pre-departure awareness sessions for the migrants. These sessions should include the facts of sexual reproductive health and a migrant's right to health insurance and state-subsidised care.
Limitations and strengths
This was a cross-sectional study, and the findings can only identify associations rather than causal relationships between the independent and dependent variables of the study. The study could not assess the supply and delivery of the family planning services, which could be possible factors influencing the unmet need.
This study also could not provide data on consistency of use of contraceptive methods and discontinuation rates. The findings of this study are, therefore, internally and externally valid only in relation to the situation of unmet need for family planning among this sample of Myanmar migrant women in Bangkok.