In Cambodia, 68% of births take place without a skilled birth attendant, resulting in alarming rates of maternal deaths. One province is piloting performance-related pay to boost outcomes. But, says Patralekha Chatterjee, the main challenge is ensuring that women go to health centres to deliver.
Inside the Red Cross Health Centre in Phnom Penh, Cambodia's capital city, a class in basic life-saving skills is in progress. The students are midwives from remote villages in Prey Veng, a desperately impoverished southeastern province in the country. Like model pupils, they attentively watch the teacher demonstrate cardiopulmonary resuscitation using a rubber doll. It is learning by doing. In the middle of a class, Meach Sarorn, a student, is called away to help out in a delivery case.
The operation theatre at the centre, with its immaculately clean environs and modern equipment, is a world apart from the government health centre at Pnoeuv village where Sarorn works. But for the village midwife, the 2-week training provides an invaluable opportunity. Not only is she picking up expertise in life-saving measures such as postpartum haemorrhage interventions and infant resuscitation and is better equipped to use the new medical gadgets her health centre has acquired, the training has vastly expanded her knowledge of antenatal and postnatal care.
Many Cambodian mothers die needlessly due to unclean water, poor sanitation, and a lack of access to basic health care and transport. A woman with a newborn travelling in an oxcart along bumpy, dusty roads is common in the Cambodian countryside. Add to that malnourishment, anaemia, multiple pregnancies, and frequent abortions. It falls on the few trained midwives working in rural areas to warn families about the dangers posed by such a mix to the lives of mothers and newborns, Sarorn says.
Cambodia has some of the most alarming health indicators in southeast Asia: a maternal mortality rate of 450 per 100 000 livebirths, an infant mortality rate of 106 per 1000 livebirths, and a healthy life expectancy at birth of 47·5 years. According to the World Health Report 2005, only 9% of pregnant women in Cambodia have more than four antenatal check-ups, and 44% have just one.
In this situation, a short training programme in emergency delivery skills for a few provincial midwives may seem like scratching the surface. But the initiative undertaken by RACHA (the Reproductive and Child Health Alliance), a Cambodian NGO, is emblematic of the stirrings of change.
“Skilled birth attendants can ensure clean deliveries and adequate temperature management for newborns. However, the vast majority of deliveries (68%) still take place without the help of such attendants in Cambodia. With a package of appropriate antenatal care, clean delivery, and appropriate newborn care, many neonatal deaths can be averted”, says Koum Kanal, professor and director of Cambodia's National Maternal and Child Health Centre.
When she goes back to her village, midwife Sarorn is expected to use her new learning while assisting deliveries. Her reward is performance-based earnings. This approach is being tested in a pilot project currently in Pearaing district, Prey Veng, and supported by external donors. “The project pays US$20 per safe delivery to the government health centre. The midwife who delivers the baby gets between $5 and $15. Part of the money also goes to community volunteers who refer a pregnant woman to the health centre”, says Cheang Kannitha, RACHA's Safe Motherhood Coordinator.
A modest user fee ranging from $2·5 to $5·00 is levied on each woman who delivers her baby at a health centre. At Pearang, where HealthNet International, an international NGO, is running the project, deliveries are free of charge in around 80% of health centres. Two out of 15 health centres, however, charge $2·5 for deliveries, according to Kong Sam An, a senior district health official at Pearang.
The jury is still out on the extent to which such an approach—melding training, user fees, and performance-based earnings for rural midwives—can help Cambodia improve its rates of maternal and infant mortality. A formal assessment of RACHA's life-saving skills training programme is expected in October, but informal indicators point to a greater awareness about safe deliveries in areas where freshly trained village midwives are working.
“The idea is to upgrade the skills of provincial midwives and to encourage delivery at health centres … we provide baby kits or hygiene kits to woman who deliver their babies at a health centre. In Pursat province, we used the interest from a microcredit programme to pay (around $1·25 per referral) a traditional birth attendant or village health support group who refer an expecting woman to a health centre”, says Kannitha.
“Most government health workers prefer being in cities. There are not enough midwives and secondary midwives in rural areas where most Cambodians live. And then there is a lack of motivation because of very poor salaries. Village midwives who are selected for our training programme are given a monetary incentive—around $20. We work with provincial and district health departments who provide us with regular feedback on the number of safe deliveries being carried out in each area”, adds Chan Theary, RACHA's executive director and a former nurse.
The key issues behind Cambodia's dismal statistics in maternal and child mortality are, unsurprisingly, politics and economics. The poor health indicators reflect the country's conflict-scarred past: the health system received a devastating blow during the Khmer Rouge (1975—79) period when an estimated 1·7 million Cambodians were killed through execution, starvation, and forced labour. Health improved following the Khmer Rouge's ousting by the Vietnamese army in January 1979.
Worryingly, 30 years on, the government's avowed aims to rebuild health infrastructure and improve health systems are seriously hamstrung by a low national health budget. The bulk of this money goes towards paying staff salaries while the widely accepted practice of “unofficial user fee” for public health facilities further disadvantage the poor.
Another key challenge is settling the question of the best way forward in dealing with public health challenges in cash-strapped countries such as Cambodia.
“Should poor people have poor options?” asks Monir Islam, Director of WHO's Department of Making Pregnancy Safer. Islam argues passionately against adopting intermediate approaches to deal with maternal and child health. A key issue in this context revolves round the desirability or otherwise of upgrading the skills of traditional birth attendants (TBA) who still play a critical role among village communities in Cambodia and many other developing countries. Islam says pouring more resources into TBA training is counterproductive and would guarantee that a country gets stuck in the “transition trap”. Instead, governments have to invest more money in expanding the pool of skilled birth attendants.
TBAs lack education and cannot deal with postpartum haemorrhage, eclampsia, or sepsis—some of the major causes of maternal mortality, he says. The best way of using a community resource like the TBAs is to treat them as key informants and encourage them to refer pregnant women to health centres.
However, in Cambodia, as elsewhere, political commitment to reduce maternal and neonatal mortality is often not translated into increased resource allocation (ie, finances, skilled personnel, adequate health facilities, and available drugs). Despite the global recognition that skilled attendants are indispensable at the time of birth, many women do not have access to basic care.
The case for greater political commitment and government investment is compelling. “From 2001 to 2005, the Cambodian government's health spending increased from 0·89% to 1·20% of GDP. But while moving in the right direction, this is clearly a very small investment in health”, says Stephen Atwood, Regional Advisor, Health and Nutrition UNICEF East Asia and Pacific Regional Office.
Cambodia does not have to look far for inspiring examples. In the past few decades, Thailand, Malaysia, and Sri Lanka have all improved maternal health substantially through a mix of strategies including a supportive policy environment, political commitment, strengthening of health systems, and boosting professionalisation of midwifery.