Midwives treated 'like civil servants' battle Cambodia's maternal deaths

By Reuters/Rina Chandran   October 16, 2017 | 05:00 pm PT
The midwives 'provide the backbone' to the health workforce for mothers and their children.

After three deliveries, including a stillborn, at her home in Perah Andong village in Cambodia, Yeng Sienghay gave birth to a healthy baby girl in the local health centre about four months ago, overseen by three midwives.

Unlike her previous three pregnancies when Yeng did not visit the health center even once, this time around she went to the center every month - and every week in her eighth month - and diligently followed the midwife's instructions.

"From my own experience, I know there is more risk in having a baby at home with a traditional birth attendant," said Yeng, 32, while nursing her newborn baby.

"At the health centre, there are more qualified people and more care for me and my baby."

Yeng is a poster child for the advances Cambodia has made in reducing its maternal mortality rate, once among the highest in the world, that has won midwives new respect in communities.

The Southeast Asian nation is one of only nine countries to have achieved the United Nations' Millennium Development Goal to cut maternal death by at least 75 percent by 2015, having lowered its ratio by 84 percent between 1990 and 2015.

In 2005 Cambodia had a maternal mortality ratio of 472 deaths to every 100,000 live births, but by 2010 this had more than halved to 206 and is now 161, according to U.N. data.

This improvement came as Cambodia made more progress than about 60 other developing countries over a 10-year period in increasing the poor's access to skilled birth attendants, according to data from the United Nations Population Fund (UNFPA).

It also made the most progress in the number of visits by pregnant women to healthcare providers.

But while 89 percent of all births are now attended by skilled health personnel compared to just a quarter in 2005, the maternal mortality rate is still higher than a regional average of 127, with authorities keen to keep the impetus going.

In the United Nations' latest set of global targets, the Sustainable Development Goals, world leaders pledged to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.

Cambodian Health Minister Mam Bunheng said from next year the government will offer women incentives of up to $200 for every baby they deliver at health centers with adequate numbers of trained midwives.

"We have tried to eliminate economic barriers for the poor, so they too can access safe reproductive services. The gap between the rich and the poor has thus been reduced in healthcare services," he said.

"Our goal of increasing the strength and capacity of midwives means they are like civil servants now - well trained, well respected and well paid," Bunheng, a gynecologist by training, told the Thomson Reuters Foundation.


Much of Cambodia's progress to date has been attributed to investments in health services that give the poor access to quality healthcare services including reproductive and maternal health, as well as an army of trained midwives in rural areas.

The midwives "provide the backbone" to the health workforce for mothers and their children, said Lene Christiansen, UNFPA's Cambodia representative.

Cambodia's health care system was rebuilt entirely after the destruction of facilities and personnel by the Khmer Rouge regime in the 1970s.

Following the 1993 national elections, the government began rebuilding the healthcare system with assistance from international non-government organisations.

But it was in 2005, as Cambodia battled one of the world's highest maternal mortality ratios, that the government reviewed the midwife system and revamped the curriculum, expanded training, increased pay and gave incentives, offering midwives $10 for a live birth at a hospital and $15 in a health centre.

The government focused on bringing more midwives into the system, training them and deploying them to rural areas where maternal and newborn deaths were the highest.

Traditional birth attendants were encouraged to work with trained midwives, and the midwives could take the civil services exam for a higher qualification and pay scale.

"I became a midwife because my family encouraged me, and the government gave me a scholarship," said Heng Sokna, Yeng's midwife.

"Midwives are respected by the community, and I feel useful helping other women," she said.

In 2010, the government rolled out a Health Equity Fund funded partly by aid agencies that enabled the poor to pay for services, including safe deliveries in health centres.

Funded fully by the government now, it covers more than 3 million poor Cambodians, or about a fifth of the population.

Social realities

The drive to reduce the maternal mortality rate continues across the Asia-Pacific region as countries struggle to reduce deaths of women from complications related to pregnancy and childbirth due to social, cultural and political realities.

An estimated 85,000 mothers died in 2015 from childbirth in the region, U.N. figures show.

The 2014 State of the World's Midwifery report estimated well-trained midwives could help avert about two-thirds of all maternal and newborn deaths, with UNFPA now supporting midwifery programs in more than 100 countries.

In these countries, midwives not only deliver babies but also advance the rights of women and girls, offer support to survivors of gender-based violence and reproductive health counselling to adolescents.

In Cambodia, there are now about 250 midwives in each province, with two to three in each health centre.

Khimsu Pairun, health director in Kampong Cham province, said the aim is to increase antenatal visits, increase deliveries in health centers, and encourage contraceptive use.

"Many maternal deaths occur because women do not get proper antenatal or postnatal care, because they were not cared for by skilled attendants and could not get help in time," he said.

In Kampong Cham's hospital, 35 midwives, dressed in baby pink slacks and shirts edged in white, deliver about 20 babies every day.

In the maternity ward, built for a few dozen beds, more than 100 women and their families cram its corridors and balconies.

Women are stretched out on mats on the floor, with baskets of food and makeshift fans beside them, and mosquito nets over their newborn babies. Many have come from distant villages.

It is by ensuring safe and affordable deliveries for these women that Cambodia can reach its SDG, said Christiansen.

"Significant efforts are needed to ensure that women from marginalized and poorer communities including ethnic minorities, migrants, geographically isolated women, the urban poor can get access to quality reproductive and maternal health services without any barriers or financial hardship," she said.

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