WHO in the Western Pacific

Cambodia reduces maternal mortality

PHNOM PENH, Cambodia – While maternal mortality has fallen worldwide by almost half over the past 30 years, the reduction has been more dramatic in Cambodia, thanks principally to improvements in health care. Since 1990, maternal mortality in Cambodia has fallen approximately two-thirds.

“Cambodia deserves enormous credit for its tremendous reduction of the number of women who die in or soon after childbirth,” says WHO Representative to Cambodia Pieter Van Maaren. “This brings the country closer to meeting the Millennium Development Goal having to do with the reduction of maternal mortality.”

Besides the improvements in health care, much of the improvement can also be explained by the country’s rapid economic growth. Six in 10 Cambodian families now have a television, mobile phone ownership has rocketed to over 60% from only 4% in 2000 and more than half of Cambodian families now have a motorbike. It means that more people can receive health messages and connect with the health system.

Access to health care has also improved through heavy government investment in transport infrastructure and in health facilities, from local-level health posts and health centres to referral and national hospitals.

However, these factors alone are not enough to account for such a dramatic improvement. It also required a commitment to adopt and implement innovative maternal and child health policies and to the implementation of strategic planning to bring them about.

“WHO is proud to have provided a range of technical assistance to the Cambodian Government, including assistance to design a mid-term review of its health strategic plan and support to the Ministry of Health to conduct an annual midwife mapping exercise,” Van Maaren says.

Millennium Development Goal 5 commits countries to reduce maternal mortality by three-quarters by 2015.

One of the most important measures that countries can take to achieve this is to ensure that there is universal access to skilled birth attendants. From the mid-2000s, Cambodia undertook a systematic programme to improve the utilization of maternal and newborn health services in public facilities, with support from WHO, international donors, nongovernmental organizations, the private sector, politicians, individuals, communities and Red Cross volunteers.

Health centres started to operate 24 hours per day, and maternity waiting houses and extended delivery rooms at health centers were added to make maternity services more accessible. Antenatal care visits, known to be a factor in the likelihood of giving birth in a health facility, also increased. While in 2000 only 39% of pregnant women had at least one antenatal check-up with a health-care provider, by 2010 this figure nudged the 90% mark.

The Ministry of Health also adopted a strategy of increasing both the training of midwives and their absorption into the health system through targeted deployment. Now all health centres nationwide have a primary midwife with one year of training, and more than half have a secondary midwife with three years of training.

To further increase the proportion of births attended by a skilled midwife, the ministry offered financial incentives. For every live birth at a health centre, the birth attendant receives a US$15 bonus, while every live birth at a referral hospital carries a $10 incentive.

This innovative and unique measure produces results. Skilled birth attendant-assisted deliveries went from 46% in 2007 to 70% in 2010, and deliveries in a health facility rose from 26% to 59% over the same period. The increase in facility-based deliveries occurred across all the whole Cambodian population. Among the richest quintile of the population the proportion doubled, while it quadrupled amongst the poorest fifth of the population.

Building on these successes and continuously improving both the quantity and level of training for midwives requires an ongoing commitment to midwifery education.

The first cohort of graduates from a new three-year dedicated midwifery training programme graduated in 2012. Together with the pre-existing additional year of midwifery training for nurses who have completed three years of nursing training, this should dramatically increase the number of midwives in the country, securing better care for future mothers.