Oum Phoeun knows about birth spacing. She knows about birth control as well. Her first four pregnancies went off without a hitch, each two to three years apart and each pregnancy culminating in her delivering with a traditional birth attendant inside her Kampot provincial home.
Each time she has gone into labor, she said last week from a recovery ward in the National Reproductive Heath Center in Phnom Penh’s Japanese Hospital, she took a lot of medicine, like penicillin, and drank a lot of rice wine after giving birth. And for the first four births, she also “took fire.”
“I had four children and everything was OK, but then for the fifth birth I selected another traditional midwife, but the new midwife had no skill and I bled too much. I had pain in my womb and stomach. I felt tired and weak, and my vision got blurry,” she said. That’s when her husband brought her to the hospital.
Though Cambodia has made great strides in the last decade with respect to maternal health, the maternal mortality rate is still among the highest in the region, with 437 maternal deaths for every 100,000 live births, according to Ministry of Health statistics. In fact, health officials point out that Cambodia has more in common with some African nations than Asian nations when dealing with the risks associated with childbirth.
But the maternal mortality rate fails to take into account the even larger number of women who have complications related to childbirth. That figure also does not take into account how much more risky childbirth is in the rural areas of the country.
“Complications can occur without prediction,” says Dr Chhun Long, program manager for the National Reproductive Health Programme. Post-partum hemorrhage, infection and obstructed labor are among the most common childbirth-related complications, says Chhun Long. And HIV/AIDS and unsafe abortions also fall under the category of pregnancy-related complications.
The UN Population Fund estimates that there are three primary factors making childbirth in Cambodia risky. First, the birth rate is still too high and birth spacing is not common enough.
“Contraceptive rate is very low,” said UNFPA Country Director Yoshiko Zenda. “There is a gap of about 20 to 30 percent [of women] not using contraception who want to, and there are a lot of unplanned or unwanted pregnancies. Women should wait 24 months [in between pregnancies, so that births are three years apart.”
Childbirth is more dangerous for women over 35 and younger than 20 years old, said Zenda. And, as Oum Phoeun’s case illustrates, the prevalence of childbirth complications is increased after the fourth pregnancy.
Complicating matters is the fact that the Ministry of Health estimates that 58 percent of pregnant women have anemia or iron deficiency or both, as a result of bad nutrition. “This is really damaging to the body. When you are pregnant the amount of blood in the body should increase,” said Zenda
After the fourth pregnancy, said Chhun Long, “the uterus is not very strong. The shape can change and the positioning of the baby is not normal. So there is a risk of rupture of the uterus due to obstructed labor.”
Cesarean section and pregnancy interventions “are only where there are facilities for the operation. In the communities, if there is no facility, the woman will die,” said Zenda. Currently, access to Caesarean sections is almost negligible, compared to the optimal rate of 4 to 5 percent. Five to 10 percent of women in developed nations give birth by Caesarean section.
A third cause of complications is that, though abortion has been legal in Cambodia since 1988, operational guidelines were not established until 2002. Outside of the National Reproductive Health Center, said Zenda, “not a single person in Cambodia is properly trained in abortions.”
As a result, abortions are often clumsy, and often lead to infection and hemorrhage.
According to Ministry of Health, 90 percent of Cambodian childbirths occur in their home. “There is nothing wrong with that,” said Zenda, “as long as the midwife is skilled.”
The UNFPA estimates that only 39 percent of them give birth with a skilled health care worker.
While acknowledging that maternal risk is higher in rural areas of the country, heath care workers from the Reproductive and Child Health Alliance NGO believe that it is a dearth of properly trained midwives in the countryside.
This is partly due to the dearth of properly trained heath care professionals left in the country in the 1980s. As a result, many midwives were hastened through the system and into health centers.
“Traditional birth attendants just learn from their ancestors from their mothers and grandmothers,” added Sam Socchea, head of the Safe Motherhood program at RACHA. She has even heard of women learning their skills in a dream. Proper midwife training, she said, takes two to three years.
To fill the gap between theory and practical experience, RACHA, in partnership with the Ministry of Health, offers “basic life saving skills” training to midwives from rural health centers. The training focuses on how to deal with childbirth-related emergencies such as hemorrhage and infant resuscitation.
In their workshops, RACHA encourages midwives not to give women rice wine after childbirth and not to try to force the baby out by applying pressure to the uterus, said Sam Socchea. And midwives are encouraged not to participate in “roasting”—a practice whereby the new mother is kept close to a fire after childbirth—which can lead to increased blood pressure and a higher rate of infection.
The Ministry of Health found that 91 percent of women in rural areas were “roasted.”
RACHA, in cooperation with the Ministry of Health, is also the only organization in Cambodia to promote a “voluntary surgical contraception,” or sterilization, program, offering vasectomies and tubal ligation services.
“That [voluntary surgical contraception] is readily acceptable is surprising-even to us. Cambodian males are not averse to having a vasectomy,” said RACHA Program Manager Richard Sturgis.
Thirty-seven surgeons and 33 midwives and midwives from 11 hospitals have been trained in the procedures and counseling, which are done on an outpatient basis. Last year, 1,172 sterilizations were performed, up from only 57 in 1997, the year of the project’s inception.
The main barrier to more widespread acceptance, said Sturgis, is not the $12.50 cost of the procedure, but rather the transportation costs to and from the clinics.
Sterilization might be an option for Oum Phoeun. “I do not want to have children because it is difficult to give birth,” she said.
Because of the complications associated with childbirth, she is unable to use birth control pills or an IUD birth control injection. “Maybe after they control my health,” she said.
And though she has successfully spaced the births of her five children, she said she and her husband have never used a condom. “I trust my husband,” she said.
But, she said that when she returns to her home, she will tell her village chief and her friends about the positive impacts of giving birth in a hospital. “It is better that way,” she said.