The maternal mortality rate in Cambodia has not improved in the last five years, according to the results of a long-anticipated national health survey released this month.
Mothers in Cambodia are still dying at a remarkably high rate—the second highest in the region next to Laos, said Sin Somuny, executive director of Medicam, which is an umbrella organization for health NGOs.
Overall, however, according to the latest Cambodia Demographic Health Survey, there has been marked improvement in nearly all other areas covered by the survey, including prenatal care, child health and HIV-AIDS, which is included in the survey for the first time.
“Maternal health is still our concern but we are optimistic about the [survey] results,” Health Minister Nuth Sokhom said Monday.
“We have made progress in prenatal care [by] about 50 percent, the child mortality rate is down, routine immunizations have increased and breastfeeding in the first six months of life is up,” he added.
The survey, conducted for the first time in 2000 by the Health Ministry’s National Institute of Public Health and the National Institute of Statistics, focuses on Cambodia’s households. A total of 16,823 women and 6,731 men between the ages of 15 and 49 were interviewed for the project in 2005 although the results are only being released now.
The survey reports a maternal mortality rate of 472 deaths of mothers during childbirth per 100,000 live births. This figure is slightly higher than the 2000 survey’s figure of 437, but health experts say this is not a significant change.
The main reason why the rate is still so high is a shortage of midwives, especially in remote areas, said Sin Somuny, executive director of Medicam. Most maternal deaths are due to complications during labor and are preventable if trained professionals are present, he said.
The Health Ministry stipulates that there should be at least two midwives in all Cambodia’s health centers, said Tung Rattavy, national manager for the ministry’s national reproductive health program.
“But there are more than 100 health centers in the country that have no midwives,” she said. Another big problem is the transportation cost for poor pregnant women to get to health centers, she added.
The government needs to reassess the benefits midwives are being offered, Sin Somuny said.
“Doctors only get $20 or $30 per month,” he said, “and midwives get much lower.” In remote areas where midwives from elsewhere live without their relatives, this is not nearly enough to act as an incentive, he said.
The government is trying to modify recruitment techniques to address the midwife shortage, Nuth Sokhom said. Rather than training midwives and then posting them at random around the country, the government is looking into recruiting women from remote villages to come and train as midwives before returning to their villages of origin, he said. On returning to the villages, they will have a support network and will be more likely to stay, he added.
There is still a way to go to reach the UN Millennium Development Goal of reducing the rate by 2015 to 140 deaths per 100,000 live births.
But some maternal health indicators are encouraging. The rate of pregnant women seeking prenatal care has nearly doubled since 2000, and the number of births attended by a trained professional is up to 44 percent from 33 percent in 2000, the survey states. Currently, 66 children under the age of 1 die and 83 children under 5 pass away for every 1,000 live births, according to the survey. In 2000, there were 95 deaths of children under the age of 1 and 83 under-5 deaths per 1,000 live births.
The improvement in child health is likely a positive indicator for maternal health, Tung Rattavy said.
“Child health is indicative of maternal health,” she said. “If the pregnant mother has poor health, the baby will be sick.”
The survey’s child and maternal health figures are likely an accurate portrayal of the situation in Cambodia at large, said Michael O’Leary, World Health Organization country representative.
Mothers and children tend to live in houses and the CDHS is a household survey, he noted. But because the survey is limited to households, some parts of the population are going to be underrepresented, he said.
Highly mobile populations such as sex workers and motorbike taxi drivers—who are likely to be engaging in high-risk behaviors—or drug users who may live on the street, are effectively not included in the survey, said Tony Lisle, UNAIDS country coordinator.
The survey reports that only 0.6 percent of adults between the ages of 15 and 49 are HIV-positive, but Lisle said this figure is “purely a snapshot” of a larger problem.
“The [survey] shows us the household prevalence rate. It doesn’t give us the comprehensive picture of the terms of the epidemic” which affects an estimated 123,100 people nationwide, he said.
“The rate among direct female sex workers in 2003 was 21.4 percent, indirect female sex workers in 2003 was 11.7,” he said. “There is no data currently available that shows this has gone down.”
Amongst men who have sex with other men, there is a 5.1 percent rate of HIV, he said.
Sampling pregnant women who seek prenatal care is a more accurate gauge of the prevalence of HIV than interviewing household members about whether they are infected, Lisle said.
In 2003, the HIV rate among women seeking prenatal care was 2.2 percent, constituting a general epidemic, Lisle said. Anything above 1 percent is viewed as a general epidemic.
That rate has likely declined to about 1.5 percent, he said, which marks improvement but is still far from the new survey’s figure of 0.6 percent.
Policemen who frequently attend brothels use condoms with sex workers almost 90 percent of the time, Lisle said. But now they are more likely to have multiple “sweethearts” with whom they use a condom only 40 percent of the time because they perceive the situation to be lower-risk, Lisle said.
“There is a possibility for these risky behaviors to refuel the epidemic,” Lisle said, adding that there needs to be a strong and consistent refocus on preventing AIDS.
“People will read the 0.6 percent figure and say ‘the epidemic’s over,’ but it is certainly not over in Cambodia,” he said.