chongphang village, pech chreada district, Mondolkiri province – Kloek Saeng, 27, needed to sacrifice a chicken and appeal to the spirits for protection before giving birth to a baby girl seven months ago.
During Ms Saeng’s labor in her small bamboo house, a traditional midwife, Seng Nhong, was there to cut the umbilical cord, wait for the placenta to come out and then light a fire under her bed to warm her tired body.
“All my family members—my sisters, brothers and husband—surrounded me and gave me courage,” said Ms Seang last week, holding her healthy daughter on her lap. “I see a lot of benefits to delivering a baby at home with traditional midwives.”
Despite a government push for women to give birth at health facilities with professional midwives, traditional birth attendants are still needed and valued in remote highland villages like this one.
Ms Saeng, a member of the Bunong ethnic group, choose to stay at home because she could not face the bumpy one-hour drive along a mud track to the health center, or the embarrassment of strangers seeing her give birth.
Most importantly, Ms Seang feared dropping blood on the road, which would bring the wrath of forest spirits down on her village.
“If such a thing happened, I would be blamed whenever villagers fall ill,” she said, adding that she would be forced to sacrifice a buffalo to appease the anger of the spirits and restore calm.
Ms Seang and most other pregnant Bunong women in Chongphang call on Ms Nhong to gently massage their abdomen, help them give birth and brew traditional remedies out of medicinal plants found in the forest to ease labor pains and speed their recovery.
“I encourage the women to go to health facilities, but they don’t want to go. They want to stay at home with me,” said Ms Nhong, 35, who first learned how to deliver babies from older women 10 years ago.
The risk of dying in childbirth in Cambodia remains alarmingly high. Cambodia has one of the worst records for maternal death in the region and Mondolkiri is one of its worst affected provinces.
Cambodia’s maternal mortality ratio has remained stagnant over the past decade and the 2008 census showed a negligible reduction from 472 maternal deaths per 100,000 births in 2005, according to Usha Mishra, chief of policy, advocacy and communication at the UN children’s agency Unicef. “It is of grave concern,” she said.
Last year the UN warned that the country was lagging behind on the Millennium Development Goal to reduce maternal deaths to 250 per 100,000 births by 2015.
About four years ago a woman was in labor for a day and a night before being rushed to the referral hospital in Mondolkiri for an emergency caesarian section, Ms Nhong said. Both the mother and baby died soon after arriving at the hospital. “I don’t know clearly about the danger signs, but if it’s very complicated during delivery I send the woman to the referral hospital,” she said.
Nhang Ravy, 55, a primary midwife dressed in pink scrubs who delivers babies at Bosra commune health center in Mondolkiri, said that last year the center stopped handing out medical kits to assist deliveries at home. “The number of maternal deaths was declining, but in one or two cases women still died,” Ms Ravy said, sitting in her office next to the delivery room. “We want to eliminate maternal deaths at home.”
Campaigns and financial incentives to get women to give birth at the health center meant deliveries increased from less than five per month in 2009 to between eight and 14 a month this year, she added.
Yet across Mondolkiri and neighboring Ratanakkiri provinces, health professionals only delivered 38 percent of the babies born in the two provinces, while only 30 percent of all the deliveries took place in health facilities, according to a 2010 survey. In contrast, health professionals delivered 71 percent of babies nationwide and 54 percent were in health facilities.
The Health Ministry does not publicly encourage training for traditional birth attendants, according to Kuch Vanna, deputy director of the provincial health department. “There is no policy to train traditional midwives how to deliver babies because we are raising public awareness to encourage pregnant mothers to deliver with skilled midwives,” Mr Vanna said.
Nevertheless the department is looking for funds to restart previous training for traditional midwives on recognizing danger signs during deliveries, he added. “Traditional midwives still play important roles.”
Nobody trains traditional midwives in Mondolkiri province anymore because the Health Ministry does not encourage it, said Dr Meak Weng, provincial program manager of Health Poverty Action, one of the NGOs that conducted training in the past. “But in reality here, they still need the TBAs [traditional birth attendants] because of a shortage of midwives coming to work in Mondolkiri province.”
Andrew Martin, country director of Health Poverty Action, said by e-mail that the government policy to encourage skilled midwives to conduct all deliveries was not yet possible in remote provinces. “Considering the current lack of adequate numbers of highly skilled midwifes, short-to-medium term advances in reducing maternal mortality can only be achieved through constructive engagement with TBAs,” Mr Martin said.
Ms Mishra of Unicef said that skilled professional midwives trained in modern medicine were still the best bet for reducing maternal mortality, although traditional birth attendants can play a role in referring women to health centers.
“Global evidence and recommendations favor delivery in a health facility with a skilled birth attendant for reducing maternal mortality,” she said. “The likelihood of complications and death of pregnant women assisted by traditional birth attendants are high,” she said.
But Brigitte Nikles, a researcher on traditional midwives from NGO Nomad Recherche et Soutien International, said that inadequate public health facilities in Mondolkiri an elsewhere meant not all women could give birth in a center and many decided not to. “[T]he most important thing is that the traditional midwife recognizes the danger signs in order to refer the woman early enough,” Ms Nikles said in an e-mail.
Her colleague Nicolas Savajol warned that given the Cambodian cultural context, “if you do not go through the traditional midwives you will not reach the people and you will not succeed.”
Traditional Bunong midwife Chrek Bran, 45, who has a good reputation in her community after delivering babies for more than 30 years, is dubious about the government’s efforts to funnel women into health centers staffed by professional midwives, noting that she volunteered at the ill-equipped Pou Chrei commune health post alongside a newly trained teenage midwife from a school in Stung Treng province.
“She is very young and the pregnant women here do not trust her,” said Ms Bran, sitting inside her wooden house next to a stack of delivery kits. The NGO Medicin du Monde trained Ms Bran a long time ago, and Health Poverty Action taught her danger signs to watch for during delivery. Still, she said she craves more training in order “to know everything.”
Last year one of her neighbors was forced to sacrifice a buffalo for breaking the traditional norms that tie women to the village during and after they give birth.
If a mother leaves her home in the first two months after childbirth, it is believed that a spirit will inflict labor pains on others, she said. Also “if they drop blood along the road, it will make the spirits angry and cause a lot of people to die or become sick.”
Villagers sometimes try to stop bleeding women from going to the referral hospital, but Ms Bran fights for them to go. “It is better to have safe delivery there to live, than keep them here to die.”