Improving maternal health and access to health services is key to achieving the goal of reducing maternal mortality. (Credit:Robert Carmichael)
PHNOM PENH, Oct 12 (IPS) - Early this year, heavily pregnant Vorn Yoeub, 37, arrived at a hospital in the western Cambodian border town of Pailin. The mother of seven other children died later that evening along with her unborn child after suffering complications from bleeding.
For most of this decade Cambodia has been trying to cut the number of deaths of women, who, like Vorn Yoeub, are the human face behind the country’s stubbornly high maternal mortality rate. The figure has been running at around 461 per 100,000 live births for 10 years, and is one of nine development objectives the country is trying to improve as part of its Millennium Development Goals (MDGs).
MDGs are development goals that the United Nations member states along with other international organisations have agreed to meet by 2015.
Progress on Cambodia’s nine goals is mixed: A conference in Phnom Penh late last month indicated that it would likely attain only three of them by 2015. And there are concerns that the global economic crisis could make attaining some of the remaining six MDGs much harder.
Sherif Rushdy, a consultant for the United Nations Development Programme (UNDP), told attendees that on the positive front, Cambodia would probably meet its targets in cutting child mortality; combating HIV/AIDS, malaria and other diseases; and reducing to zero the number of casualties from landmines (which is specific to Cambodia).
But it will almost certainly miss another three: Reducing maternal mortality to 140 deaths per 100,000 live births; achieving universal nine-year education; and ensuring environmental sustainability.
"[These three goals] are flashing a red light, and the country is unlikely to reach its goals in these areas," he said.
Two other MDGs – eradicating extreme poverty and hunger; and promoting gender equality and empowering women – are also thought unlikely to be met unless Phnom Penh changes its approach.
Rushdy told attendees that progress towards the final goal – developing a global partnership for development – could not be assessed since targets were not set.
Why such mixed results on two of the key healthcare goals: Little or no progress on reducing maternal mortality combined with "spectacular progress" – in the words of Rushdy – in cutting child and infant mortality? After all, they are closely linked.
In an interview with IPS, Dr Lo Veasnakiry, the Ministry of Health’s director of planning, said there are solid reasons behind the declines in death rates of infants and young children.
One is the government’s commitment to support the health sector financially despite the impact of the global financial crisis ripping through Cambodia’s economy. Another is its policy to improve access to child-based services and their availability.
"And thirdly, we have support from the health partners in terms of technical and financial services," he said. One of these is the United Nations Children’s Fund (UNICEF).
Malalay Ahmadzai, UNICEF’s mother and child health specialist, added several other factors to the success mix, among them the strategy to improve breastfeeding practices.
But improvements have also come from areas that at first sight appear to have little in common with health – primary education, for example. Mothers with some education have an improved understanding of health matters, she said. The strong economic growth of the past decade has also helped, as have better roads and quality of care in this predominantly rural society.
"Things are very much linked," Ahmadzai said.
This combination of improvements has helped lower the number of infant deaths to 60 per 1,000 live births, well on the way to meet the MDG of 50 per 1,000 live births.
Such factors have also driven down the number of under-fives dying, from 124 per 1,000 live births in 1998 to 83 per 1,000 currently. Rushdy told the conference that Cambodia should meet its goal of 65 per 1,000 live births.
Yet it still leaves the question of the country’s extremely high maternal mortality rate. One senior UNDP staff said statistical modelling of the data shows the true figure could be anywhere between 300 and 700 deaths per 100,000 births. But whatever the true figure, there is widespread agreement that the target of 140 will not be achieved.
Dr Veasnakiry cited a lack of money and insufficient technical expertise. And, he added, the initial target was set too high. He has proposed that the government revise upwards the target of 140 deaths per 100,000 live births to 250 deaths. He rejects the suggestion that this is simply shifting the goalposts. And, he points out, some progress is better than none.
"We think the [revised goal of] 250 is likely to be achieved," he said, citing gains in a number of the underlying indicators related to maternal or infant health. For example, this time last year, 79 of Cambodia’s 967 health centres lacked midwives. "But by the middle of this year all the [remaining] 79 health centres are staffed with midwives."
Another improvement is the government’s introduction of an incentive for midwives: Those who work in rural health facilities are paid 15 U.S. dollars for each baby born alive. Those working at hospitals – in larger, urban areas – get 10 U.S. dollars. "This has produced a positive impact on the [successful number of] deliveries," he said.
And while just one-third of births were attended by skilled health workers a decade ago, that number rose to 58 percent last year. The target for 2015 is 80 percent.
Pre-natal visits are also up from around 30 percent in 2000 to 80 percent last year while the number of Caesarean sections for births with complications has also increased – an indication that more women with problem births are getting appropriate medical intervention. All of this gives him cause for optimism. "We can use these proxies to look at the progress for the future," he said.
But if the true maternal mortality numbers remain opaque, the afflictions killing five Cambodian women a day in childbirth are clearer. A 2005 Japanese-funded study found more than half die from bleeding, while eclampsia kills another one in five.
"The complications [with maternal mortality] are unpredictable," said UNICEF’s Ahmadzai, "and the onset of complications can be very quick."
She said rapid reaction is vital in addressing what health experts call "the three delays" behind the high death rate among women of reproductive age. The first delay is the decision by the family in this predominantly rural population whether or not to take the woman to the health clinic. The second is access, or simply getting to the clinic, and financial aspects such as affordability. The third is the quality of care women get once they reach the clinic.
"If any of these three delays exists, then the mother [who is bleeding] dies within an hour or two or three," she added.
The solution is a mix of improved resources and trained staff: "more skilled birth attendants, good supplies, quality improvement of services, and then improving access," said Ahmadzai.
Speaking to IPS, the UNDP’s Rushdy said the "stubbornly" high maternal mortality rate has other causes too. "This is a gender issue – girls and mothers continue to be neglected," he said. "Girls’ nutrition is the first to be cut when there are financial difficulties in households. So one root cause is a general bias against women."
Another is the loss of skills in many areas such as health. Most of Cambodia’s educated people either died during the Khmer Rouge regime or fled overseas.
Rushdy believes the MDG to eradicate poverty and hunger — which are inextricably linked to health, women’s in particular — will not be met unless Cambodia can shift economic growth away from its narrow urban base of garment manufacturing, tourism and construction. He said the solution is to promote development in rural areas, where the majority of Cambodians live.
"There are ways to mitigate the risks, such as providing free access to health care. Health problems are the ones that drive people into poverty," he said.
