As officials turn their attention to the maternal mortality rate, experts in Pursat say the maternal health situation there can shed light on challenges faced across the Kingdom.
Sok Lin writhes in pain as she awaits the birth of her child last
month, while her mother-in-law Cheam Kav looks on.
AT 9:27 on the morning of March 30, nearly 18 hours after she checked into Pursat's Sampov Meas Referral Hospital to give birth to her first child, Sok Lin's grimaces and groans gave way to tears as the pain of her contractions intensified.
"This child wants to come out," she said as she writhed on a wooden cot, clutching and twisting the blankets and diaper rags she had brought from her home in nearby O'Kamboa village.
Cheam Kav, 48, Sok Lin's mother-in-law, massaged her back and sprinkled water on her face. When not doing that, she leaned against a wall and peered into the adjacent office in which four midwives sorted medical records.
The experience of a hospital birth was a new one for Cheam Kav, who delivered all 12 of her children at home with the aid of a traditional midwife.
"Some villagers still use those midwives, but I don't feel safe with them anymore," she said, adding that her view had changed after she watched television ads promoting hospital births and heard doctors stress the importance of emergency obstetric care, particularly for difficult deliveries.
Though Sok Lin, 21, was not expected to face any complications, Cheam Kav said she was comforted by the fact that emergency care would be available should anything go awry.
But she said she wished the midwives would pay a bit more attention to her daughter-in-law, whose cries were growing louder and more anguished by the minute.
"I want to give birth very soon," Sok Lin said between clenched teeth. "But the midwives, they just tell me to wait."
A top priority
Increasing the number of births attended by skilled health care personnel is at the heart of the effort to reduce Cambodia's maternal mortality rate, a problem that has long confounded health officials. The 2005 Cambodia Demographic and Health Survey (CDHS), the source of the most recent reliable maternal health data, reported a nationwide rate of 472 deaths per 100,000 live births - the third-highest rate in the region behind Laos and East Timor.
If recent comments by government officials and development partner representatives are any indication, the effort to reduce the rate has assumed a leading role on the national health agenda.
During various speaking appearances last month, the issue was specifically addressed by Minister of Health Mam Bunheng, UN Resident Coordinator Douglas Broderick and Prime Minister Hun Sen.
To be sure, improving maternal health involves more than merely keeping women alive.
In a 2005 report, USAID found that for "every woman or girl who dies as a result of pregnancy-related causes, between 20 and 30 more will develop short- and long-term disabilities", including uterine ruptures and pelvic inflammatory disease. Citing "best estimates", the report went on to say that 42,000 Cambodian women sustain injuries or disabilities caused by pregnancy-related complications each year, compared with the estimated 2,100 who die.
Data on these conditions ranges from biased to nonexistent, but the most recent National Health Statistics (NHS) report from the Ministry of Health and recent interviews with maternal health experts indicate that the most common pregnancy-related complications in Cambodia include postpartum haemorrhages, uterine ruptures and infections.
A handful of such conditions can have long-term effects. Infections, for instance, can lead to infertility. And uterine tears that are left untreated or treated improperly can cause, among other things, incontinence and uterine prolapse, in which the uterus descends from its position in the pelvis down into the vagina.
Pregnant in Pursat
Dr Niklas Danielsson, a medical officer for child and adolescent health at the World Health Organisation's Cambodia office, said these conditions are consistently underreported because of the "shame" that tends to come with them, which discourages afflicted women from accessing medical care.
In 1997, the Reproductive and Child Health Alliance (RACHA) opened its Pursat office, largely because the province had one of the highest maternal mortality rates at the time, said Executive Director Chan Theary.
Since then, for a range of reasons, Pursat's maternal mortality rate has fallen and is now roughly on par with the national rate, Chan Theary said, adding that she believes the maternal health situation in Pursat is something of a microcosm of the situation nationwide - a view echoed by Provincial Health Department Director Khlem Sokun.
The CDHS did not report provincial maternal mortality rates. Dr Sieng Kimseng, director of Sampov Meas operational district, could not provide data on pregnancy-related injuries and disabilities, saying he had asked the Ministry of Health "many times" for the equipment necessary to track this data but had not received it.
Khlem Sokun said half of all births in Pursat are attended by skilled health personnel. But he added that some midwives are poorly trained and not always sensitive to the needs of their patients.
Other problems include the lack of equipment at some health centres and the fact that health officials can visit the province's remote areas only once a month, making it difficult to promote antenatal care, he said.
Speaking generally, Khlem Sokun said the maternal health situation in the province had improved considerably over the last decade, in large part because of the presence of organisations such as RACHA, which works to train midwives and ensure that health centres have the equipment required for emergency obstetric care.
But Chan Theary stressed that negative pregnancy outcomes persisted.
"In Europe or in the US, when you get pregnant you're happy, you're blessed. And also for the rich women in Cambodia, it's a happy thing," she said.
"But for poor women in Pursat, it's just another worry, another problem."
No access to care
On the same day Sok Lin went into labor, Orm Lin, 43, sat under the house he shares with his brother-in-law in nearby Chamcar Chek village and reflected on the changes wrought by the March 2008 death of his wife, who was stricken with eclampsia during her sixth pregnancy.
Eclampsia is a condition in which a pregnant woman develops dangerously high blood pressure and sometimes suffers kidney failure, seizures and heart failure. The NHS indicates that eclampsia is among the most common pregnancy complications in Cambodia.
Orm Lin said his wife, Vorn Serey, 41, complained of a severe headache and numbness in her legs one day eight months into her pregnancy.
When she visited the hospital, she received an intravenous drip - Orm Lin does not know what it contained - and was sent home. Shortly after the visit, her legs began to twitch and then convulse. She was admitted to the hospital at 4pm on March 12 and died shortly after noon the next day.
Because he could not understand the doctors, Orm Lin at first did not know what killed his wife. Only when a RACHA doctor visited his house did he learn that his wife's symptoms pointed to eclampsia.
He also learned from the RACHA doctor that his wife had been encouraged, during an antenatal care visit at Sampov Meas Referral Hospital, to check into the hospital as she neared the end of her third trimester. Doctors evidently were concerned about the pregnancy, both because it was her sixth and because she was over 40, as older women and women who have had many children are at greater risk for complications.
Orm Lin said he believed his wife chose not to tell him about the doctor's warning because she knew he would not be able to afford a hospital stay - he makes 200,000 riels (US$49) per month as a guard at Pursat prison.
"I still regret that I didn't know in advance," he said. "My relatives, they blame me for letting my wife get sick like that. I just tell them I didn't know."
At 9:47 on the morning of March 30, one of the midwives at Sampov Meas Referral Hospital told Sok Lin that the time for delivery had arrived. She stood up from the cot where she had spent the past 18 hours and a midwife escorted her into the delivery room, which was closed to everyone but the midwife team, Sok Lin and one family member. Because her husband, a fisherman, was on a boat 110 kilometres away from Pursat, her mother-in-law, Cheam Kav, stood at her side during the delivery.
At 9:53, one of the midwives returned to the cot to grab a handful of the cloth diapers Sok Lin brought with her to the hospital. Four minutes later, Tan Mealiny, the head of the midwife team, emerged from the delivery room and removed her motorbike from a locked closet. She was late for a wedding party, she said before driving off.
The other midwives continued on without her, and at 10:20, Sok Lin's son, Nhim Rovid, was born. The delivery was smooth, the midwives said, and the baby was healthy.
Though she had earlier expressed concern about the level of attention the midwives were giving her daughter-in-law, Cheam Kav offered a rosy assessment of the hospital birth process once it was over.
"We're happy with the service and that they took care of our daughter," she said.
As she breastfed Nhim Rovid for the first time, Sok Lin said, "I was very worried about the delivery process before. But now I am happy. The child looks just like my husband."