The keys to lowering Cambodia’s maternal mortality rate are training additional attendants and improving emergency care.

COMMENT

Dr Niklas Danielsson

IN 2000, Cambodia, together with 189 other countries, signed the UN Millennium Declaration. By doing so, the government committed to achieving Millennium Development Goal 5 (MDG 5), which calls for a three-quarters reduction in maternal mortality between 1990 and 2015.

Maternal mortality is measured as the Maternal Mortality Ratio (MMR), or the number of women who die from pregnancy-related conditions per 100,000 live births.

Cambodia’s MMR has not improved over the past 15 years. The 2008 national census estimated MMR at 461, one of the highest in the region and not significantly better than in 2000 or 2005. Every year, some 1,800 Cambodian women die from preventable and treatable complications of pregnancy. That is more than the number of women who die from malaria, tuberculosis and HIV combined.

Maternal deaths are concentrated around the time of childbirth and in the period after an unsafe abortion. Four conditions – post-partum haemorrhage, eclampsia, obstructed labour and infection – are responsible for the majority of deaths. The number of deaths can be rapidly reduced if new resources are made available and if concerted efforts are focused on preventing and treating these four conditions together with providing better access to modern contraception.

Post-partum haemorrhage (PPH) is the No 1 cause of maternal death. It is an acute bleeding from the uterus after the birth of the baby. A woman can bleed to death within two hours unless properly treated. Appropriate routine care around delivery, including an injection of a drug that stimulates the uterus to contract (oxytocin), and early initiation of breastfeeding, considerably reduces the risk of PPH. A timely blood transfusion can mean the difference between life and death.

Eclampsia is a condition where a pregnant woman’s blood pressure rises to life-threatening levels and causes kidney failure, heart failure and seizures. Eclampsia is rare but can lead to the death of both the mother and the unborn child if not treated urgently and correctly. It is a medical emergency that every skilled birth attendant must be able to recognise and manage.

Obstructed labour is an important cause of maternal deaths in communities in which undernutrition in childhood is common, resulting in small pelves in women, and in which there is poor access to health facilities with the capacity for carrying out caesarean sections. It is also an important cause of infections and long-term disabilities such as obstetric fistulas and incontinence. Untreated obstructed labour often leads to asphyxia and stillbirth.

Infections after delivery (puerperal fever) and after unsafe abortions can develop into sepsis and lead to death unless promptly treated. Prolonged labour and poor infection control increase the risk of puerperal fever. Unsafe abortions are a common cause of infection leading to infertility and sometimes death.

The best chance for Cambodia to achieve MDG 5 is to adopt a strategy for quickly increasing the number of deliveries assisted by skilled birth attendants with a focus on health centres, and to fast-track interventions that will make emergency obstetric care available to all women. There are no shortcuts to good delivery care. The concentration of deaths around the time of delivery from bleeding, eclampsia and infections means that access to skilled attendants at birth, and timely referral for emergency care, constitute the only realistic approach to rapidly reduce the number of maternal deaths in the short term.

Women are today deprived of good quality delivery services because of financial barriers including official and unofficial fees. Simply the fear of anticipated and unknown costs can deter women from using health facility services. Improvements in financial and geographical access to good-quality care around birth should be at the centre of efforts to eradicate poverty and create fair health-financing mechanisms.

Mother and child health outcomes are intimately linked. The most direct effect of a maternal death on child survival is in the newborn period. Risk factors around birth are more important for perinatal death than pre-pregnancy or antenatal factors. A newborn child who survives her mother’s death at birth is extremely vulnerable. It has been estimated that if nine out of 10 women were to give birth in a health facility, the newborn death rate could be reduced by 23-50 percent. The high maternal mortality in Cambodia contributes substantially to the high newborn mortality.

The failure to reduce maternal mortality in Cambodia is of grave concern, particularly in view of the impressive improvements in other health indicators during recent years. Reaching the target for MDG 5 is a formidable challenge for the government of Cambodia. But the high maternal mortality rate also represents a unique opportunity to adopt a new approach and justifies extraordinary measures.

The government proved with HIV that it could reverse a catastrophic increase in infections over just a few years by focusing on the most essential interventions. The same approach should be adopted for reducing maternal deaths. Studies, reviews and experience from across the world clearly indicate that it is possible to dramatically reduce maternal deaths by providing universal access to three critical health services: skilled attendance at birth (SBA), emergency obstetric and newborn care (EmONC) and safe abortions.

The recently introduced incentives to health centres for deliveries have demonstrated that it is possible to rapidly increase skilled attendance at birth. This incentive represents an innovative and effective way of quickly increasing the proportion of women who deliver in health centres. It deserves wider recognition. Other innovative solutions must be urgently identified to ensure that all women have access to EmONC. The current situation in which women are denied life-saving procedures, such as blood transfusion, caesarean section and treatment for eclampsia because they are unable to pay hospital fees in advance, is unacceptable. Immediate solutions must be found, not only for increasing availability of EmONC services at referral hospitals, but also for eliminating financial barriers to such services. One option would be for the government to reimburse hospitals for EmONC procedures and remind hospital directors that denying women emergency obstetric services because of failure to pay will not be tolerated.

International partners in health must rise to the challenge of reducing maternal deaths in Cambodia. Controlling HIV and malaria, and responding to pandemic threats has been widely supported without concern for sustainability. Reducing maternal deaths deserves the same pragmatic approach. It has been shown over and over again that women and their families prefer modern delivery care over traditional unskilled practices when the quality of care is good, when they are treated with respect and when they can afford the services.

Once change in behaviour has been achieved and new society norms have been established for delivery care, the practice of seeking skilled attendance around birth will be sustained. This would require a large initial investment over a five- to 10-year period, which is currently beyond the means of Cambodia. Unfortunately, international support for maternal health is at present dwarfed by the hundreds of millions of dollars that bilateral donors and international organisations invest in HIV, the flu pandemic and malaria control in Cambodia.

Commitments to gender equality in development aid will remain lip service as long as women in Cambodia are denied basic health services, including family planning, safe abortions, skilled birth attendance, and emergency obstetric and newborn care. Cambodia needs an emergency plan to make these services available to all women. International partners have an obligation to support such a plan.

Dr Niklas Danielsson is the maternal and child health team leader at the World Health Organisation office in Cambodia.