TBA Va Kam, 67, shows with a bag of traditional medicine how she removes a placenta.
nwashed hands; Speeding up labor by simultaneously pushing on the mother's abdomen
and either pulling on the baby's head or stretching the vulva by hand . . .
Cutting the umbilical cord with a rusty razor or piece of bamboo and then tying
it with unsterilized string . . .
Putting burned cow dung on the baby's navel to treat infections. Forbidding breast-feeding
for three days after birth. Massaging the uterus to treat excessive bleeding . .
Since these are all common practices during childbirth in the countryside, it is
easy to see how maternal and child mortality rates got to be among the highest in
Traditional Birth Attendants (TBAs) deliver two-thirds of Cambodia's babies. Most
are older women who have learned their trade from a relative or another TBA. Others
were trained under the Pol Pot regime, while some taught themselves.
The Ministry of Health (MoH) estimates one-fifth of women's deaths in the seven years
to 2000 were from pregnancy-related causes - "an alarming figure".
"Normally TBAs can help, but because of lack of knowledge, lack of skills and
lack of support, they can make people die who should not have," says Professor
Koum Kanal, director of the Maternal and Child Health Center (MCHC).
Despite the lack of formal medical qualifications and techniques that are often dangerous,
the country's 10,000 TBAs are widely trusted. Their services don't cost much - a
chicken or 10,000 riel - they are well-regarded, and are seen to have obstetric skills
that ensure safe childbirth.
"People feel it's normal," says Kanal. "They don't think their life
is in danger."
Prom Than is a midwife who trains TBAs for international NGO CARE. She says rural
people will take advice from a TBA over a doctor or midwife.
She surveyed 24 TBAs in Koh Kong's Botum Sokor district. All told her they push on
the mother's abdomen to speed up labor, a method that can harm both mother and baby.
However, Than rarely encounters a TBA who admits responsibility for a death.
"When the baby dies in under one month they always say the first mother came
back. She didn't want it to live with the present mother," she says of Cambodia's
prevalent Buddhist belief.
Another TBA custom in the district is to brand women who die in childbirth as "very
bad". The result is that the family feels disgraced, buries her, and moves elsewhere.
The overall goal of the MoH's strategic plan released in August is to improve mother
and child health. That should help alleviate poverty and improve the country's socio-economic
Two explicit aims for the next five years are to cut infant mortality from 95 to
84 deaths per 1,000 live births, and maternal mortality from 437 to 305 deaths per
100,000 live births.
The ministry says that will require a campaign to increase the number of formally
trained midwives. Around 60 a year currently graduate from the MoH's one year midwife
program, which follows a three year nursing degree.
But that is too few say officials, who calculate Cambodia will still lack 1,500 midwives
by 2005 unless funding increases. Worse still, many of those who do train are reluctant
to work in remote areas, and lack experience. The result is that the country's rural
majority will continue to rely on TBAs, with all the dangers that entails.
"While we are waiting for the replacement of TBAs by midwives, we still need
someone to be a birth attendant in communities," says Dr Chhun Long, manager
of the National Reproductive Health Program.
TBAs are not unique to Cambodia: decades of studies show they assist up to 80 percent
of deliveries in developing nations, and support women through pregnancy, childbirth
and postpartum care.
In the last 20 years money has been poured into TBA training programs around the
world on the assumption that would bring down maternal mortality.
The Safe Motherhood Initiative, launched in 1987, advocates training TBAs in developing
nations. WHO, UNICEF and UNFPA stated in 1992 they would "promote the training
of TBAs in order to bridge the gap until there is access to acceptable, professional,
modern health care services for all women and children".
The MoH's strategic plan has no money set aside to re-train TBAs, and instead relies
on NGOs. They distribute home delivery kits and train TBAs in safe delivery practices
that range from basic hygiene, such as washing their hands, to recognizing dangerous
complications. So far around one in five have been trained.
But more recent studies cast doubt on just how effective training has been. Around
15 percent of all pregnancies - regardless of the country - present life-threatening
complications, and there is little a TBA can do once those occur.
Studies also show that most retrained TBAs fall back into their old habits without
careful monitoring. As a result many have soured on the notion of training them.
Dr Wim van Damme of MSF-Holland-Belgium says training programs are a waste of time.
"It is a kind of nostalgic training. Keeping everyone busy with workshops on
TBAs is useless," says Dr van Damme. History, he says, shows the only way to
reduce maternal mortality is to get away from traditional activities.
"That happened in Sweden 200 years ago, England 150 years ago, and Indonesia
20 years ago," he says, adding that while the most remote areas will prove the
exception, places with medical facilities such as Battambang and Siem Reap need to
focus on properly trained midwives.
UNICEF, which runs TBA-training programs in several remote provinces, says it is
unclear whether they have any great effect.
"There's no evidence that intensive training of TBAs could reduce maternal or
infant mortality," says Dr Thor Rasoka, UNICEF's provincial health advisor for
Kampong Speu and Stung Treng.
He stresses UNICEF does not encourage new TBAs, but trains existing ones in hygiene,
collecting data about pregnant women, and ensuring they encourage mothers to seek
ante-natal care at health centers.
"It is better to collaborate than have them uncontrolled," he says.
Jesse Rattan, health sector coordinator for CARE, says training is crucial as it
remains a fact that in Cambodia TBAs deliver the majority of babies.
"But the focus must be to get them to refer complicated cases," she says.
"All over the world it's been challenging to get TBAs to refer to providers
who can deal with complications."
A survey of untrained TBAs in Kampot by the Reproductive and Child Health Alliance
(RACHA) revealed 42 percent did not know what to do if a woman bled too much after
delivery. Since more than half had never visited their nearest health center, they
never referred clients to one.
Sam Sochea, RACHA's safe motherhood coordinator, trains TBAs and midwives in Siem
Reap, Pursat, Kampot, Takeo and Prey Veng, and says working with them certainly helps
on that score.
But the particular problems facing the country's health services mean that isn't
always a good solution, says the MCHC's Professor Kanal. A lack of staff and funds
means only two-thirds of the country's 937 health centers function properly.
"In our plan, health centers have to have five staff, but some only have one,"
he says. "Quality can only be achieved when we have enough resources and funding."
Stung Treng is one province that suffers from such problems, says midwife Joy Scott.
In the last six years she has trained 500 TBAs for NGO Youth With A Mission. She
meets them every three months and runs a refresher course every two years.
TBAs deliver 98 percent of the babies in the province, she says, whereas most of
the midwives at the health centers in the province are "young girls who maybe
haven't done a delivery and don't want to live in isolation".
So while Scott believes it would be ideal to have properly trained midwives in remote
areas, she says that is at least ten years away.
Instead she tells TBAs problem deliveries must go to the referral hospital, and is
encouraged by the number that now do so. Before she began the referral system, using
incentives and travel money, there were only two a year. Last year TBAs referred
at least 60.
A Kampot woman rests above a fire with her newborn baby.
In summary, says Dr Chhun Long, TBAs are prevalent due to traditional reasons, the
lack of health services, and socio-economic factors.
"Also when mothers have too many children, they don't want to leave home,"
he says. "And when they are too poor, they can't spend the money for transportation."
On the outskirts of Phnom Penh is the relocation site for the squatters who lost
their homes in last year's fires. Anlong Kngann has four TBAs, and around 30 percent
of pregnant women use their services despite the site's free health clinic.
Yet problems still arise. Village chief San Sokha tells of one mother who died the
previous week. She bled for 15 days after a TBA helped deliver her baby at home.
Khim Chanry is a 43-year-old TBA at the site. She was trained by the Khmer Rouge
in 1977, then by her aunt and uncle in the 1980s and finally by an NGO in 1996.
She says the NGO teaches better techniques. These days if she detects a problem such
as high blood pressure or swelling she sends the mother to a hospital.
Changing the system will prove difficult, says MCHC's Professor Kanal. It can be
done, but that must be with an eye on the local perspective.
"We cannot use experiences from people in other countries," he says. "We
need to adapt, we need to change the behaviors of providers and users, but I believe
we can progress."
Late July in Kampot's isolated Koh Sla valley: a smiling one-legged father waves
the Post into his home to view his newborn. Inside the roadside hut tears are rolling
down the onlookers' cheeks, but they don't spring from emotion. The tiny space is
filled with smoke.
When the TBA delivered the boy three hours earlier, she lit a small fire under the
mother's bed, told her she would be unable to breastfeed for three days, then left
to visit the local pagoda.
Lying on the bed above a fire is meant to burn away the impurities from pregnancy.
Known as "roasting", its benefits are expounded by TBAs and tolerated by
"I tell them to light a fire under the bed after I deliver," says TBA Khim
Chanry. "Because after giving birth, the body is cold and needs to be heated
Dr Chhun Long of the National Reproductive Health Pro-gramme says studies show it
is not harmful provided it is not too hot. Even trained midwives attending home deliveries
will allow the practice, but only after they give careful instruction.
"Some say it can be useful psychology," he says, "so there's no government
plan to stop roasting."
That suits TBA Va Kam. When CARE trains her next month, it will tell her to stop
removing the placenta by hand. She will also learn that the colostrum (the first
and most nutritious breast milk) does not give newborns diarrhea. Of roasting, she
says: "It is a Khmer custom. It gives good skin and good health."
The NGO's health sector coordinator Jesse Rattan says they try not to impose Western
medicine on cultural practices that are relatively neutral to health. "It's
a strong tradition," says Rattan. "It may even be a period when a woman
gets enforced rest and doesn't have to jump up into the fields."
Roasting's popularity is countrywide, experts say. In the south-western province
of Koh Kong, TBA Ouk Poon is another aficionado. "Every old man tells me that
sleeping on a bed with fire underneath is good. It warms you up and you will not
be sick so often," she says.
Poon has picked up another local habit: she gets mothers of newborn babies to sit
on a rock warmed by fire every morning for three weeks.
"When they sit on the rock it prevents the uterus from coming out," says