A nurse prepares instruments for an abortion in a Phnom Penh clinic.

Over 70 percent of rural Cambodian women lack any understanding of effective contraceptive

methods or safe abortion, a reproductive health doctor says.

They get pregnant, try to abort the pregancy by themselves, and each year 32,000

women need treatment after botched abortions.

Compounding the problem, in 2005 health centers turned away 24,000 women seeking

legal first-trimester abortions.

Chamreun Sosivann, Clinic Manager of Reproductive Health Association of Cambodia

at Siem Reap, said rural women tend to try to terminate unwanted pregnancies by themselves.

"They try to induce an abortion by using pills rather than coming to a clinic,"

she said. "This is very dangerous - and many of these women also don't know

how to prevent pregnancy, for example by using birth control pills."

Safe abortion services are not readily available in Cambodia, said Tung Rathavy,

deputy director of the National Maternal and Child Health Center (NMCHC) and National

Reproductive Health Program Manager.

"Only 47 percent of public hospitals and about 15 percent of health centers

offer any kind of abortion services," she said. "We still lack health centers,

medicines and qualified staff, even though the number of women seeking abortions

is increasing every year."

Maternal health has been made a priority in health sector but despite the government's

efforts, results are lagging.

A 2005 survey on abortion and abortion-related complications conducted by the NMCHC,

the National Institute of Public Health and IPAS - a US based international NGO that

works to prevent deaths and injuries from unsafe abortion - examined all of Cambodia's

71 public hospitals and 115 health centers.

The results were alarming: an overwhelming majority of health providers said they

considered death from unsafe abortion to be one of Cambodia's most serious health

problems.

Each year, approximately 32,000 women seek treatment for abortion complications at

government health centers in Cambodia. In the majority of cases, they are only seeking

such care after a do-it-yourself abortion attempt - often unaided, sometimes with

help from pharmacists, traditional medical practitioners or other unqualified healthcare

providers - has gone wrong.

"We need to ensure that safe abortion and birth spacing services are readily

accessible to every women who needs them," said Eng Huot, secretary of state

at the Ministry of Health. "This will help women to avoid unwanted pregnancy

and thus reduce the tragedy of unsafe abortion."

The survey also found that only one in five of the health care providers interviewed

correctly understood the provisions of the Cambodian law on abortion.

In 1997 the government adoped a new law on abortion that made first-trimester abortion

more widely available and second-trimester abortion available if necessary in case

of rape, fetal abnormality, or if full-term pregnancy would have posed a risk to

the mother's life.

Yet in 2005 nearly 24,000 women in the first trimester of pregnancy who sought an

abortion were turned away from the health care facilities they first approached,

the survey found.

Consequently, for many rural Cambodian women looking to end an unwanted pregnancy,

unskilled healthcare providers are the most accessible option, whatever the risks.

But the risks are high: the World Health Organization estimated that 10 to15 percent

of women who get abortions from unskilled practitioners will subsequently need to

seek care for complications resulting from unsafe abortion techniques.

There is clearly a need to bring about a change in attitude among healthcare providers

to ensure they are giving women the option of safe abortions, said Tamara Fetters,

senior research associate for IPAS.

"Studies from other countries have clearly shown that provider attitudes toward

abortion and women who seek them can create serious, often insurmountable barriers

to women receiving care," she said. "Understanding and addressing these

attitudes is essential to ensuring that women can get the care they need and thus

to protecting their health."

Efforts are being made to improve the situation in Cambodia. In December last year,

The United Kingdom Department for International Development (DFID) signed a $2.9

million agreement with Ministry of Health to improve women's health and their access

to lawful abortion. A further $725,000 will be used to provide women with maternal

health services.

But access to safe abortions is not the only thing Cambodian women lack - they need

education on effective contraceptive methods too. Sixty-four percent of all women

seeking abortions interviewed for the 2005 survey did not want to become pregnant

in the next several months, and many were potentially ready to stop childbearing.

Allowing these women to leave health-care facilities without giving them contraceptive

advice - as is often the case - puts them at risk of another unwanted pregnancy and

thus potentially an unsafe abortion, Rathavy said.

There is an urgent need for better education about effective contraception, Sosivann

said. This could help prevent unwanted pregnancies and unsafe abortions. Although

her clinic does not provide abortion services, the number of women seeking help for

DIY abortion complications was increasing annually.

Ros Thoeun, program director at Marie Stopes Cambodia, a local NGO working on women's

health issues, said that one of the most pressing problems they have to deal with

is women with DIY abortion complication.

"The number of young mothers using abortion pills obtained on the black market

is increasing," Thoeun said, "It is very hard to access rural women and

provide information about abortion, so they often unwittingly endanger themselves

when they seek to terminate their pregnancy."

The Cambodian Demographic and Health Survey for 2000 estimated the maternal mortality

ratio (MMR) at 437 deaths per 100,000 live births, which equates to roughly 2,000

deaths a year and a lifetime risk of dying from pregnancy related causes of one in

36.

Cambodia's MMR is ten times higher than Thailand and four times greater than Vietnam.

In Cambodia, only 19 percent of married women are using a modern method of contraception.

One-third of women have no access to any kind of contraception and fertility rates

are high, with a vast disparity between urban and rural birth rates - rural being

far higher. Rathavy expected that the result of the Demographic and Health Survey

for 2005 will be released in 2007.