Training of village volunteers and support for health centres has helped halve the infant and maternal mortality rates over the last decade, Dani McDonald reports.

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Dane Toe lies in a hammock in the cool shade below her house in Pom Thol village, in Kampong Speu province’s Oudong district. She is just five days old. Her mother, Sokly Torn, 34, lies on a bamboo platform next to her, watching her every breath. Just two metres away a cow stands beneath a tree, seeking respite from the glaring sun.

This is Sokly’s first child, and her and her daughter’s health are testament to the startling decline in infant mortality rates, made possible – in part – by support from village volunteers, more effective health centres and a co-ordinated effort by non-governmental organisations like the Reproductive Health Association of Cambodia (RHAC).

Between 2000 and 2010, the infant mortality rate fell from 95 to 45 deaths per 1,000 live births, according the 2010 Cambodia Demographic Health Survey.

RHAC has played a key role in this. The USAID-funded NGO was established in 1996 with just 10 staff. Last year it had 700 spread across14 provinces where they supported 475 government health centres, servicing 6.87 million men and women.

RHAC associate director Dr Chivorn Var summed up its work as supportive of local health centres and the physical and social infrastructure necessary to improve them. Its staff train village health volunteers and provide health centres with equipment, allowing health centres to operate more effectively.

“We also help at the district level, with training and mentoring to improve the capacity of health centre staff,” he said. Chivorn Var pointed out that in 2009 only 48 per cent of the 300 health centres RHAC was supporting had family planning services. “After mapping out which health centres did not have the capacity [for teaching family planning], we trained them, provided the equipment and then worked with local authorities to promote our services,” he said.

Maternal mortality

For Sokly, undergoing her first pregnancy at age 34 was not something to be taken lightly. Childbirth is still a danger for women in Cambodia despite the steep fall in the maternal mortality rate to 206 per 100,000 births, according to the 2010 CDHS.

RHAC project officer Bunseng Khun said poverty and lack of access to education left families in rural areas vulnerable because they could not afford healthcare and were unaware of how to ensure safe pregnancy and birth.

Sokly benefited from regular prenatal check ups by a village health worker who also urged her to attend antenatal sessions at the local health centre. “The health centre taught me to take care of myself and to eat more nutritious food. They also provided me with iron pills and a tetanus injection,” she says.

Sokly attended the Damnak Smach health centre after a village health volunteer Sitha Nim advised her to.

Sitha Nim also runs a small shop where posters explain the importance of safe water, birth spacing and the signs that precede going into labour.

She has worked as a village health volunteer for RHAC for three years, roaming house to house on a monthly basis educating families about family planning, birth spacing, prenatal and antenatal care.

She uses colourful and simple posters advising pregnant women to eat fresh fruit and green vegetables, take plenty of iron, and avoid alcohol, riding motos, or carrying water. “The main thing is contraception and then providing the information to the pregnant woman,” she says.

“I like to help the people in the village. I want to explain to people about the safe service in the health centre and to not use traditional birth attendants,” she added.

Traditional birth attendants [TBA] are now a thing of the past in Oudong, according to Bunseng.

Damnak Smach Health Centre ?hief ?urse Narint Hou says he has noticed an improvement in deliveries and an increase in antenatal care during the last couple of years.

Damnak Smach village has a population of 956. On record there are 471 pregnant women, 29 infants, and 28 children under the age of five.

The health centre has eight staff, three of which are primary midwives, meaning they can perform deliveries but not caesearans. It also provides family planning, antenatal care, delivery, prevention of mother-to-child transmissions of HIV, counselling and health education.

Staff work five days a week, but a rotational duty calendar allows the centre to remain open on weekends.

Infant mortality rates are 0 per cent, Narint said, but if the delivery is difficult the patient is referred onto the referral hospital.

RHAC pays for transport for mothers to attend their antenatal care four times throughout their pregnancy.

If a family is poor, Narint said he finds the support from the commune council to pay for transport to the hospital or health centre for delivery because the council has a budget for this.

Health centres need more support

The health centre is not fully supplied and Narint purchases medication himself. He is reimbursed with user fees.

Despite the increase in patients, midwife Simorn said there was still a lack of midwives to treat each patient.

An antenatal check takes 15 to 20 minutes per patient, and on average the health centre receives10 patients a day.

RHAC midwife Thearin Ung agreed. “They do not have enough midwives in the remote areas. There are fewer midwives in the health centres. Clients can access the centre, but the problem is the provider.

“They just have one or two people so when many clients come, we can’t provide a service on time. It depends on the district and the workload in the health centre – it’s a lot of work and when we have less staff, one person needs to serve many,” Thearin said.

In Oudong there are three health centres in the remote areas: each has two midwives.

As of February, there were 681 women using family planning services. In 2011, the clinic distributed family planning services to 893 women. Over the next year, the clinic aims to continue to improve the quality of family planning services in order to continue to attract couples who are seeking safe, voluntary, high quality services.

Despite the positive turn around of clients using the health centre, Narint said he would like to see some improvements on the actual centre itself.

He said no improvements had been made to its structure since it was built in 1996.

He would like to see more space to serve patients – currently the waiting room is in the same area as the consultation/delivery room.

Safe water is another necessity for the health centre. It relies on a pond behind it, which dries up during the dry season.

Narint carries the water to the centre for cleaning purposes. He said he buys clean water for drinking, but sometimes is forced to boil pond water.

Still, for Dane, lying in her saffron hammock, her peaceful sleep is the result of the great effort made to ensure her survival. She will be part of Cambodia’s future, rather than an all-too-brief part of its past.