When Theary* discovered she was pregnant with her third child, she knew she didn’t want another baby. The 34-year-old, who lives in poor conditions in Kandal province, had stopped taking birth control pills, afraid that they were causing the child she was breastfeeding to become sick. This latest pregnancy was an accident. So she approached her nearest Marie Stopes International Cambodia centre, and in June received a safe abortion.
Theary’s contact with Marie Stopes could have stopped there. However, thanks to a new technology being implemented by the reproductive health NGO, she was easily able to make contact with a counsellor and access information about what contraception was available to her, and how to use it.
A new mobile phone service used by the NGO leaves six automated voice messages on clients’ phones once they’ve had an abortion, either advising them on family planning methods, prompting them to request a phone call with a counsellor or state that they have no problems. The system they use is called Verboice, and is created by the technology nonprofit InSTEDD.
Dr Sann Channa, head gynaecological surgeon at Phnom Penh Municipal Referral Centre, said that it’s often hard for women to go directly to the clinic to access information about contraception and reproductive health.
“They might forget about their appointment because they’re busy with work, or there might be personal reasons,” she said. “This kind of technology helps women access this information remotely.”
Chris Smith, who is in charge of Mobile Technology for Improved Family Planning (MoTIF), the name of the mobile technology program at Marie Stopes International Cambodia, said: “The message is designed to remind the client about contraceptives and also to act as a conduit for additional support, so a client listening to the message can press 1 [on their keypad] to request to speak to a counsellor, press 2 if they’re fine, or press 3 to opt out. They can also sign in for a pill reminder and an injection reminder as well.”
Post-abortion family planning is crucial, Smith said, in order to inform women of the options available to them, advise them on reproductive health issues and reduce the rate of repeat abortions. He said: “What we found was a lot of clients find it hard to make decisions about contraception at the time when they come to seek abortion services. They often need a bit more time to think about it, so it gives us an additional opportunity to maintain communication with a client.”
Abortion has been legal in Cambodia since 1997 and can be performed any time up to 12 weeks of a woman’s pregnancy. Because of the prevalence of unsafe abortions carried out behind closed doors, it’s impossible to give a figure to the number of abortions carried out in the country. However, according to the Asian Safe Abortion Partnership, abortion-related deaths contribute up to 29 per cent of maternal deaths in Cambodia. According to the World Health Organization (WHO), one of the major dangers of unsafe abortions is the lack of aftercare and counselling and, rather more drastically, a lack of intervention should there be severe bleeding.
But even at Marie Stopes, which gives women access to safe abortion services, many women don’t end up receiving follow-up checks and counselling. Smith said that due to a number of reasons including clients living far from the clinic, being busy with work and not wanting family to know about their abortion, the time when they sought abortion would often be the only time they’d make contact with the clinic.
Marie Stopes International Cambodia has been trialling MoTIF since October 2012 in clinics all over the country. So far, Smith said, the results look positive, with the use of post-abortion family planning having increased from 33 per cent to 56 per cent.
According to Smith, Marie Stopes was keen to latch onto the increasing use of mobile technology. The organisation found that 80 per cent of its clients had a mobile phone – and this was fairly consistent with national data. Smith added: “It really is the only way we can maintain contact with clients, especially those in a somewhat sensitive situation who have come to seek abortion services – we can’t use post, we can’t use email, we can’t go to them face to face.”
Cambodia’s reproductive health sector isn’t the only area that Verboice technology benefits. InSTEDD started implementing the tool in the Kingdom in 2012, using it to support several organisations including an election hotline, which gave people information about last year’s general election, and a road safety awareness program.
But reproductive health does seem to be a common use. In January last year, the Reproductive Health Association of Cambodia (RHAC), an NGO, formed an agreement with InSTEDD to use Verboice for its Reproductive Health Hotline program, which got off the ground in November.
In this program, men and women are encouraged to call a hotline in order to access advice and information relating to a number of sexual health issues, including not only contraception but also sexually transmitted diseases and cervical cancer. Users will call the number and be directed, with interactive voice response, through a number of options before picking what it is they wish to talk about. Like Marie Stopes, the service also provides an option for speaking with a counsellor. Since the hotline started, it’s had more than 1000 callers.
Phearak Peng, program support officer at RHAC, said that before the hotline was created, access to information about sexual health issues was scarce. He said: “They can’t find information anywhere and if they don’t know what to do they’ll face the consequences. I think providing this service is very helpful to the people who want to know, who need help. It empowers women and men to make their own choices.”
*Name has been changed to protect identity.
Unlike for Marie Stopes, which prides itself on providing safe abortion services for women, abortion is a sensitive subject for the Reproductive Health Association of Cambodia (RHAC). Much of the organisation is funded by USAID which imposes a ban on funding for abortion overseas, even in countries like Cambodia where it’s legal.
The Reproductive Health Hotline’s only mention of abortion is the advice women can receive about post-abortion care, something that RHAC does provide. But despite the organisation offering safe abortion services in a Kampot clinic, which is completely separate from the jurisdiction of USAID funds (funded instead by the International Planned Parenthood Federation), the USAID-funded clinics in Phnom Penh do not refer women to these services.
Phearak Peng, program support officer at RHAC, said: “We know that in Phnom Penh and other places except Kampot, we cannot offer women abortion services. When I started, the orientation clearly stated, ‘You cannot talk about abortion when you are under USAID funding.’ That’s why it’s restricted. We don’t refer our clients to the Kampot clinic; it’s a grey area.”
Denying women safe abortions can drive them to seek unsafe methods. Given the fact that unsafe abortions account for more than 47,000 maternal deaths worldwide, it’s a tough spot for RHAC to be in, ethically. Refusing funding from USAID would jeopardise much of the organisation’s work. When asked if he regretted the fact that RHAC doesn’t refer women to somewhere they can access safe abortion, Peng said very clearly: “Yes, actually we do wish we could do that.”
