Of all the things troubling Ros Thoeun these days, it's the emergence of black market

abortion pills that disturbs him the most.

"For about a year we've seen more and more young mothers come to us after taking

pills they buy at the market. They have Chinese writing," he told the Post.

"What's happened is that they've taken the medication and had an incomplete

abortion. After two or three days there's a tremendous amount of bleeding, so they

get scared and come to us."

As program director for local women's health NGO Marie Stopes Cambodia, Thoeun is

at the poorly fortified frontlines of an ongoing struggle to provide Cambodia's mothers

with safe reproductive healthcare.

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

ratio (MMR) at 437 deaths per 100,000 live births. This equals 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's, and four times greater than Vietnam's.

In a December 21 speech on women's health British Ambassador David Reader noted that

"up to one third of maternal deaths in Cambodia are caused by unsafe abortion."

"I recognize that women are still using unsafe abortions," said Minister

of Women's Affairs Ing Kantha Phavi. "A report from the Ministry of Health showed

that the majority of maternal deaths is caused by unsafe abortions. We don't have

reliable data because women are ashamed to speak about it."

In 1997 Cambodia made first-trimester abortion legal on demand and a second-trimester

abortion legal if it was to safeguard the health of the mother or in the case of

rape or a fetus' incurable disease. But cultural barriers, unsafe medical practices

and a dearth of family planning options have contributed to a health care crisis

that Thoeun reduces to a single, perfect question:

"Our statistics show that only 18 or 19 percent of Cambodians are using contraceptives,"

said Thoeun, "So, what are the rest of the people using?"

On a recent afternoon the waiting room of the Marie Stopes near Phnom Penh's Chba

Ampov market is overcrowded with young women. According to Thoeun, it's a mix of

unwed mothers, garment factory workers, and prostitutes. Each wears an unmistakable

mask of apprehension. He told the Post that roughly half of the patients that enter

the clinic have some form of sexually transmitted disease; the number is higher for

garment workers.

"You can see the situation," Thoeun said. "We have five employees

and about 1,000 patients every month. If we had more staff or more funding we could

help so many more."

A range of government and healthcare officials confirmed that Cambodia has a lack

of safe healthcare options for mothers, especially in poor rural areas. It's an increasing

problem that has recently sparked international concern. In December the United Kingdom

Department for International Development (DFID) signed a US$2.9 million agreement

with the Ministry of Health to help improve women's health and implement Cambodia's

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

services.

On January 6 a $1.8 million grant from the Asian Development Bank's Japan Fund for

Poverty Reduction was awarded to the Ministry of Women's Affairs to establish a Women's

Development Center (WDC) in Siem Reap and upgrade an existing facility in Kampong

Chhnang. The government will contribute $400,000 to the four-year project, which

is envisioned to benefit roughly 12,000 women.

It's a promising approach to alleviating a problem exacerbated by the fact that the

United States, and NGOs that receive US-funding, do not participate in programs that

include abortion services.

"Unplanned pregnancy happens everywhere in the world and it's legal to provide

a choice for women," Thoeun said. "But in Cambodia good, safe services

are very limited and hard to access. The problem is much worse in the countryside.

Thirty percent of Cambodians are still giving birth at home."

Britain-based Marie Stopes operates three clinics in Cambodia. Their fee for an abortion

is based on the patient's economic means and averages around $20, according to Thoeun.

Though most abortion services are offered by the private sector and NGOs, there is

a thriving market for untrained civilians willing to terminate births outside of

the medical community and for about half the price. Thoeun told the Post that in

remote areas villagers use traditional herbs, alcohol and chemicals to eliminate

the fetus.

"Whenever you need medical care and you don't have enough money it puts you

at risk, because there are people who will do unsafe abortions for a very small amount

of money," said Dr Reid Sheftall, director of the American Medical Center in

Phnom Penh.

"It is impossible to do an abortion for, say, $10 or $15 because you have to

sterilize instruments and have an anesthesiologist there. You have to use medicine

to sedate the patient and you have to dispose of the tissue properly. It's not possible

to exercise caution for $10," he said.

Responding to written questions, Smith from the DFID explained that unsafe abortion

techniques can be fatal.

"Woman may die as a result of complications from unsafe abortions," she

said. "Others may survive the operation but sustain long-term damage or disease

such as incomplete abortions, infections, hemorrhage and injury to internal organs

such as puncturing or tearing of the uterus."

Healthcare experts say that improving access to safe abortions is only part of the

solution. Family planning, surgical contraception and awareness campaigns are cited

along with increased medical training as potential paths to progress.

According to Smith, Cambodia's Millennium Goals for maternal health are to reduce

by 75 percent the maternal mortality ratio.

"We are glad to hear that DFID has given some money for this; it's good news,"

Thoeun said. "Working in this area we are challenged a lot. We have day-to-day

challenges just trying to save peoples lives. We hope the government will become

more involved and the knowledge improved. We wish for that."

In the meantime, Thoeun still has a crowded waiting room and a number of new problems

arising in the wake of a rapidly changing society - problems like the abortion pills.

Known in pharmaceutical terms as misoprostal and mifepristone tablets, the medicine

costs about $15.

"This kind of drug sells on the black market and it's not recognized by the

Ministry of Health. It is very dangerous for a woman," Thoeun said. "They

don't know how to take it because the instructions are written in Chinese. The drug

is for women less than seven weeks pregnant. But most women who use this kind of

drug never know how pregnant they are - they use it and sometimes use too much."