Resource gaps frustrate midwives

Photo by: SOVANN PHILONG
Than Sopheap (third from right), 38, Nuon Srey Mom (second from right), 25, and Pech Leas (far right), 30, wait in the hallway of the Treal Health Centre for midwife consultations.

The Phnom Penh Post
http://www.phnompenhpost.com/

Written by Robbie Corey-Boulet and Sam Rith
Wednesday, 10 June 2009

As officials in Phnom Penh mark National Midwife Day by acknowledging their ‘critical role’, midwives in Kampong Thom grapple with resource shortages and limited outreach efforts

Kampong Thom Province

ON MONDAY morning, three neighbors from Kiri Andeith village waited in the hallway of the Treal Health Centre, located in Kampong Thom's Baray district, for midwife consultations. All were pregnant, and all were anxious.

Nuon Srey Mom, 25 and two months pregnant, said she did not have enough to eat, adding that the long days at her job as a farm labourer frequently left her dizzy and short of breath.

Than Sopheap, 38, said she was worried that her age would leave her susceptible to pregnancy complications.

And 30-year-old Pech Leas said she was concerned because nine years had elapsed since she gave birth to her first and only child.

"I'm worried that too many years have passed since I had my first baby," she said. "I want a skilled midwife this time because I'm afraid it will be difficult to deliver."

As a group, they entered the office of Ma Saren, 56, a midwife of 19 years who said she counsels between 120 and 150 pregnant women each month, advising them on issues including diet, the importance of antenatal care and the signs that often foretell complicated deliveries.

She said her job has grown easier in recent years, citing the hiring of a second midwife to help out at the centre, as well as an incentive payment program instituted last year, through which she receives US$15 for every successful birth performed there.

These improvements, however, have not been extended throughout Kampong Thom province, which continues to grapple with resource limitations, said Khiev Pharin, a provincial health officer for UNICEF Cambodia.

Last year 27 percent of births in the province were attended by skilled health personnel, according to provincial health department data. Though this marked an increase of 9 percent since 2007, it remained far below the 2010 Millennium Development Goal target of 70 percent.

The number of births taking place in health centres rose nearly 10 percent to 12.2 percent, but it remained below the national average of 22 percent reported in 2005, the last year for which reliable national maternal health data is available.

Midwife Day
At an event Tuesday morning marking National Midwife Day, Koum Kanal, director of the National Maternal and Child Health Centre (NMCHC), acknowledged that midwives' workloads had increased along with demand for their services: Skilled birth attendants performed 44 percent of live births nationwide in 2005, up from 32 percent in 2000.

In his remarks at the event, held at the NMCHC in Phnom Penh, Minister of Health Mam Bunheng told roughly 100 midwives from all 24 provinces and municipalities that he wanted "to reconfirm that the government and the prime minister recognise that you all have a very critical role".

He said a subdecree currently at the Council of Ministers would establish a midwifery council to work in concert with the Cambodia Midwives Association to advocate for resources and other forms of government support.

Mam Bunheng also called for additional outreach, which, as in other provinces, has proved difficult in Kampong Thom.

Khiev Pharin said the province's 149 midwives are often overworked, meaning they can make only one outreach visit per month.

As a result, he said, they are often unable to reach women in remote areas, who are more likely to turn to traditional midwives, who cannot provide emergency obstetric care if the delivery turns dangerous.

According to World Health Organisation estimates, approximately 15 percent of deliveries require emergency care.

Ma Saren also cited a need for more outreach to women who are inclined to avoid health centres altogether, saying, "For people who live far away from here, it's a bit difficult to get them to come".

To supplement the midwives' outreach work, UNICEF and the WHO launched a pilot programme in March in which two villagers in eight villages have been enlisted to visit pregnant women and encourage them to go to health centres, particularly if they suspect pregnancy complications could arise.

Nao Sinom, 38, who participates in the program in Banha Chhi village in Santuk district, said she visits three families each month. She said many of the women who are reluctant to visit health centers do not have money for medical fees.

"People who cannot afford it, they just say they don't want to go to the centre," she said, adding that villagers had recently decided to pool donations to cover some of the payments.

Deployment
The Ministry of Health has adopted the goal of deploying at least one trained midwife at each health centre this year.

In Kampong Thom - a province that Pen Sophanara, a communications associate for the UN Population Fund, described as middle-of-the-road in terms of midwife deployment - all health centres have one midwife, but only 26 percent have two.

Treal Health Centre has two midwives, including Ma Saren. It is open around the clock, and both the health centre chief, who lives next door, and one midwife are on-site at all times.

These advantages notwithstanding, sometimes there is little the centre can do.

In the case of Nuon Srey Mom, the 25-year-old pregnant woman who complained of fatigue and lack of food, Ma Saren could tell her only "to have enough food to eat and to stop working". During many consultations, she said, "We just have the ideas for them. We don't have the budget to actually help them overcome the challenges they face."