Better HealtH ServiceS Project:Improving Maternal and Newborn Health in Cambodia

tecHnical Brief

august 2011 the project brief is made possible by the support of the american People through the United States agency for international Development (USaiD). the contents of this project brief are the sole responsibility of Urc and do not necessarily reflect the views of USaiD or the United States Government.

Background

Until very recently, maternal and newborn mortality in Cambodia

had remained relatively unchanged at disturbingly high rates: In 2008 maternal mortality stood at 461 per 100,000 live births. However, the 2010 Cambodian Demographic and Health Survey (CDHS) shows significant improvements in indicators related to maternal and childhood deaths over the last 10 years:

¡Maternal mortality declined sharply from 461 to 206 per 100,000 live births

¡Deliveries assisted by a skilled provider increased from 32% to 71%;

¡ Facility births increased from 10% of all births to 54%;

¡ Use of antenatal care (ANC) increased from 38% to 89%;

¡ Use of modern contraceptive methods rose from 19% to 35%;

¡ The average number of children women have fell from four to three;

¡ Full vaccination of children 12–23 months of age grew from 40% to 79%; and

¡ Increasing proportions of children with symptoms of acute respiratory infections, fever, or diarrhea are being taken to a health facility or provider for treatment.

Cambodia has made the greatest progress in reducing child mortality, the focus of Millennium Development Goal (MDG) 4. Mortality rates for both infants and children under five have fallen: infant mortality from 95 deaths per 1,000 live births to 45 and under-five mortality from 124 deaths per 1,000 live births to 54. Maternal mortality has also declined, which puts Cambodia on track to reach national goals and to accelerate efforts to reach MDG5, which calls for a 75% reduction in the maternal mortality ratio to 140 by 2015.

The Better Health Services Project (BHS) funded by the U.S. Agency for International Development (USAID) and implemented by University Research Co., LLC (URC), is a key contributor to health systems strengthening in Cambodia. It builds on the achievements of USAID’s Health Systems Strengthening Project (2002–2008), which URC also managed. BHS’s overall aim is to improve the quality of care and utilization of public health facilities in Cambodia, with a particular emphasis on increasing equity of access for the poor. BHS works with the Cambodian Ministry of Health (MOH)

2 Better Health Services Project: Improving Maternal and Newborn Health in Cambodia

to strengthen capacity through coordinated activities that address both clinical and support services (i.e., health financing, quality improvement, MOH planning, supervision, and health information systems). The project works at the national level and also has more focused efforts in in 11 provinces where USAID concentrates its support, nearly half of the country. Project activities are closely coordinated with USAID partners, including the Reproductive Health Association of Cambodia (RHAC) and the Reproductive and Child Health Association (RACHA).

BHS’s approachThe major direct causes of maternal mortality in Cambodia are similar to those in other developing countries: excessive bleeding following delivery which is exacerbated by high levels of anemia, severe pregnancy-induced hypertension, unsafe abortion, and infection. Obstructed labor, a major cause of maternal mortality in other contexts, contributes relatively little to maternal deaths in Cambodia.

Most complications and deaths occur during or shortly after delivery or sometimes after an unsafe abortion. It is frequently difficult to predict which women will experience complications during childbirth, but once complications arise, women must have rapid and appropriate care to prevent death. Systematic implementation of correct, evidence-based, timely diagnosis and treatment is still a key problem in Cambodia. Cambodian women need the assistance of skilled health care providers at delivery, and those providers must be able to provide high-quality care

for normal births and identify and respond quickly and effectively to complications when they occur.

Access to maternal and newborn health services and care are improving, but death rates are still high compared to other countries in the region. Health Equity Funds (HEFs), largely supported by the BHS project, have significantly reduced financial barriers to care for the most needy Cambodian families, resulting in increased access to and use of essential health services, including facility deliveries, by the poor. Increased secondary education of women has also likely contributed to the reduced rates of maternal and newborn deaths, as have improvements in roads, transport and telecommunications.

Through the implementation of globally recognized best practices and interventions, BHS has been addressing the clinical and systemic challenges to reducing maternal and newborn mortality by focusing on:

¡ Reducing financial and other barriers to antenatal care, skilled deliveries at facilities, and postnatal care;

¡ Improving the capacity of hospitals and health centers to provide high-quality antenatal, delivery, and postpartum care for normal births;

¡ Improving health facilities’ capacity to ensure urgent and high-quality care before, during, and after delivery for complicated births;

¡ Reducing the unmet need for family planning; and

¡ Educating and empowering women, families, and other key stakeholders in communities to improve their ability to 1) stay healthy or improve their own and their baby’s health during pregnancy and in the first six weeks postpartum, 2) better prepare for safe childbirth, 3) prevent pregnancy-related and postpartum problems at home, 4) quickly recognize danger signs, and 5) respond quickly and effectively to maternal and newborn complications when they occur.

BHS’s activities reflect a women-centered approach that strengthens Cambodian health systems and builds on Cambodian government policy and priorities – principles of USAID’s Global Health Initiative.

Key achievements to DateA recent mid-term review of USAID’s efforts in maternal, newborn, and child health found higher quality health services, higher rates and better quality of family planning services, and more cesarean sections being done in in areas supported by USAID partners.

a midwife provides counseling for a pregnant woman and writes notes in her Mother and child Book.

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BHS efforts have already resulted in:

¡ Strengthened policies and guidance at the national level, developed in close collaboration with the MOH, national programs, the Fast Track Initiative for Maternal Mortality Reduction (discussed below), and other donors and partners;

¡ Improved access to and provision of emergency obstetric and newborn care services at designated hospitals and health centers;

¡ Improved access to and quality of skilled birth attendance, antenatal and postnatal care, and key lifesaving interventions in maternal and newborn health;

¡ Improved access to and quality of family planning and post-abortion care services; and

¡ Reduced financial barriers to care at provincial, district, and local levels.

BHS’s assistance in maternal and newborn health (MNH) covers all seven core interventions of Cambodia’s Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality: 1) emergency obstetric and newborn care, 2) skilled birth attendance, 3) family planning, 4) safe abortion (BHS supports post-abortion care but not abortions), 5) behavior change communications, 6) removing financial barriers to access, and 7) maternal death surveillance and response.

emergency obstetric and newborn care (emonc)As part of Cambodia’s EmONC Improvement Plan (2010–2014), BHS and other partners are upgrading government-selected hospitals and the skills of hospital staff to EmONC standards or strengthening services at existing EmONC hospitals. Most EmONC expansion and improvements in key, lifesaving interventions for MNH at health centers are being supported in USAID-assisted provinces in collaboration with RHAC and RACHA. Working together, USAID partners are well ahead of schedule in implementing Cambodia’s EmONC Improvement Plan.

BHS contributions include:

¡ Facilitating policy change to support implementation of EmONC;

¡ Upgrading facilities and strengthening processes to meet EmONC standards;

¡ Ensuring 24-hour availability of EmONC in BHS-supported facilities;

¡ Building capacity and investing in clinical training for doctors and midwives, focusing on improving the delivery of key interventions in MNH; and

¡ Supporting broader efforts in infection control, health information systems, hospital and health center assessments, referral system strengthening, and health financing.

Skilled Birth attendanceBHS is strengthening skilled birth attendance through policy development, training, coaching and on-the-job training, special training sessions, clinical case reviews, and Midwifery Alliance Team meetings. In support of these efforts, BHS also provides enhanced behavior change communication and monitoring and evaluation.

Guidelines and protocols: BHS led the partners in developing Safe Motherhood Protocols (SMPs) for health centers, adopted nationally in 2010, and is leading the same process for hospital SMPs. The protocols include the introduction of drugs and techniques for preventing and treating postpartum hemorrhage and eclampsia. BHS is also developing clinical practice guidelines and other forms of standards (for clinical care, infection control, hygiene, laboratory processes, etc.) to improve skills and standards-based care.

Clinical training: BHS works closely with the MOH to build the capacity of clinical health center and hospital staff by providing guidelines, protocols, training, and coaching in selected clinical interventions that save the lives of mothers and newborns. The project has facilitated the development of a standardized, national curriculum for in-service training of midwives; strengthened pre-service training; and developed continuing medical education opportunities for physicians and midwives.

Hospital management: BHS is working to improve hospital management for patients, wards, and the hospitals themselves. Improvements include expanding facilities to provide adequate room for labor, delivery, and postpartum care for mothers and families; ensuring 24-hour delivery coverage; seeing that health facilities have lights and running water; ensuring adequate drugs, equipment, and supplies

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to safely deliver babies and manage complications; and improving infection control. All hospitals in the country received eclampsia treatment kits, which provide essential equipment for saving the lives of women experiencing complications from eclampsia or severe pre-eclampsia during pregnancy or childbirth.

Quality improvement: Hospitals in target areas are paying increased attention to quality due to regular clinical case reviews of problem cases that either occur in or are referred to hospitals. The reviews focus on identifying strengths and weaknesses and developing action plans to prevent their recurrence and ensure better treatment when they do occur.

Midwifery Coordination Alliance Team (MCAT) meetings are a forum where midwives and doctors from hospitals and health centers and representatives from two government levels—the provincial and operational district levels—discuss current problems, referrals, and cases. These sessions also provide focused training and an opportunity for clinical staff and government managers to interact, get to know each other as colleagues, and provide input to health center care for difficult cases. The sessions also serve as an impetus for changes and improvements in hospital performance.

Monitoring: In addition to improvements in the national health information system for reporting maternal and newborn morbidity and mortality, BHS helped the MOH develop a new antenatal care register. The project led an effort to combine three separate registers ( an ANC

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register, a separate register for the prevention of mother-to-child transmission of HIV (PMTCT), and a third register for Linked Response) into one acceptable to all of the vertical programs. BHS then helped disseminate the new register, now being systematically applied nationwide.

Implementing key interventions: BHS is leading a collaborative effort with the National Maternal and Child Health Center, local partners, and UNICEF to prioritize the “key interventions” for reducing maternal and neonatal deaths: prevention and treatment of postpartum hemorrhage, prevention and treatment of eclampsia and severe pre-eclampsia, essential newborn care and immediate postpartum care, and newborn resuscitation. The project is holding national and regional level workshops for health staff to gain consensus and support for implementation of these interventions in health facilities.

One internationally recognized key intervention is the active management of the third stage of labor (AMTSL), which has three components: giving oxytocin, providing controlled cord traction, and massaging the uterus. Training in AMTSL and introducing an AMSTL stamp on the partograph (a form used during delivery to monitor its progression) led to a sharp increase in the use of AMSTL and a concomitant decrease in heavy bleeding in hospitals piloting this approach (Figure 1). The stamp reminds the provider to practice AMTSL and enables him/her to record the provision of its components. Providers also record on the stamp whether they have checked the uterus every 15 minutes in the first hour after delivery and every 30 minutes in the second hour.

eclampsia kits contain all the necessary equipment, including MgSo4, and short instructions for use, including pictorials for managing eclampsia and severe eclampsia.

figure 1: Correct Use of AMSTL in deliveries in 9 BHS-supported hospitals, March 2011 (n=2657)

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Until recently, health centers had sole responsibility for FP counseling and services in Cambodia; hospitals did not provide these services. BHS is working to fill this gap and recently achieved significant successes. His Excellency the Minister of Health, after policy dialogue with BHS and other USAID partners, twice in early 2011 publicly stressed the need for FP service provision in hospitals, not just in health centers. Additional policy dialogue and this demonstrated, high-level support led the Central Medical Store to fill hospital requests for FP commodities, something previously impossible. These important accomplishments establish the necessary foundation for facility level changes at hospitals.

With BHS support, hospitals in four provinces (Pursat, Battambang, Banteay Mean Chey, and Siem Reap) have discussed these policy changes, collected baseline data, and developed plans to introduce FP counseling and provision. The detailed hospital plans outline the requisite staff training, equipment, minor renovations, infection control improvements, establishment of commodity provision chains, and documentation systems. These hospitals are establishing multipurpose counseling corners to support individual and group counseling on FP, breast feeding, nutrition, and maternal and newborn care and to ensure easy access to a full range of informational materials and job aids. BHS has also translated, printed, and distributed the World Health Organization’s “Contraceptive Wheel” and “Family Planning. A Global Handbook” into Khmer. Both are being used in training and as reference materials.

Post-abortion careBHS also works to improve the quality of post-abortion care services in selected hospitals, providing significant support for improvements in MNH and addressing the unmet need for FP counseling and provision for post-abortion clients. This includes such interventions as the introducing FP counseling corners in hospitals and IUD insertion. BHS is also using various policy and training fora to sensitize decision makers on the important links between FP and safe motherhood, links that have been largely ignored until now in Cambodia. During maternal death audit meetings, BHS stresses the links between FP counseling and provision, safe abortion, and maternal health.

family Planning (fP)Short-term FP methods, such as birth control pills, injectables, and condoms, are available in health centers countrywide, with pills and condoms also for sale in local pharmacies. Some local partners also work with community health volunteers who function as Community Based Distributors, training them to counsel on informed choice and provide birth control pills and condoms when these methods are desired.

However, these short-term methods are not appropriate for all couples, and many couples prefer a broader array of choices. Additionally, preferences are changing: A growing percentage of married couples want to limit their family size and are moving toward long-term and permanent methods (Figure 2), which have been less available in Cambodia.

In response to these unmet needs, a number of partners are focusing on improving access to long-term methods in health centers. BHS is expanding the number of health facilities that provide more choice in methods by focusing on:

¡ Introducing the provision of routine FP services in hospitals;

¡ Establishing linkages between FP services and other reproductive and maternal health services, such as postpartum and post-abortion care and HIV testing and treatment;

¡ Increasing access to long-term and permanent FP methods, such as IUDs and voluntary surgical contraception; and

¡ Improving FP counseling skills among health staff.

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figure 2: Unmet need for family planning, birth spacing, or limiting family size in Cambodia

Sources: Survey on Awareness, Attitude, Fertility Practice and Contraception, 1995, CDHS 2000, CDHS 2005.

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Behavior change communication (Bcc)BHS uses BCC techniques that target women and their families to increase demand for essential care and to improve household practices. Women and their families receive information through print materials (e.g., leaflets, brochures, posters, stickers, small booklets) and radio/TV spots. The

materials are distributed through multiple channels, including the hospital counseling corners mentioned above, health facility staff, outreach campaigns, and local governance mechanisms (primarily Commune Councils). All such activities are linked with more comprehensive approaches—health equity funds, conditional cash transfers, and community

health insurance, discussed below—to stimulate demand.

BHS also uses BCC to improve health providers’ behaviors in key areas. Materials and job aids (e.g., desk cards, pocket handbooks, films, posters, stickers, and clinical practice guidelines) have been developed for health staff; are being provided in counseling corners in hospitals and health centers; and are linked to coaching, supervision, and trainings.

Collaborating with the MOH, local USAID partners, and Save the Children, BHS developed a Mother-Child Health Book Handbook for use in Cambodia. It offers information on how to care for the health of the mother and child, as well as home-based health records covering the mother from pregnancy to postpartum and the child from birth to age five. It is used as part of the Community Based Health Insurance and Conditional Cash Transfer work in Angkor Chum Operational District and BHS plans to use it in 2 additional Operational Districts as part of Community Based Health Insurance expansion beginning in late 2011.

BHS recently finalized and screened a 25-minute DVD video in Khmer and English, entitled “A Safe Delivery,” which was shot in a rural health center and features local health staff and two rural Cambodian women and their husbands. The video shows a normal delivery of one woman and the initial assessment and then successful referral, from the health center to a hospital, of the second, who experienced complications. It highlights safe and evidence-based practices for normal childbirth, including emotional support, infection control, AMSTL, immediate skin-to-skin positioning of

the baby, and immediate breastfeeding. The video’s primary purpose is as a tool for pre- and in-service training of midwives and doctors. BHS is developing a learning package, to accompany the video, that will stress evidence-based practices in delivery care, cleanliness and infection control, effective provider-patient communication, and immediate newborn and postpartum care. The National Reproductive Health Program will lead the distribution of the video and learning package. Thus far, the national program, BHS, UNICEF, RHAC, RACHA, and the World Health Organization have agreed to use the video and package.

removing financial Barriers to accessHealth Equity Funds (HEFs), largely supported by BHS, are a pro-poor health financing scheme that targets government-identified poor households in an area and provides financial and social support so that the poor can access government health services. HEFs cover the direct costs of health services and medications for the poor as well as transport reimbursement for patients and money for food expenses for their patients’ caretakers while poor patients are hospitalized. About 35% of Cambodia’s population is poor, as defined by the Ministry of Planning, and thus eligible for HEFs.

BHS spearheaded HEFs in Cambodia, where BHS-supported HEFs now cover 34 of 77 operational districts. HEF support has substantially increased utilization by the poor of public health services, as evidenced by large increases in ANC and childbirth services at health facilities by HEF enrollees. HEFs are also contributing to the dramatic increases in facility based births in Cambodia (Figure 3). In 2010, 70% of poor women covered by HEFs gave birth in a public hospital or health center compared to only 40% of non-poor women. This represents a 45% increase in facility births for poor women since 2008.

Community Based Health Insurance and Conditional Cash Transfers: BHS is now piloting additional schemes, at the request of Cambodian health authorities and provincial and district governors in three geographical areas, to further reduce financial barriers to health care and provide additional incentives for rural households to use preventive and curative care during the critical 1,000 days from early pregnancy until the child’s second birthday. These schemes include Community Based Health Insurance and Conditional

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Cash Transfers for ANC, delivery, postnatal care for mothers and newborns, growth monitoring and promotion for children up to 24 months, and immunizations.

Addressing transport costs: BHS is also testing schemes to improve referrals for obstetric complications in two provinces. It introduced a new scheme in Banteay Mean Chey in April 2010 to provide remuneration to health centers for referrals and transport for all obstetric emergencies. Preliminary results from an ongoing 12-month evaluation are encouraging. They suggest that obstetric referrals are now more timely and more often correct (e.g., the health center contacts the referral hospital in advance, qualified staff accompany the woman, and adequate documentation is brought to the referral hospital). The remuneration scheme is also helping program managers improve and monitor the referral system.

In early 2011, BHS initiated a slightly different and more comprehensive referral scheme in Battambang province. The Banteay Mean Chey referral scheme could not be exactly replicated because RHAC was already supporting remuneration for obstetric referrals through its “purchase service scheme” in four of Battambang’s five operational districts. RHAC is also taking the lead to improve self-referrals from home to health facilities. BHS and RHAC agreed to maintain RHAC’s remuneration scheme in the four districts and for BHS to add a Banteay Mean Cheay-like scheme in the fifth. This new scheme, initiated in early 2011, includes, in addition to the remuneration system described in the previous paragraph, a standardized referral form for all referrals between all health facilities in all five districts, a

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figure 3: Facility-based deliveries by poor and non-poor women in URC-supported districts

memorandum of understanding covering the use of HEF funds for ambulances, and a cell phone hotline for communication between all peripheral units and the delivery ward in the Battambang provincial hospital.

Maternal Death Surveillance and responseOnly some 30% of estimated maternal deaths in Cambodia are currently being reported through the health information system: The rest are “invisible.” Making maternal deaths more visible by counting them and carefully analyzing the causes and factors that contribute to each are important for political leverage and focused improvements in the health system. BHS is improving processes and systems for maternal death surveillance and maternal death audits. These audits consist of an investigation of every maternal death, analysis of causes, and definitions of concrete actions for systems improvement. BHS is linking maternal death surveillance efforts with good governance interventions at the community level.

next StepsCambodia has made great strides in the last 10 years, with assistance from BHS and the Health Systems Strengthening Project, to make pregnancy safer and to significantly reduce maternal and newborn deaths. Continued BHS support over the next few years will accelerate these achievements and ensure that strategies undertaken by the project are documented and those that are successful are scaled up in a sustainable fashion.

a cambodian mother rests with her newborn infant.

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