Obstetric Referral in the Cambodian Health System - What

Works?9th September 2015

CambodiaThe legacy of conflict

Maternal Health in Cambodia One of highest MMR rates in Asia

Weak referral identified as one cause Policy priorities

Reducing maternal mortality Improving quality of health service delivery

Ongoing reform of the Operational District system

Obstetric Referral in the Cambodian Health System – What Works?

4 objectives Investigate delivery journeys to and back from

public healthcare facilities for pregnant rural women

Identify existing positive resources in the public system

…

Adapting Appreciative Inquiry

Investigating Positive Journeys What works NOW

Birth experiences < last 2 years Rural province …. 30 interviews with stakeholders involved in

referral Pregnant women Their family members (husbands, mothers) Community based volunteers Midwives and doctors Health centre / hospital leaders

Snowball recruitment Thematic Framework analysis

(Husband’s story). His wife was pregnant with their first child, contractions started at around 9:00am. He brought his wife to the HC, arriving around 10:00am. He called the midwife via the number posted on the wall. When she arrived, she examined the woman and said that the cervix was just 1cm dilated so the couple should wait at the HC. The midwife allowed him, his mother-in-law and sister-in-law into the delivery room and the baby was born at 6:00am the next morning... Suddenly, the woman had so much bleeding. The midwife phoned DRH to inform them of a referral at around 7/8am. Two midwives stayed with his wife and the HC director drove the (HC) ambulance. The midwives constantly checked his wife’s condition and kept calling DRH to prepare to stop the bleeding when they arrived. DRH staff used a wheelchair to greet his wife – he lifted his wife from the ambulance to put her in it. His mother-in-law carried the baby. Both entered ICU with staff, who called to a more skilled midwife to assist. Had that midwife not come on time, the DRH staff were planning to refer further. Staff didn’t inform the family about his wife’s condition but taught him how to clean his wife and what medicine to buy for her. During the stay at the hospital, the family was not asked to fill any form except to pay 50,000Riel ($12.5) room fee. Before discharging the woman, staff advised them to take the given medicine and not have fire-roasting. Many relatives came to visit the woman at home.

Existing Positive Resources… Facilities exist and function Awareness of where to go to give birth Staff follow a philosophy of care Proactive referral: community HC onward Effective teamwork within and between facilities Active partnership between health system and family Strong support provided by husbands, brothers Community wide collaboration at time of/after birth Proactive, confident and transparent hospital leadership SOA status?

Limitations

Can be read as examples of ‘best practice’ – can’t say its widespread

Subject to usual caveats on interviews

So What? Important balancer to referral literature in LIC

that emphasises barriers, problems and deficits Necessary to acknowledge and recognise that

procedures are followed, medical staff can be wonderful, co-operation and teamwork can be found

Interviewees made some very specific recommendations (e.g. on facility design)

Need to disaggregate SOA/non SOA - may be an implication that don’t need to pay for performance