Phnom Penh
Cambodia is one of the poorest countries in Southeast Asia. Given its turbulent past, decades of civil war and the devastating policies of the Khmer Rouge to name just two, it faces extra hurdles on its way to improving health care for its citizens.
Cambodia is working to reduce the number of women who die in childbirth and to lower the number of infants and children under age five who die.
The figures in the two efforts reveal an anomaly: While Cambodia has succeeded in dramatically cutting the ratio of children who die each year, the maternal mortality figure has not dropped in a decade.
Around 460 Cambodian women die in childbirth for every 100,000 births. The country had hoped to bring that figure down to 140 deaths per 100,000 births by 2015 as part of its commitment to its Millennium Development Goals, or MDGs.
Dr. Lo Veasnakiry, who heads the Ministry of Health's planning unit, blames the lack of success, in part, on a shortage of funds and expertise, but he also says the target was excessively optimistic. "The global MDG said that [each] country had to reduce two-thirds of the baseline information when they started the MDG. From a global viewpoint [it's] not only Cambodia - a lot of countries have not made significant progress in terms of maternal deaths," he said.
A study in 2005 found that around half of the Cambodian women who die in childbirth succumb to massive blood loss. A quarter die from eclampsia, which is a problem related to high blood pressure.
Malalay Ahmadzai, the mother and child healthcare specialist for UNICEF in Cambodia, says both conditions require rapid treatment - in the case of blood loss a woman can die within a few hours.
She says the onset of maternal complications is unpredictable, and the response is often slowed by what health experts call "the three delays". "The first delay is decision-making in the family whether to seek care or not. The second is the roads - roads counts as one of them - but costs, costs, roads and access. And third is the quality of care," she said,
The solution is a mix of better resources, more trained medical staff, and better roads - the logic being that the quicker patients get to a clinic, the better their chances of survival.
Cambodia's inability to save mothers contrasts with its success in lowering infant and child deaths.
The country aims to reduce the ratio of infants dying before their first birthday to 50 per 1,000 live births - or five percent.
Ten years ago the rate was almost twice that. Today's rate is six percent, putting Cambodia well on its way to hitting its target.
It is a similar story with deaths among children under five; the rate has dropped to 83 per 1,000, down sharply from 124 a decade ago.
Lo says the government's financial commitment to the health sector has proved vital to saving children. He also credits the cash and technical help from health partners such as UNICEF.
Ahmadzai says other factors play a part, too. "One has been the strong performance of the national immunization program. That has been one key promising intervention identified. Second has been the improvement in breastfeeding practices, and that goes back to a lot of community work plus support to the health centers and so on," she said.
Tackling maternal mortality, on the other hand, requires that good quality care be quickly available at health clinics. And in much of Cambodia, the quality of care is insufficient.
One problem health care providers have here is getting good data on the maternal mortality rate. Some officials say it actually could be anywhere between 300 deaths and 700 deaths per 100,000 births.
A more accurate figure will emerge next year when the five-yearly nationwide health survey is taken.
The Ministry of Health's Lo is optimistic that the new data will show an improvement in the rate.
That is because every one of Cambodia's almost 1,000 healthcare clinics now has a midwife. A year ago around 90 percent did.
Also, more women receive care before giving birth than ever before, and more midwives are present at births.
But even Lo does not expect the improvement will bring the goal of 140 deaths per 100,000 births within reach. He recently proposed that the government raise the target to 250.
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