Presentation by Gillian Dalgetty (University of Leeds) on ReBUILD Responsive Fund project on Obstetric Referral in the Cambodian Health System given at internal programme webinar, 9th Sept 2015.

1. Obstetric Referral in the
Cambodian Health System - What
Works?
9th September 2015

2. Cambodia
The legacy of conflict

3. 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

4. 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
 …

6. Adapting Appreciative Inquiry

7. 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

8.  (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.

9. 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?

10. Limitations
 Can be read as examples of ‘best practice’ –
can’t say its widespread
 Subject to usual caveats on interviews

11. 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