Perceived barriers to utilization of maternal health services in rural Cambodia
Introduction
The maternal mortality ratio in Cambodia was 472 per 100,000 live births as of 2005 [1], the third highest of all South Asian countries [2]. The major causes of maternal mortality in Cambodia, as elsewhere in the world [3], are abortion-related complications, obstructed labour, hemorrhage, eclampsia, sepsis, and infection [4]. Utilization of services provided by skilled birth attendants (SBAs), such as midwives and physicians, is generally considered an effective way to address these issues and reduce maternal mortality [5], [6], [7], [8]. In Cambodia, 78% of deliveries are performed at home, and 56% of deliveries are performed with the assistance of untrained providers, such as traditional birth attendants (TBAs) [1]. In general, the assistance of TBAs does not substantially reduce maternal mortality and morbidity, regardless of whether the attendants are trained or untrained [9], [10].
Two types of factors, i.e. factors related to the service-providers (SBAs) and factors related to the service-users (pregnant women), are likely to contribute to the low use of SBA services in Cambodia. The availability of SBA services is somewhat limited due to a serious shortage of healthcare personnel (service-providers) [11]. Cambodia is identified as one of the countries showing acute shortage of health professionals (e.g. physicians, midwives, and nurses) with a ratio of only one per 1000 people [12]. This ratio is much lower than 2.5 per 1000 people, the minimum requirement for ensuring at least 80% of births are served by SBAs [12]. There is still a shortage of healthcare personnel in Cambodia: during the Khmer Rouge Regime (April 1974 to January 1979), many educated people, including health professionals, either left Cambodia or were killed [13]. However, the current Cambodian government has addressed this need by prioritising the professional development of healthcare personnel [14], [15], and the number of physicians and midwives increased by 10.3% from 1996 to 2005 [14], [16]. Since the introduction of a national health coverage plan in 1996, the government has been constructing and rehabilitating governmental health facilities throughout the country with the aim of providing a minimum package of health services, including SBA services. Nevertheless, particularly in rural communities, women (service-users) often do not utilize the SBA services. In rural Cambodia, only 39% of women have a SBA present during delivery, while more urban women (70%) access SBAs delivery care services [1].
Various perceived barriers of women to use of health facilities for maternal health services have been identified in multiple low income settings. These are direct and indirect costs [1], [17], [18], [19], [20], poor geographic access (distance, poor road conditions, transport problems, etc.) [1], [17], [19], quality of care (poor facilities, lack of essential drugs, poor treatment by health professionals, etc.) [1], [17], [19], [21], limited knowledge about services available [19], ill-mannered attitude of health professionals [19], [22], [23], women's physical condition (i.e. the concept of normal versus abnormal pregnancy) [17], [22], [24], [25], self-efficacy from previous experience [24], socio-cultural and traditional norms [22], [24], [25], [26], psychological security with relatives presenting during delivery [25]. In addition, a study found correlations of factors influencing women's use and non-use of maternal health services, across six developing countries—Bangladesh, Bolivia, Ghana, Indonesia, Malawi, and the Philippines: residence location (urban vs. rural), socio-economic status (rich vs. poor), maternal education (more vs. less), antenatal care (more vs. less), and birth order (less vs. more) [27].
However, in Southeast Asia including Cambodia, earlier studies have not clearly identified the reasons, or women's decision making process underlying this non-use. This study, therefore, aimed to identify the barriers to utilization of maternal health services, particularly of delivery care services provided by SBAs, by surveying reproductive-age women in rural Cambodia.
Section snippets
Study area
This study was conducted in September and October of 2006 in six purposively selected communities, two in each of three Ministry of Health operational districts in Kampong Cham Province, Cambodia. The operational districts were Kampong Cham—Kampong Siem, Memot, and Kroch Chhmar.
Qualitative data collection
We conducted semi-structured interviews (SSIs) and focus group discussions (FGDs) with reproductive-age women.
Selection of interviewees
Participants in each SSI and FGD were selected by purposive sampling of reproductive-age women aged 15–49
Results
The SSIs and FGDs conducted with a total of 66 women helped us identify five barriers to the utilization of maternal health services: (i) financial barriers; (ii) physical barriers; (iii) cognitive barriers; (iv) organizational barriers; and (v) psychological and socio-cultural barriers.
Discussion
This study used SSIs and FGDs to identify five types of barriers to the utilization of maternal health services in Cambodia: (i) financial barriers; (ii) physical barriers; (iii) cognitive barriers; (iv) organizational barriers; and (v) psychological and socio-cultural barriers. Fig. 1 summarizes the findings of this study by depicting the perceived barriers, and the relationships of the perceived barriers, that may contribute to lower utilization of governmental maternal health services. This
Acknowledgements
The authors gratefully acknowledge Shuji Noguchi, Chiaki Kido of System Science Consultants Inc., Imelda G. Pagtolun-an of Phil Koei, and Hiromi Obara of International Medical Center of Japan for their valuable advice in the study design. We also thank to Chinsam Viseth, Phou Maly, Ly Sreypeou and Seng Dara for their tremendous help in data collection. Last but not least, the authors herewith express their sincere gratitude to Japan International Cooperation Agency and the Ministry of Health,
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