Elsevier

Health Policy

Volume 95, Issues 2–3, May 2010, Pages 255-263
Health Policy

Perceived barriers to utilization of maternal health services in rural Cambodia

https://doi.org/10.1016/j.healthpol.2009.12.011Get rights and content

Abstract

Objective

The aim of this study was to identify the underlying causes of Cambodian women's non-use of maternal health services provided by skilled birth attendants.

Method

A qualitative study of 66 reproductive-age women was conducted in Kampong Cham Province, Cambodia. Data were collected through 30 semi-structured interviews and 6 focus groups.

Results

We identified 5 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.

Conclusions

The Cambodian Ministry of Health and its development partners should take these barriers into account when promoting the use of maternal health services. These barriers should be addressed proactively. A successful approach to increasing use of maternal health services should involve changes to both service programs and public education.

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,

References (46)

  • Ministry of Health (MoH)

    Maternal death audit data from 10 provinces obtained from January 2005 to December 2006

    (2006)
  • World Health Organization (WHO)

    Global action for skilled attendants for pregnant woman

    (2002)
  • United Nations Population Fund (UNFPA)

    Maternal mortality update 2004: delivering into good hands

    (2004)
  • World Health Organization (WHO) et al.

    Making pregnancy safer: the critical role of the skilled attendant. A joint assessment by WHO

    (2004)
  • World Health Organization (WHO)

    Make every mother and child count. World Health Report

    (2005)
  • M.A. Koblinsky et al.

    Organizing delivery care: what works for motherhood?

    Bulletin of World Health Organization

    (1999)
  • E.A. Goodburn et al.

    Training traditional birth attendants in clean delivery does not prevent postpartum infection

    Health Policy and Planning

    (2000)
  • Japan International Cooperation Agency (JICA). The development study on strengthening maternal and child health...
  • World Health Organization (WHO)

    Working together for health. World Health Report

    (2006)
  • L. Chhun et al.

    Safe motherhood situation analysis of Cambodia

    (1997)
  • Ministry of Health (MoH)

    National health workforce development plan 1996–2005

    (1997)
  • Ministry of Health (MoH)

    Health sector strategic plan 2003–2007

    (2002)
  • Ministry of Health (MoH)

    National health statistics 2005

    (2006)
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