Kampong Thom province
Sem Phai, a 35-year-old rice farmer in Kampong Thom province’s Prasat Sambor district, has three children and says she cannot afford any more.
But living in Tang Krasao village, which lies a bumpy hour-long drive from Kampong Thom town, means that Sem Phai’s options for preventing unwanted pregnancies are limited.
She tried using a contraceptive pill but soon stopped after noticing that it was causing her to become “thinner and thinner”.
“I don’t want more children because I’m poor and I’m afraid I can’t earn enough to support them when they grow up,” she said. “I want to spend time working to support my family.”
Local healthcare workers say some women in Sem Phai’s position prefer to abort unwanted pregnancies than to seek family planning services, citing accessibility, affordability and expediency as major considerations.
Authorities have long cited a lack of healthcare services in rural and remote areas as one of the major obstacles to reducing the Kingdom’s maternal mortality rate which, based on 2008 census data, is pegged at 461 deaths per 100,000 live births and is widely cited as among the highest in the region.
Up to a quarter of these deaths are related to unwanted pregnancies, meaning that “roughly one woman dies every 10.5 hours from unsafe abortion”, according to the NGO Marie Stopes International, which has recently introduced Midwives on Motos, a new programme designed to improve access to safe family planning services in remote areas.
Along with 14 other women, Sem Phai visited her local health centre last month to receive a hormonal implant. The implant, which is inserted just beneath the skin on the woman’s upper arm, protects against pregnancy for three to five years and is not usually accessible for women in remote villages like Tang Krasao.
Sitting on a wooden bench outside the open door of the healthcare centre while waiting her turn to receive the implant, Sem Phai said her initial fears about side effects had been quashed after a consultation with Khy Sophorn, an MSI midwife visiting from Kampong Thom town.
“At first, I felt scared about this because I heard the rumour that it hurts women,” she said.
In a group discussion before beginning individual consultations, Khy Sophorn explained to the women assembled that the implant would not “walk around their bodies” or make them too weak to do physical work.
Sosy Vorn, a midwife based in Tang Krasao village who has been practicing in Kampong Thom province for more than 20 years, said such rumours were common and that there was often an initial distrust of modern contraceptives like the implant.
“Family planning methods are new to Cambodia and lots of women have heard stories of bad side effects. It will take some time to build trust in family planning methods,” she said. “Some women just want to see what happens with their neighbour’s implant; if it goes well then maybe they will do that too.”
She said that some women in remote areas still use abortion as a form of family planning and see it as preferable to medium-term contraception methods.
“Some of the women like to use abortion rather than family planning,” she said. “A surgical abortion takes only five minutes and doesn’t hurt after, but for family planning, they have to take some time to do that.”
The need for accessible family planning services was made evident in the 2005 Cambodia Demographic and Health Survey, which found that 59 percent of married women in Kampong Thom province did not want any more children, yet only 30 percent of them reported using modern contraceptive methods.
An estimated 1,700 women die during childbirth or as a result of becoming pregnant in Cambodia every year, according to a May report from the Ministry of Health, which cites transportation problems as one of the top three “critical delays [to accessing services] that can make the difference between life and death”.
The report also highlights the importance of access to family planning, noting that, “Globally, there is strong association between low MMR and high rates of family planning”.
Nationwide, the number of married women using family planning methods rose from 18.5 percent in the year 2000, to 28 percent in 2009, according to the report. The Kingdom has set a target to more than double this number to 60 percent by 2015, as part of a wider goal to reduce maternal mortality rates to less than 250 deaths per 100,000 live births by 2015.
Che Katz, MSI’s country director, said taking services to people in remote areas was one of the most immediate ways to work toward such goals.
“Midwives on Motos is about how to access women and men who are really underserved with family planning services and sexual reproductive health services,” she said.
“People in urban centres have more access to health services, or [semi-urban] centres, but when you move further out to into the rural or remote areas, it’s quite hard for them to get access to services. The cost of travel can be just prohibitive for poor women.”
Midwives on Motos began in Kampong Thom province in March following the introduction of similar programmes in Battambang, Siem Reap and Koh Kong provinces in January. MSI claims to have provided more than 660 women with family planning services through the programme.
Katz said, along with other MSI programmes, Midwives on Motos had a notable impact on reducing the number of maternal deaths.
“This year we will have averted 315 maternal deaths directly from our work.... and more than 4,000 infant deaths, and we’ll have saved the government of Cambodia and the people of Cambodia US$21 million in health services costs,” she said. “So that’s a very measurable impact that we’re having.”
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