Assessing the emergency obstetric care system in Pursat, Cambodia through the UN Process Indicators and positive deviant mothers

Cambodia's maternal mortality ratio remains among the highest in Southeast Asia. Connecting women in need with timely emergency obstetric care (EmOC) is necessary but challenging because many women in Cambodia (78%) give birth without the assistance of a skilled midwife. The author conducted an EmOC systems assessment of Pursat Province in Cambodia during 2007 with the assistance of the Reproductive and Child Health Alliance. A unique combination of existing conceptual frameworks and indicators were utilized – the Three Phases of Delay in EmOC, positive deviance, and the UN Process Indicators. Through the UN Process Indicators, the author identified 184 (11%) obstetric complications which were treated at a qualified EmOC facility, 121 (7%) treated at other health facilities, and an estimated 1,389 (82%) unrecorded and presumably without a skilled midwife. Annual trend data for delivery location and attendant in Pursat showed that Tasah Health Center saw greater recent success in bridging the gap between mothers and EmOC structure despite typical barriers. In-depth interviews and focus groups were conducted using a mixed-methods, ethnographic approach. Poor mothers who lived more than five kilometers from the Tasah Health Center and yet delivered there were interviewed. Results showed that these women covered delivery costs by putting money aside, buying health insurance, or borrowing money from neighbors at high interest rates. Therefore, health centers should record services and complications according to the UN Guidelines to fully monitor the EmOC system, and maternal intervention programs should include financial literacy/planning by transferring the skills of positive deviant mothers.