CMB/97/PO1

“Reproductive Health/Birth Spacing and Sexual Health in Cambodia”

Sub-ContractSocio-Cultural research and Training in Support of Reproductive Health in Cambodia

REPORT ON FIRST PHASE OF FIELD WORK

August 1998

BACKGROUND

The Social Research Project

A research sub-contract was set up with the Royal University of Phnom Penh (RUPP) in March 1998. Theprotocol was designed,with considerable input from the Country Support Team in Bangkok, to provide social science data to assist the National Reproductive Health Program and to build research capacity within the RUPP.

The research objectives set out in the project document state that population based surveys will be conducted on operational aspects of the National Reproductive Health Program and data will be collected on socio-cultural aspects of client behaviour as they relate to reproductive health. The research project will, over the course of four phases,address all the areas outlined in the project document with the exception of maternal mortality, this is being done in detail by an NGO who have clinical staff able to do professional studies.

The research was designed to be complementary to the four week Research Training course that was held in the RUPP in April 1998. Four junior staff from this course were recruited to work on the programme and all participants of the course are invited to attend a one day workshop at the end of each research phase to discuss the field experiences, the data analysis and the results. Course participants are encouraged to contribute ideas for the next phase of data collection and the directions that they think the research should go.

The research project was designed to give the students exposure to both quantitative and qualitative methods of research. Given the high standard of research concerning women's beliefs and attitudes towards reproduction already carried out in Cambodia[2,3,5] ,it was decided that an in-depth study of where women access reproductive health services, reasons for their choice of provider and details of the service given would be an appropriate area of study. The number of clients using different service delivery outlets will provide quantitative data, while details of their reasons for choosing certain providers and their level of satisfaction with the provider will give an opportunity for students do carry out in-depth qualitative research.

Reproductive Health in Cambodia

A national Knowledge Attitudes and Practices survey conducted in 1995 showed that 71% of women said they would like to have access to modern methods of contraception either to delay their next pregnancy or to limit the size of their family. Yet only 13% of women were using any birth spacing method and only half of these were using a modern method. The injectable depo provera, IUD and the daily pill were the most popular methods cited. In 1996 a qualitative study of perceptions of contraception showed that discontinuation of hormonal methods was mainly related to fears that changes in the menstrual cycle would lead to sterility or other complications such as cancer or 'drying up' of the skin. Many women believed that the IUD could 'wander' round their body. Rural women feared that heavy agricultural work would result in the IUD either spontaneously falling out or that it could move and pierce the womb resulting in severe bleeding and possibly death. Condoms are associated more with disease prevention and extra-marital sex than with contraception. They arenot popular with either men or women in that they diminish the pleasure of sexual intercourse and women fear that they will slip off the penis and become lodged in the womb[2].

Childbirth is usually assisted by a Traditional Birth Attendant, whose services include antenatal, delivery and postpartum care. Some traditional practices can be dangerous, for example, pressing on the fundus to hasten delivery and heating women by building a fire under their bed for several days during the postpartum period[3]. Maternal mortality is 473:100,000 live births[4] and abortion is believed to be high with 14% of married women in Phnom Penh reporting having had at least one abortion[1].

LOCATION AND METHODS

A longitudinal study was set up. This will continue for 12 months with four phases of research; each consisting of five weeks of field work followed by eight weeks for data entry and analysis. Data on health care provision will be collected continuously from health centers, drug sellers, traditional healers and traditional birth attendants. This first phase of field research was focussed on collecting health center data, setting up the recording system with the drug sellers and traditional healers and starting interviews with women and men in the communes.

The study is being conducted in one commune in each of two provinces. Prey Veng province has been part of the National Reproductive Health Project since its inception in 1995 and is one of the Asia Development Bank Accelerated Development Districts (ADD). Pursat province is one of the eight provinces brought into the project in 1998. The two communes were chosen to be within 30 minutes travelling time of the provincial capital and to have a functioning health center that includes a pharmacy and some laboratory facilities.

Svay Antor health center is located near the middle of the commune about 13 kilometers from Prey Veng town. It is situated about one kilometer to the east of a market village that is at the junction of the main north south highway and a secondary road leading to the east. There are seven villages in Svay Antor commune with an estimated population of 8300 living in 1710 households[6]. The health center, however, covers a further six villages in the neighbouring commune of Pre Khla bringing the target population for the health center to nearly 14,000.

Kandieng health center is located in a small trading village eight kilometers from Pursat town. It serves a dispersed population, the majority of whom live along a river leading to the Tonle Sap. The estimated population of Kandieng commune is nearly 6000[6] living in 1060 households. There are two smaller health centers in adjacent communes which only function on one day a week.

Sample and methods

The sample in both communes consists of 1) health providers; health center staff, drug sellers, traditional healers and traditional birth attendants, and 2) health seekers; women of reproductive age and men living in the same villages. Samples of the questionnaires and record books are appended.

1)Health providers

a) Health centers. All staff at the health centers were interviewed at the start of the project with informal discussions and observation continuing throughout the field work period. Details of all reproductive health services given during the three months prior to the start of the field work (March, April, May) were recorded.

b) Drug Sellers. The owners of all pharmacies in the communes were interviewed and asked to complete a short questionnaire on their social background and pharmaceutical/medical training. Following this they were given an exercise book and asked to keep a tally of all sales of drugs for purposes related to reproductive health; birth spacing, pregnancy, delivery, postpartum and sexually transmitted diseases. These diaries were checked every two or three days.

c) Traditional Healers (Kru Khmer) and Traditional Birth Attendants (TBA). All Kru Khmer and TBAs living in the communes were interviewed and those who provided any services related to reproductive health were asked to keep records of the number and type of services given.Weekly visits should be made to each Kru Khmer and TBA to check the number of clients they have seen in the previous week and to ask for details of services given.

2)Health Seekers.

a) Women of reproductive age. One hundred women who were recorded as attending the health center for birth spacing services in Svay Antor and fifty who did so in Kandieng were targeted for interview in their homes. (The numbers attending in Kandieng were too small for it to be feasible to interview more than 50.) In addition 200 women in each commune who did not go to the health center were identified by taking the house of index women and interviewing one woman resident to the left and one to the right of the index woman's house (two in the case of Kandieng). We are therefore controlling for distance from the health center.

b) Men. The husband of the index woman and two men of the same age group resident in the same village will be interviewed. This will give a sample of three hundred men in Svay Antor and 250 men in Kandieng, again controlled for distance from the health center.

RESULTS

1) Health Providers

Table 1 shows the number of clients seeking reproductive health care from different providers in the two communes. This data is very preliminary and should not be quoted under any circumstances. It is only presented to givean idea of the range of services given in thenon-formal sector.

a)Health Centers

At Kandieng health center there is one medical assistant, three nurses, three midwives, one injectionist, two laboratory technicians and one pharmacist. In Svay Antor there are four medical assistants, two nurses, four midwives, one pharmacist and one injectionist.

During the three months prior to the start of field data collection the health center at Kandieng provided birth spacing services to 86 people, antenatal care to 98 and delivered nine babies. No patients attended for STD treatment. Over two thirds of birth spacing clients lived within five kilometers of the health center and the remainder between six and ten kilometers. Of those attending for antenatal care 90% lived within five kilometers of the health center and all of the nine women who are recorded as having delivered at the health center lived in the immediate vicinity.

During the three months prior to the field work in Svay Antor 155 women attended for birth spacing services, 83% of whom lived within 5 kms of the health center. Forty three women attended for antenatal care, twelve of whom came from over ten kms from Svay Antor and 29 women are recorded as giving birth in the health center, 18 of whom lived in the immediate vicinity, seven lived between 5 and 10 kms away and ten were from further afield. During this period 24 people came for STD treatment, nearly half of whom lived more than 10 kms away.

b)Drug sellers

With one exception the drug sellers in Kandieng all run general grocery or hardware shops. Initially 19 drug sellers were contacted and interviewed but seven were not asked to keep diaries as they did not sell birth spacing or other products related to reproductive health. In Svay Antor nine of the 20 drug sellers interviewed had no other occupation, seven were concurrently employed in the formal health system, three ran grocery stores and one was a teacher. Two of those originally interviewed moved away from the area and one was dropped as they only sold a very limited range of drugs such as aspirin.

The majority of drug sellers were in their mid thirties with an age range from 24 to 60. In Kandieng the majority were women whereas in Svay Antor two thirds were men. In Kandieng seven had secondary education and none had any tertiary training.In Svay Antor four had some tertiary education. Overall five of the drug sellers had had some formal medical or pharmaceutical training. They had been selling drugs for an average of six years.

In both Kandieng and Svay Antor the daily pill was the most common form of birth spacing sold, 57% in Kandieng and 42% in Svay Antor. In Svay Antor the Chinese pill was also popular, accounting for 38% of sales compared to only 15% in Kandieng. Depo-provera was sold to the remaining 20% of birth spacing clients in Svay Antor and to 25% in Kandieng, where one pharmacist inserted six IUDs to private clients.

Between 200 and 300 people were seeking STD treatment form drug sellers in both communes. We were surprised to find over 400 women in Svay Antor and 200 in Kandieng buying drugs for conditions related to pregnancy, childbirth and the postpartum period. Data on symptoms described and treatments given were not collected in this phase.

c) Traditional Healers and TBA

There are four traditional healers in Svay Antor who were interviewed and who are keeping records of their clients. In Kandieng there are nine, two of whom are married and are very well known in the district. The nine traditional healers in Kandieng saw a total of 274 patients for reproductive health problems during the month of June. Of these over one half were for STDs, a fifth for post partum problems, 15% for problems related to child birth, and the remainder for antenatal care.

In Kandieng nine TBAs were identified and interviewed and in Svay Antor there were ten. In both locations the women were aged between 40 and 85 with a mean of 58 years. They had been working as TBAs for an average of 25 years with a range of two to 50 years. The majority had learned their skills from a relative or a spiritual healer, about half had, at some time, received some training from an NGO. They delivered about five babies a month as well as providing antenatal and post partum care.

3)Health Seekers

a)Women

To date 116 women have been interviewed in Svay Antor and 96 in Kandieng. Their ages range from 19 to 48 with a mean of 33 years.In Svay Antor nearly a quarter have never been to school and only seven have any tertiary education, whereas in Kandieng only 11% have never been to school and nearly a quarter have some tertiary education. In Svay Antor three quarters are farmers whereas in Kandieng less than a half farm, with a quarter working as traders and a fifth having no employment outside the home. In Svay Antor all women were currently married while in Kandieng ten percent were either widowed, divorced or separated. In both locations the majority of the women's husbands were farmers with a sprinkling of skilled and unskilled workers, moto drivers, traders and military or police.

In both locations the vast majority of women had given birth to their most recent child at home. In Kandieng two thirds of those interviewed were not using birthspacing. Of those that were the majority used the injection. Nearly half of the women said they had obtained their birth spacing from the health center with remainder having patronised mainly drug sellers and private clinics. in Svay Antor only 20% were not currently using birth spacing again the injection was the most popular method (64%), just over half of those using birth spacing said they obtained services from the health center with the remainder mostly using drug sellers or mobile clinics.

These data are very preliminary, with only about one third of the data collected in both locations. The majority of which is likely to be from women identified through the health center records as using birth spacing.

b)Men

In Svay Antor 137 men have been interviewed but in Kandieng only 18 have so far been included in the study. Their ages range from 19 to 60 and the majority are farmers, about a third of whom have primary education. The majority rarely travel away from their homes and about a fifth report having had an STD in the last six months for which they sought treatment from either a drug seller or a traditional healer. Other health problems were either left untreated or treated through a drug seller.

Again these data are very preliminary, with only one third of the data collected in Svay Antor and

less than 10% in Kandieng.

Field experiences and problems encountered

1)Health Providers

a) Health Centers

In both communes we had very good co-operation from health center staff. The record books were kept well and easy to use. The staff were friendly and very open about the problems they faced and in telling us some of their activities. There appeared to be no attempt to hide their private practices and it was admitted that some of the deliveries recorded in the health center books had in fact occurred in the woman's home and the midwife had been paid for the service. Others were willing to show us private clinics in their homes or to discuss the mobile service they gave in the community.

Difficulties were occasionally encountered in finding staff, particularly in Kandieng. In this commune all staff provide services outside the health center. The two smaller health centers in Kandieng district are only open one day a week when they hold a vaccination clinic.

b)Drug Sellers

Owing to the limited number of drug sellers who had any professional training we did not ask for details of their qualifications. However at the workshop held at the end of this first phase of research participants with a medical background asked for more details of training, which will be collected next time.