To reduce avoidable trauma deaths TMC with partners delegated life-saving skills to non-doctors. In a three-year prospective pilot study in Cambodia 2005-07 we applied the same strategy for complicated deliveries. Where pregnant women are weak due to malnutrition and endemic diseases, we regard delivery complications a trauma to mother and child – and manage the complications accordingly.
The study was carried out in rural Northwestern Cambodia where access to health services is poor and poverty, infectious diseases and land mines are endemic.
Bringing life-saving skills to the village
Most programs aimed to reduce maternal deaths focus on hospital performance and obstetric protocols. In communities where most mothers deliver at home, such strategies will fail. The Delivery life support (DLS) is a chain-of-survival model that takes life-saving skills to those closest to the women at risk; to the traditional birth attendant (TBA) in the villages, to midwives and medics at the rural health centers, and to the non-graduate surgeons at the districts hospitals. The DLS study in Cambodia is a national pilot study in cooperation with the Cambodian Ministry of Health.
The pre-intervention survey by TCF Cambodia identified three main causes for maternal deaths:
- Post-partum bleeding
- Prolonged labour.
The DLS training protocol comprises of hands – on methods to manage these complications, as well as danger signs in pregnancy. The district hospital capacity is upgraded, new surgical techniques introduced and blood service established. The TBAs and midwives travel to rural and remote villages to conduct antenatal classes for pregnant women and their husbands. These classes are essential when it comes to empowering the women most at risk. In 2010 approximately 2000 women attended.
Waiting house before delivery
During the training period midwives, medics and TBAs have contributed with valuable information about what problems the women from remote villages face. As a respond to this info, TCF – Cambodia has built waiting houses on the premises of 6 health centres. These houses enable expecting mothers to travel to the health centre some time prior to delivery, thus making the services at the HC more accessible. The health centres report a 30 – 100 % increase in deliveries after the waiting houses were built.
Cambodian health authorities consider implementing the concept of waiting houses in national policies.
TBAs – skilled or non-skilled?
The DLS database in Cambodia consists of comprehensive prehospital information on delivery complications. There is however, a mismatch between this recognition of TBA skills on the one hand – and TBAs being categorized as non-skilled birth attendants on the other hand, excluded from most traditional training programs in maternal care in Africa and Asia.
WHO’s definition of skilled birth attendants also affect Cambodian national guidelines. By 2010 TCF-C and TMC became aware of an increasing pressure from Cambodian health authorities on TBAs to NOT attend deliveries in their villages. The official policy is to fine or even imprison the TBAs, however at the same time these women are under dramatic pressure from villagers who persuade and threaten them to “catch babies” because there are no others alternatives. The working conditions for the TBAs are thus becoming increasingly worse without any improvement of delivery services for poor women in remote areas.
In stark contrast to international and national policy, the preliminary analysis from the first 3 years of training in Cambodia show a significant reduction in maternal and perinatal mortality in our catchment area. Interestingly enough the largest reduction was in the group of mothers being delivered by the TBAs. The findings indicate that TBAs are life savers, similar to our experience with first helpers in war trauma systems.