Factors influencing the retention of secondary midwives at health centres in rural areas in Cambodia: the role of gender-a qualitative study.

BACKGROUND: Retention of skilled midwives is crucial to reducing maternal mortality in rural areas; hence, Cambodia has been trying to retain at least one secondary midwife who can provide basic emergency obstetric care at every health centre even in rural areas. The factors influencing the retention of midwives, but not solely secondary midwives, have been identified; however, the security issues that affected female health workers during the conflict and the post-conflict years and gender issues have been unexplored. This study explores these and other potential factors influencing secondary midwife retention and their significance. METHODS: Sequential two-stage qualitative interviews explored influential factors and their significance. The first stage comprised semi-structured interviews with 19 key informants concerned with secondary midwife retention and in-depth interviews with eight women who had deliveries at rural health centres. Based on these interview results, in-depth interviews with six secondary midwives who were deployed to a rural health centre were conducted in the second stage. These midwives ranked the factors using a participatory rural appraisal tool. These interviews were coded with the framework approach. RESULTS: Living with one's parents or husband, accommodation and security issues were identified as more significant influential factors for secondary midwife retention than current salary and the physical condition of the health centre. Gender norms were entrenched in these highly influential factors. The deployed secondary midwives who were living apart from one's parents or spouse requested transfer (end of retention) to health centres closer to home, as other midwives had done. They feared gender-based violence, although violence against them and the women around them was not reported. The health workers surrounding the midwives endorsed the gender norms and the midwives' responses. The ranking of factors showed similarities to the interview results. CONCLUSIONS: This study suggests that gender norms increased the significance of issues with deployments to rural areas and security issues as negative factors on female health workforce retention in rural areas in Cambodia. This finding implies that further incorporating gendered perspectives into research and developing and implementing gender-responsive policies are necessary to retain the female health workforce, thereby achieving SDGs 3 and 5.

Socio-cultural change in conflict and post conflict settings: five decades of giving birth in Cambodia.

BACKGROUND: This paper explores the changing experience of giving birth in Cambodia over a 53-year period. During this time, Cambodian people experienced armed conflict, extreme privation, foreign invasion, and civil unrest. METHODS: An historical perspective was used to explore the changing place and nature of birth assistance given to Cambodian women between 1950 and 2013. Twenty-four life histories of poor and non-poor Cambodians aged 40-74 were gathered and analysed using a grounded thematic approach. RESULTS: In the early lives of the respondents, almost all births occurred at home and were assisted by Traditional Birth Attendants. In modern times, towards the end of their lives, the respondents' grand-children and great grand-children are almost universally born in institutions in which skilled birth attendants are available. Respondents recognise that this is partly due to the availability of modern health care facilities but also describe the process by which attitudes to institutional and homebirth changed over time. Interviews can also chart the increasing awareness of the risks of homebirth, somewhat influenced by the success of health education messages transmitted by public health authorities. CONCLUSIONS: The life histories provide insight into the factors driving the underlying cultural change: a modernising supply side; improving transport and communications infrastructure. In addition, a step-change occurred in the aftermath of the conflict with significant influence of extensive contact with the Vietnamese recognised. TRIAL REGISTRATION: None.

Weighing the options for delivery care in rural Malawi: community perceptions of a policy promoting exclusive skilled birth attendance and banning traditional birth attendants.

To address its persistently high maternal mortality, the Malawi government has prioritized strategies promoting skilled birth attendance and institutional delivery. However, in a country where 80% of the population resides in rural areas, the barriers to institutional deliveries are considerable. As a response, Malawi issued Community Guidelines in 2007 that both promoted skilled birth attendance and banned the utilization of traditional birth attendants for routine deliveries. This grounded theory study used interviews and focus groups to explore community actors' perceptions regarding the implementation of this policy and the related affects that arose from its implementation. The results revealed the complexity of decision-making and delivery care-seeking behaviours in rural areas of Malawi in the context of this policy. Although women and other actors seemed to agree that institutional deliveries were safer when complications occurred, this did not necessarily ensure their compliance. Furthermore, implementation of the 2007 Community Policy aggravated some of the barriers women already faced. This innovative bottom-up analysis of policy implementation showed that the policy had further ruptured linkages between community and health facilities, which were ultimately detrimental to the continuum of care. This study helps fill an important gap in research concerning maternal health policy implementation in Low and middle income countries (LMICs), by focusing on the perceptions of those at the receiving end of policy change. It highlights the need for globally promoted policies and strategies to take better account of local realities.

The commercialization of traditional medicine in modern Cambodia.

Globally, traditional medicine has long been used to address relatively common illness, mental ill health and during childbirth and post-natal care. However, traditional medicine is primarily provided by the private sector and it is unclear how far expenditures on traditional medicine contribute to household impoverishment. A life history method was used to understand the health seeking experience of 24 households over the last 60 years in Cambodia, a country with high out-of-pocket expenditures for health. The life histories suggest that traditional medicine in Cambodia has been undergoing a process of commercialization, with significant impacts on poor households. In the earlier lives of respondents, payments for traditional medicine were reported to have been flexible, voluntary or appropriate to patients' financial means. In contrast, contemporary practitioners appear to seek immediate cash payments that have frequently led to considerable debt and asset sales by traditional medicine users. Given traditional medicine's popularity as a source of treatment in Cambodia and its potential to contribute to household impoverishment, we suggest that it needs to be included in a national conversation about achieving Universal Health Coverage in the country.

Social movements and public health advocacy in action: the UK people's health movement.

There are growing calls within public health for researchers and practitioners working to improve and protect the public's health to become more involved in politics and advocacy. Such a move takes practitioners and researchers beyond the traditional, evidence-based public health paradigm, raising potential dilemmas and risks for those who undertake such work. Drawing on the example of the People's Health Movement, this short paper argues that advocacy and social movements are an essential component of public health's efforts to achieve great health equity. It outlines how the Scottish branch of the People's Health Movement sought to overcome potential tensions between public health evidence and advocacy by developing a regional manifesto for health via transparent and democratic processes which combine empirical and experiential evidence. We suggest that this is an illustrative example of how potential tensions between public health research and advocacy can be overcome, through bottom-up movements of solidarity and action.