Master’s Thesis

Traditional Practices and Cultural Perceptions

Concerning Reproductive Health among Rural
Cambodian Women

Department of International Cooperation Studies

Graduate School of International Development
Nagoya University

Student Number: 300302185

Name: HAK SOCHANNY
Academic Advisor: Professor TAKAHASHI KIMIAKI
March 2005

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 ACKNOWLEDGEMENTS

The accomplishment of this thesis owes a profound debt to a large number of generous
individuals and institutions. Amongst them, the greatest credit is extended to my academic
advisor Professor TAKAHASHI Kimiaki for his insightful advice, constructive guidance and
ongoing encouragement throughout the term of my study. My sincere thank goes to Mrs.
Melisanda Berkowitz who helped me to make my writing throughout the thesis
comprehensible and advised me about style of academic writing.

I am also highly appreciative of other professors in the Department of International

Development and Department of International Cooperation Studies, Graduate School of
International Development (GSID), Nagoya University, whose courses have added immensely
to my academic capital and shaped my subsequent learning.

I am deeply thankful as well to the Asian Development Bank (ADB) for the scholarship I
received for my two-year schooling at GSID.

At the field level, I am deeply thankful to Racha (Reproductive And Child Health Alliance),
and all the participants involved in this endeavor for kindly and extensively sharing their
invaluable time, knowledge and experience. I am further indebted to the advice and
facilitation of Mme. Sun Nasy, Racha deputy executive director and Dr. Sol Sowath, Racha
Kampot provincial coordinator. Thanks go to the organization, and especially to Angkor Chey
branch office, for helping me physically reach the sites, hosting me and graciously
introducing me to village people. Without this kind assistance, this study would never have
happened.

I am grateful for the cooperation of National Maternal and Child Health Center (NMCHC),
CDRI library, UNDP library, NPHI library and GSID library whose ample material resources
advantaged this research.

Sincerely, a special word of heartfelt thanks goes to my dear soul mate NGIN Chanrith for
advice and tireless guidance on conducting field survey and how to do research. Lastly, I
deliver my wholehearted acknowledgement to my family who always supported and
encouraged me to complete the study.

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 TABLE OF CONTENTS

Acknowledgements…………………………………………………………………………….. i
Table of Contents……………………………………………………………………………….. ii
List of Figures…………………………………………………………………………………... v
List of Tables…………………………………………………………………………………… vi
Glossary of Special Terminology………………………………………………………………. vii

CHAPTER ONE: INTRODUCTION

1.1 Introduction……………………………………………….……………………. 1
1.2 Formulation of the Problem……………………………….…………………… 3
1.3 Country Background……………………………………..…………………….. 3
1.4 Research Background………………………………………………………….. 4
1.5 Research Significance………………………………………………………….. 6
1.6 Research Objectives……………………………………………………………. 6
1.7 Research Questions…………………………………………………………….. 7
1.8 Research Methodology…………………………………………………………. 7
1.8.1 Research Design………………………………………………………………... 8
1.8.2 Data Gathering…………………………………………………………………. 9
1.8.2.1 Secondary Data Gathering……………………………………………………... 9
1.8.2.2 Primary Data Gathering………………………………………………………... 10
1.8.2.3 Data Collection…………………………………………………………………. 14
1.8.2.4 Data Analysis……………………………………………………………........... 15
1.9 Explanation of Term ‘Reproductive Health’…………………………………… 15
1.10 Outline of the Thesis…………………………………………………………… 16

CHAPTER TWO: THEORETICAL FRAMEWORK

2.1 Introduction……………………………………………………………………. 18
2.2 Conceptual Complexities of Health Care System……….……………………... 18
2.3 Practical and Conceptual Factors Inducing Health Seeking Behaviors………... 23
2.4 Discussion and Conclusion….………………………………………………..… 26

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CHAPTER THREE: OVERALL HEALTH STATUS, REPRODUCTIVE HEALTH AND
CULTURAL PERCEPTIONS

3.1 Introduction……………………………………………………………………... 28
3.2 Overview of the Health Sector………………………………………………...... 28
3.2.1 Budget Expenditure on Health Sector………………………………………….. 30
3.2.2 Health Sector Reforms……………………………….......................................... 32
3.3 Women and Reproductive Health Conditions…………………………...……… 35
3.3.1 Maternal Health and Mortality………………….……………………………… 35
3.3.2 Maternal Health at the Primary Level………………………………………….. 37
3.3.3 Abortion……..………………………………………………………………….. 38
3.3.4 Adolescent Fertility and Health Problems……………………………………... 38
3.4 Cultural Perceptions on Illness and Health Care……………………………….. 39
3.5 Cambodian Views Regarding Pregnancy, Delivery and Postpartum…………... 42
3.5.1 Views of Normality and Abnormality of Pregnancy…………………………… 42
3.5.2 Views of Normality and Abnormality of Delivery……………………………... 44
3.5.3 Views of Normality and Abnormality of Postpartum…………………………... 45
3.6 Conclusion…………………………………………………………………….... 47

CHAPTER FOUR: EMPIRICAL FINDINGS: THE FACTS OF TRADITIONAL PRACTICES

DURING PREGNANCY AND POSTPARTUM PERIOD

4.1 Introduction……………………………………………………………………… 49
4.2 General Information on Study Areas……………………………………………. 50
4.2.1 Characteristics of Health Center………………………………………………… 51
4.2.2 Characteristics of Villages in the Survey………………………………………... 53
4.3 General Characteristics of Informants…………………………………………... 54
4.3.1 Target Women…………………………………………………………………… 55
4.3.2 Traditional Birth Attendants (yeay mobs)………………………………………. 57
4.3.3 Trained Midwives of Health Centers…………………………………………… 58
4.4 Delivery Status…………………………………….............................................. 59
4.5 Traditional Practices…………………………………………………………….. 68
4.5.1 Maintaining Body Heat…………………………………………………………. 71
4.5.1.1 How ‘Lying by Fire’ is Done……………………………………………………. 74
4.5.1.2 Why ‘Lying by Fire’ is Done…………………………………………………..... 75
4.5.2 Traditional Medicines………………….……………………………………....... 79
4.5.3 The Use of Hot Rock…………………………………………………………..... 86
4.5.4 The Practice of Body and Face Steaming (spong)……………………………… 89
4.5.5 Injections………………………………………………………………………… 93

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4.5.6 Other Practices…………………………………………………………………... 96
4.6 Reasons behind Practices………………………………………………………... 99
4.7 Concluding Analysis of Traditional Practices Impact on Health………………... 102

CHAPTER FIVE: BRIDGING THE GAPS BETWEEN MODERN HEALTH CARE AND
TRADITIONAL HEALTH CARE FOR DEVELOPMENT

5.1 Introduction…………………………………………………………………….. 105

5.2 Traditional Beliefs and Practices Concerning Reproductive Health in
Developing Countries…………………………………………………………... 105
5.3 How Can Traditional Beliefs and Practices Concerning Reproductive Health
be Integrated into Modern Healthcare Policies?.................................................. 109
5.3.1 Women’s Perceptions of Traditional Practices…………………………………. 109
5.3.2 Health Staff’s Perceptions of Traditional Practices…………………………….. 113
5.3.3 Synthetic Discussion of Traditional Practices………………………………….. 115
5.4 Synopsis of Major Research Findings………………………………………….. 120
5.5 Recommendations……………………………………………………………… 122
5.6 Recommendations for Further Research……………………………………….. 129
5.7 Limitations of the Study………………………………………………............... 129

REFERENCES ……………………………………………………………….. 131

APPENDIX …………………………………………………………………… 141
KHMER TRADITIONAL MEDICINES USED DURING PREGNANCY
KHMER TRADITIONAL MEDICINES USED DURING POSTPARTUM
QUESTIONNAIRES SURVEY

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 LIST OF FIGURES

FIGURE 1.1: Research Methodology Employed in the Study…………………………… 9

FIGURE 2.1: Health Care System………………………………………………………... 23
FIGURE 2.2: Factors Influencing Health Services Utilization…………………………… 26
FIGURE 3.1: Funding of Health Sector By Source of Finance…………………………... 31
FIGURE 3.2: Illness Healing Process: A Traditional Decision Tree……………………… 41
FIGURE 4.1: Composition of Health Center Team………………………………………. 53
FIGURE 4.2: Linkage between Level of Education and Assistance during Delivery (n=60). 67
FIGURE 4.3: Traditional Practices (n=60)…………………………………………………. 70
FIGURE 4.4: Relationship of ‘Lying by Fire’ and Level of Education (n=60)……………. 79

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 LIST OF TABLES

TABLE 4.1: The number of Distribution of Sample by Age, Education, Number of

Pregnancy, and Number of Living Children………………………………….. 55
TABLE 4.2: Assistance during Delivery of 10 HCs in Angkor Chey District,
Kampot Province in the First Semester of 2004……………………………… 67
TABLE 4.3: Summary of Activities and Practices Mentioned by Women…………………. 71
TABLE 4.4: The Practice of ‘Lying by Fire’……………………………………………….. 79
TABLE 4.5: Medicines Used by Postpartum Women……………………………………… 96
TABLE 5.1: Traditional Practices from Women’s Perspectives……………………………. 112
TABLE 5.2: Traditional Practices from Health Practitioners’ Perspectives………………... 114

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 Glossary of Special Terminology

Catchment Area: Is the geographical zone surrounding the health facility under its
responsibility. The inhabitants of the area are the target population for the health facility.

Complementary Package of Activities (CPA):The referral hospital receives cases referred

from the health centers and manages complicated cases, operations, inpatients and serious
illness requiring admissions. Such services are referred to as the CPA.

Health Coverage Plan (HCP): The HCP is the national framework for developing the health
system infrastructure based on population and geographical access criteria, and standardized
health facilities and services.

Health Sector Reform: this is a comprehensive process of structural change in the financing
and organization of health services to strengthen the health system. The Ministry of Health
(MoH) began the process of reform in 1994 based on the fundamental principle of improved
access to health care for all of the population.

Kru Khmer: Traditional healers using traditional medicinal and/or ‘magical’ treatments or
health processes.

Kru peet or peet: Trained health care worker, refers to anyone with formal medical training
such as physicians, nurses, medical assistants, midwives, pharmacists, lab technicians.

Live birth: The complete expulsion or extraction from its mother of a product of
conception, irrespective of the duration of the pregnancy, which after such separation,
breathes or shows other evidence of life, such as beating of the heart, pulsation of the
umbilical cord, or definite movement of voluntary muscles, whether or not the
umbilical cord has been cut or the placenta is attached. Each product of such a birth is
considered live born.

Maternal mortality: Women who die while pregnant or during the 42 days, which follow the
pregnancy.

Maternal morbidity: Morbidity is the state of being sick. Maternal morbidity is therefore
understood as all diseases and disabilities caused by complications during pregnancy and
childbirth.

Maternal mortality ratio: The death of a woman while pregnant or within 42 days
of termination of pregnancy, irrespective of the duration and the site of the pregnancy,
from any cause related to or aggravated by the pregnancy or its management, but not
from accidental or incidental causes, expressed per 100 000 live births.

Operational District (OD): The OD is the most peripheral sub-unit within the health system
closest to the population. It is composed of the OD office, the OD referral hospital and health
centers. The OD office is managed by a Director, two Vice Directors and other staff. Each of
the Vice Directors are responsible for the referral hospital and the health centers.

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Postpartum: the words postpartum and postnatal are sometimes used interchangeably. The
postpartum period starts shortly after the birth of the placenta. It is supposed to last 42 days
after birth.

Primary health care centre or Health Center (HC): A centre that provides services
which are usually the first point of contact with a health professional. They include
services provided by general practitioners, dentists, community nurses, pharmacists
and midwives, among others.

Primary midwife: The length of training is one year and a high proportion of this category
work at district and health center level.

Sawsaye: ligaments, nerves, veins and fibers

Secondary midwife: The length of training is three years and this category work in all levels
of care. They also carry out private deliveries in the home.

Toah : Relapse: To fall back into illness after convalescence or apparent recovery; to fall back
into wrongdoing or error.

Traditional Birth Attendants (TBAs) or Traditional Midwives: A traditional birth

attendant (TBA) who initially acquired her ability by delivering babies herself or
through apprenticeship to other TBAs and who has undergone subsequent extensive
training and is now integrated in the formal health care system.

Women of reproductive age (or women of childbearing age): Refers to all women
aged 15 to 49 years unless otherwise specified.

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 Chapter One

INTRODUCTION

1.1 Introduction

This chapter commences with problem formulation, a brief background on the country and

research, research significance, objectives and questions. The following section explains the

research methodology applied in the study. The last section of the chapter discusses the term

‘reproductive health’ which is used throughout the study, and lastly provides an overview of

thesis organization.

1.2 Formulation of the Problem

The idea for the study was shaped by my previous work experience as a community and

capacity building program assistant at Reproductive and Child Health Alliance (Racha) which

was an international organization starting its health projects in 1996. In early 2004 it was

converted into a local non-government organization (NGO).

From 1999 to early 2003, I often attended activities relating to health education, particularly

focusing on improving women’s health and improving behavior of rural people toward proper

practices of health care. In all experiences, I observed that attitudes of health care of providers

towards cultural beliefs and practices could either positively or negatively influence women’s

compliance with the care offered.

By participating in many activities regarding health education, I became keenly aware of how

few women accessed the formal health care system during pregnancy, delivery and

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postpartum period. Many women came to provincial hospitals only when their problems

became severe and only after they had unsuccessfully tried to solve the problems at home.

The health outcomes these women were woeful; some died at home or on the way.

Ultimately, rural women face many life threatening problems especially in places where

public facilities and resources are limited.

1.3 Country Background

Cambodia is situated in Southeast Asia. Total population in 1998 was more than 11 million

(DHS 2000). It is located in the west part of the Indochina peninsula, and is bordered by

Vietnam, Laos, and Thailand. It is composed of 20 provinces, 193 districts and 1547

communes (DHS 2000). Cambodia has a tropical climate dominated by monsoon resulting in

distinct rainy and dry seasons. The country is a predominantly agrarian society with

approximately 80% of total population living in rural areas, and about 36% of people living

below the poverty line(Beaufils 2000).1 A recent survey pointed out that only 16.2% of rural

dwellers have access to health centers (ADB 2001).

Due to political instability and civil war, females outnumber males; the overall sex ratio is 92

males per 100 females (DHS 2000). The population has a large percentage of children under

15 years old (42.8%), while the percentage of population over 65 years is 3.5% (DHS 2000).

These figures indicate the high dependency ratio, and have implications for health

development.

1
Those who live under the poverty line is defined as those who spend less than $0.50 a day.

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According to the study by ADB 2001, about 92% of total deliveries were undertaken at home

of which 75% were handled by yeay mobs (traditional birth attendants) (ADB 2001). There

was wide variation between those living in rural areas where number of trained midwives is

limited, and those who live in urban areas. There is a shortage of trained health staff to work

at district and health center level, where approximately 3 trained midwives serve every 1,000

populations (Cambodia Yearbook 2000).

1.4 Research Background

Traditional beliefs in Cambodia2 is a mixture of Indian and Chinese medicine and spiritual
TP PT

animistic beliefs, although the exact origins of many concepts are uncertain (Chap &

Escoffier 1996). Cambodians believe in the spirit of trees and ancestors. In every village we

can see a small cottage of neak ta (ancestor spirit), and under trees there is also a small shrine

in the form of a cottage built from hay and containing some offerings. When people are ill

they pray and offer an offering3 to those spirits to beg their blessings for the sick person. Due
TP PT

to the strong influence of Chinese medicine, the human body is believed to be combined of 4

elements -earth, water, fire and wind. Many diseases are believed to be caused by wind (kjol),

while fire is used to cure the diseases. When a person dies, his/her body becomes earth and

water. The belief in hot and cold states of women’s body is strong. For instance, women are

believed to be in a cold state in the postpartum period, so postpartum women are covered with

thick clothes from head to toe in order to avoid wind which causes ill-health in their later age

(DHS 2000; White 1996). In contrast, during pregnancy, women are believed to be in hot state,

so they are advised to avoid eating or doing something believed to be hot (White 1996). So far,

2
TPSince the words ‘Cambodia’ and ‘Khmer’ are synonymous, I will use them interchangeably throughout the
PT

thesis.
3
TPOfferings for general spirits of trees or ancestors consist of bananas and incense. No money is included
PT

for these offerings.

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research on this field is very limited and only a few ethnographers have studied about these

beliefs (van de Put 1992; Ebihara 1968).

Traditional practices have been viewed as a major cause of maternal mortality in Cambodia

(White 1996; Kuhlman 2004; Jennifer 1997). However, the problem of maternal mortality is

very complicated and its causes are intricate, involving many factors (White 1996).

Traditional beliefs and practices on the part of pregnant women and yeay mobs are

questionable. Women believe that in order to gain good health condition in later age, during

pregnancy and postpartum they should perform several practices advised by their older

relatives. Yeay mobs perform several traditional practices during assisting birth and advise

women to practice what they believe are health-promoting behaviors.

Moreover, all practices of yeay mobs who have not been trained by trained health staff were

old habits that they adopted from one another. There are a few studies focusing on beneficial

practices of yeay mobs. For instance, Kuhlman (2004) recommended that some practices of

yeay mobs and kru khmers (traditional healers) are beneficial, such as yeay mobs’ skill in

massage to pregnant women during labor, and kru khmers’ skill in incantation for women

during labor and after birth.

Most of the extant information about Khmer beliefs and practices surrounding pregnancy

focuses either on Khmer refugees in camps along the Thai-Cambodian border or refugees

resettled in third countries (Choulean 1982; Douglas 1994; Frye 1989; Kulig 1989; Rice

1994; Sargent et al. 1983; Sargent & Marcucci 1988). A few studies based in Cambodia

included information about attitudes and practices related to birth are preliminary or

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evaluative studies performed by NGOs engaged in MCH projects (Biacabe n.d.; Healy &

Chandoravann 1994; Sonnois 1990). Moreover, the study of women in refugee camps and

those who resettled in third countries do not represent the current practices and beliefs of

Khmer women. Particularly, it is almost impossible to find studies of the beliefs and practices

of those who live in rural areas.

Women are believed to be in a hot state during pregnancy (White 1996). Thus, she has to do

everything in order to avoid being hot. The practices mainly concern food restrictions. The

postpartum period is noted for traditional practices associated with ang phleung or ‘lying by

fire’ or ‘roasting.’ The belief is that the birth leaves the mother cold and wet; mothers lie by

fire to warm their bodies and dry out their insides (White 1996; UNFPA 1999; Kuhlman 2004;

DHS 2000).

There are gaps in the available research on cultural beliefs and postpartum care. Studies

investigating the impact of culture on the postpartum period have mainly concentrated on

infant feeding in two villages in Cambodia (Kuhlman 2004), and breastfeeding and have been

conducted in countries such as China (Chee & Horstmanshof 1996), Australia (Gorrie et al.

1998), UK (Whelan & Lupton 1998). Most of these studies describe differences among

women who live in different countries.

Finally, scope for incorporation of cultural beliefs into health care in Cambodia has been

neglected, and it remains a key problem in health sector development. Consequently, I argue

that this study is significant in its attempt to maintain indigenous beliefs of local people

instead of replacing those beliefs by modern practices of health care, and in encouraging

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cultural rituals which are important factor to support women during pregnancy, childbirth and

postpartum (Fok 1996; Du 1998; Kaewsarn & Moyle 2000).

1.5 Research Significance

This research is significant in providing an understanding of traditional practices during

pregnancy, delivery and after delivery and their positive and negative effects on health of rural

Cambodian women. In addition to producing important recommendations and suggestions to

improve the health of the people, especially reduce maternal mortality and morbidity, and to

incorporate positive beliefs into the public health system, it suggests approaches which are

most effective for reaching the goal of reducing maternal mortality and morbidity.

While the research findings are of the Cambodian context, the researcher believes that health

care systems in other developing countries can draw some relevant and applicable lessons and

experiences from this study.

1.6 Research Objectives

The thesis explores the traditional beliefs and practices of rural Cambodian women regarding

health care during pregnancy, delivery and postpartum period, and explains culture-related

reasons behinds these beliefs and practices.

The exploration of traditional beliefs and practices is done through actual field survey. The

study assesses the impact of the beliefs and practices identified from the field survey on

mothers’ and children’s general health, based on perspectives of target informants. I argue that

traditional practices are not the main factors contributing to high maternal mortality rate in

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Cambodia. In fact, some traditional practices may be harmless and beneficial to health if they

are performed in appropriate ways.

The study also aims to understand these practices and the rationales underpinning such

practices. By understanding these culture-related reasons, it suggests ways to incorporate

positive beliefs and practices into the public health system and policies.

1.7 Research Questions

In order to respond to the above stated objectives, the study aspires to answer the following

questions:

① What health-related customs do rural Khmer women practice during pregnancy, delivery

and postpartum?

② How can these beliefs and practices be incorporated into the public health system and

policies in order to improve their reproductive health?

③ What are local people’s perceptions regarding traditional beliefs and practices and what

kind of recommendations can be made to NGOs and government agencies working in

related fields?

1.8 Research Methodology

A variety of methods were used to design the research and in data gathering and analysis. The

research employed the case study method, which is a qualitative research instrument to deal

with the research questions. The research approach involved a triangulation of secondary

materials review and empirical research consisting of: interviews with trained health workers

and the interviews with village women and yeay mobs, and informal talks with senior

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villagers of the study sites.

1.8.1 Research Design

As represented in Figure 1.1, the case study methodology utilized a qualitative approach and

was based on a triangulation of secondary materials review, empirical research and group

discussions and informal talks. The empirical research methods were a combination of

interviews with health service providers, yeay mobs and village women. In addition, group

discussions were held with target women who experienced child birth or pregnancy at least

once in their life times, while informal talks were held with relevant senior villagers, both

males and females.

This study used a descriptive research design to find out traditional beliefs and practices and

culture-related reasons behind those beliefs and practices concerning pregnancy, delivery and

the postpartum period among married women of reproductive age (MWRA)4 in rural areas.

The researcher employed both semi-structured interviews and open-ended interviews.

The research questions were explored through a synthetic analysis of actual field survey at

remote areas, Angkor Chey district, Kampot province. The primary aim of the interviews was

to discover the prevalence of current traditional practices surrounding pregnancy, delivery,

and postpartum and to identify the reasons behind those practices. By understanding the

common practices and common health perception of informants, the study aims to uncover

the values that underlay those practices and the scope for incorporating those practices into

modern health care.

4
MWRA are women aged 15 to 49 years old either formally married or not married and living in union
with men (consensual unions) (www.census.gov/ipc/wwww/wp96glo.html)

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 Figure 1.1: Research Methodology Employed in the Study

Secondary Data Review

Empirical Research Empirical Research

Interview with health service providers Interview with yeay mobs and women

Group Discussions
& Informal talks

Data Analysis

1.8.2 Data Gathering

1.8.2.1 Secondary Data Gathering

The secondary data review covered government and NGO materials, such as evaluation

reports, academic research papers, planning, training manuals, and annual reports. It was also

strengthened by reviewing the literature available from multiple sources. The literature review

aims to delve into health care practical experiences of rural people during pregnancy, delivery

and post delivery.

The discussions of the study are based primarily on the findings of White (1996) about

‘crossing the river.’ This phrase, directly translated from the Khmer phrase, states that when a

woman gives birth it is like crossing a river, and she faces many potentially life-threatening

problems. Simply put, the pregnancy, delivery and postpartum periods in very critical for

women’s lives. In White’s analysis, she notes that traditional beliefs and practices delay

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women from seeking health from public health services and health professionals.

In addition to existing literature review, especially journal articles from before 1997, the

writer was only able to access abstracts available in the university library.

1.8.2.2 Primary Data Gathering

Based on the literature review and theoretical framework constructed, three different kinds of

questionnaires consisting of semi-structured and open-ended questionnaires were developed

for village women, yeay mobs, and health workers. Discussions also concerned how the

traditional practices could be incorporated into public health policies how those behaviors

(positively and negatively practice) may have affected people’s health.

Four health centers of Angkor Chey Operational District were chosen, and eleven villages

were visited. In the meantime, 60 village women were interviewed individually, and 14 yeay

mobs and 7 trained health workers were also interviewed. Besides the individual interviews, 3

focus group discussions were conducted with a total of 18 participants.

At the beginning of the study, every woman and yeay mob was introduced to the researcher

by VHSGs (Village Health Support Groups). They were told about the objectives of the

research. They were assured that their words and perspectives would be used to improve

public health of their village and would not be used for any other objectives. I assured them

that their reflections on health services provided by health center staff would not affect their

relationship with health center staff. Moreover, I also assured the informants (especially

those who participated in group discussions) that they were free to leave the group or

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terminate the interview at any time, and that their names would not be linked to any written

presentation of data.

(1) Interviews with village women

Semi-structured and open-ended interviews, designated within the construct of the theoretical

framework, were held singly with village women. The aims of the interviews were to find out

what kind of practices they followed and what kind of restrictions they observed after delivery

and during pregnancy. Another intention was to find out how they felt about the current

practices (both traditional and modern). Lastly, the interviews also aimed to find out

perceptions of these women on using health facilities versus practicing traditional health care

at their homes.

Sixty women were interviewed, among them two women had just given birth a week before

the interview started.

Target women were screened from the VHSGs’ register books throughout this study and target

women interviews were conducted on a voluntary basis. In order to comply with the

objectives of questionnaires, subjects were required to fulfill all of the following criteria:

¾ Ethnically Cambodian;

¾ Cambodian language speaking;

¾ Married women of reproductive age and with a child under three years of age; and

¾ Women who are healthy and have healthy babies.

(2) Interview with Traditional Birth Attendants (TBAs): Yeay mobs

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Semi-structured and open-ended interviews were also held with each yeay mob. All yeay

mobs who were interviewed had more than 10 years’ experience. They were popular in their

villages and were recognized as primary health care providers for women. The interviews

aimed to probe their knowledge and practical experiences attending births and offering

postpartum care to new mothers, and their perceptions of modern health care. Also, the

interviews focused on advice they give to new mothers. They also aimed to identify

differences between the care provided by trained midwives and the care provided by yeay

mobs.

Fourteen yeay mobs were interviewed. There were no age guidelines for selection. Like the

target women interviews, yeay mobs had to be ethnically Cambodian and Cambodian

language speaking. Furthermore, all yeay mobs had to be currently practicing which was

defined as having attended as many deliveries as possible.

(3) Interviews with Health Practitioners

Similar types of interviews were conducted separately with health practitioners at national

level and health center level. The intent of the interviews was to obtain insights into

characteristics of traditional health care versus modern health care, health staff’s view of

health services, and the relationship between community and health care providers. Based on

the insights, the author aimed to develop recommendations and suggestions for improving the

health of the people.

Five health center trained midwives were interviewed about their practical experiences and

perceptions and also their perspective on future health care plans in the villages of the health

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centers’ catchment areas. In addition, one midwife who works for National Maternal and

Child Health Center (NMCHC) in Phnom Penh was also interviewed. Finally a health

practitioner who is responsible for community capacity building at Racha was interviewed in

order to get his opinions about the practice of health education, the relationship of villagers

with their health center, how health centers have implemented their activities and in which

ways people can participate in health improvement.

The criteria for selection of trained health center midwives were similar to criteria for

selection of target women, but the selected midwives were required to have some experience

in attending home births. There was no age guideline for choosing trained midwives.

(4) Group Discussions and Informal Talks with Senior Villagers

Group discussions and informal talks were conducted separately. Group discussions were

done with women who experienced birth or pregnancy at least once in their lifetimes.

Selection criteria for participants in the group discussions were similar to the selection criteria

for individual interviewees, but there was no age guideline for the participants.

Informal talks surrounding general health conditions were conducted among relatives of target

women such as mothers, senior relatives and husbands, and also with health staff. This was

also to note the overall perceptions of health services compared with traditional practices. Any

senior villager who had experience with childbirth was encouraged to participate in the talks.

In order to find out the socioeconomic status of each informant, all individual interviews and

focus group discussions began with conversation about the most obvious and natural subject

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at the moment, rice cultivation, and other productive work in villages. I tried to elicit from

participants their households’ expected rice yields and land holdings. An expected and usual

surplus of rice indicated the informant was rich. Just enough food for the family for the year

indicated a medium family. An expected and usual shortfall in rice supply for the family

indicated the family was poor. The interviewer then attempted to shift the conversation to the

subject of study based on the questionnaire form.

1.8.2.3 Data Collection

Three focus group discussions were held during the data collection. These groups were held in

three health centers, Champey, Damkom and Dambok Kpos health centers, with one group

discussion for each health center. A total of 18 women participated in the 3 groups. Each

group had between 5 and 7 participants and lasted on average one hour and thirty minutes.

Eighty one individual interviews were conducted in which sixty target women, fourteen yeay

mobs, five health center trained midwives, one chief of nurse division in NMCHC and one

Racha staff member were interviewed. These interviews lasted approximately one hour each.

VHSGs helped to arrange meeting places for the groups and to gather participants. Focus

group discussions and individual interviews with target women and yeay mobs were most

often carried out during midday or early afternoon, during the time after the women had eaten,

when they usually took a midday rest. The individual interviews with trained midwives and a

midwife of MNCHC and Racha staff were conducted during working hours.

Focus group discussions were held under trees and beneath the houses. Some target women

informants who initially agreed to participate in the study withdrew once they understood my

- 14 -
detailed aims. Apparently some of them feared that I was a government agent, despite my

assurance to the contrary. Some women informants had to cut the interview short because of

some interruption in their attention, such as a crying child.

Over four hours and thirty minutes of group discussions were audio-taped. Individual

interviews with trained midwives and the staff of NMCHC and Racha were recorded on more

than seven hours of audio tape.

Prior to the actual study, I contacted the Racha deputy executive director in Phnom Penh and

provincial coordinator in Kampot branch office to discuss about the procedure of the study

and to select study areas. Under facilitation of the provincial coordination, I was able to meet

with the deputy head of the provincial health department, and later with the director of

Angkor Chey Operational District, to tell them about the objectives of the study and ask

permission for conducting the survey. Then I stayed for nearly three weeks at the Angkor

Chey district, Kampot province, and traveled to villages of the study areas in the morning and

returned in the evening, by mainly motorcycle as the main transportation.

1.8.2.4 Data analysis

Qualitative analysis is used to analyze the result of research. Factual and perceptual data

derived from informants’ responses, the author’s observations and informal talks were

analyzed qualitatively through content analysis. The analysis of related secondary data is

mainly presented in narrative description.

- 15 -
1.9 Explanation of the Term ‘Reproductive Health’

Reproductive health is defined as: “a state of complete physical, mental and social well-being

and not merely the absence of disease or infirmity, in all matters relating to the reproductive

system and to its functions and processes. Reproductive health therefore implies that people

are able to have a satisfying and safe sex life and that they have the capacity to reproduce and

the freedom to decide if, when, and how often to do so. Implicit in this last condition are the

rights of men and women to be informed and have access to safe, effective, affordable and

acceptable methods of family planning of their choice. It also includes the right of access to

other law, and the right of access to appropriate health-care services that will provide couples

with the best chance of having a healthy infant. It also includes sexual health, the purpose of

which is the enhancement of life and personal relations, and not merely counseling and care

related to reproduction and sexually transmitted diseases.” (WHO 2002:1).

The respect of, reproductive health covered by this study is women’s health during pregnancy,

delivery and postpartum period. The health of women during these periods is important and

requires great attention from all health sectors -popular sector, professional sector and folk

sector (see chapter 2 for the details of each sector).

1.10 Outline of the Thesis

This paper comprises five chapters. Each chapter deals with various elements of the study as

follows.

Chapter 1 starts with country background, research background, research significance,

research objectives and questions, and research methodology, triangulation of secondary data

- 16 -
review, empirical research and informal talks with senior villagers. The chapter ends with

explanation of the term ‘reproductive health’ and outline of the thesis.

Chapter 2 explains a two-faceted theoretical framework on health care systems and factors

affecting health seeking behaviors of Cambodian people. Firstly, it discusses the health care

system model adapted from the Kleinman model (1980). Second, it probes factors affecting

health seeking behaviors of Cambodian people. This model is adapted from van de Put

(1992).

Chapter 3 provides a macro analysis of Cambodia’s health status, reproductive health and

cultural perceptions, primarily examining the historical context of health sector reforms, and

women’s health status. The analysis specifically gives a background insight into health

conditions in Cambodia, which is essential for comprehension of actual context of the study.

Chapter 4 discusses empirical findings of the study which consist of identifying traditional

practices surrounding pregnancy, delivery and postpartum. The chapter also deals with

analysis of impacts of those practices on the health of women.

Lastly, chapter 5 discusses studies of traditional practices from many developing countries. It

discusses the traditional practices of rural Cambodian women by comparing them with

traditional practices in other countries in an attempt of identify practices which are harmless

and/or beneficial for women’s health. Finally, the chapter presents conclusions based on the

results of the discussion and provides recommendations for improving health of Cambodian

women in rural areas. It also pinpoints areas for further studies and notes the study’s limitations.

- 17 -
 Chapter Two

THEORETICAL FRAMEWORK

2.1 Introduction

This chapter analyzes the theories which useful for investigating existing traditional health

practices in Cambodia, in particular in rural areas, and to highlight significant factors

affecting health seeking behavior of Cambodian people. The theories are chiefly derived from

Kleinman’s (1980) understanding of health care systems and van de Put’s (1992) shadowing

health seeking behaviors of Cambodians and their influential factors. The two models aim to

respond to several questions. Firstly, what is the health care system? And what factors

determine health seeking behaviors in Cambodia? Lastly, how do the factors intertwine with

one another? The two models are treated separately as the first model depicts the overall

health care system within a generic realm, while the second model applies solely to the

Cambodian health context.

2.2 Conceptual Complexities of Health Care System

In most societies people suffering from physical discomfort or emotional distress have a

number of ways of helping themselves, or of seeking help from other people. They may, for

instance, decide to rest or take a home remedy, or ask advice from friend, relatives or

neighbors, or consult with local health practitioners, traditional healers or elders, or whatever

is available and accessible to them. It is not uncommon for Cambodians to follow one or two,

or all, of the above steps. In different locations, the therapeutic options available differ

according to location, and the individual’s ability to pay. Some rich people prefer to get

treatment from modern health practitioners, while the poor prefer to seek treatment from the

- 18 -
available resources around location they are living prior to accessing modern health services

which require expenditure on both transportation and treatment fees.

The concept of health care system was defined by Kleinman (1980) related to cultural

perceptions of clients and the methods of treatment. He argued that health care systems as

well as beliefs about sickness are cultural constructions, shaped distinctly in different societies

and in different social settings within those societies (Kleinman 1980:38). The treatment of

disease is different from culture to culture; it is sometimes coincident with modern practices

of treatment.

Health care systems are both the result of and conditions for the way people react to illness in

social and cultural settings and include beliefs and patterns of behavior which are governed by

cultural rules. He asserted that the study of those systems can lead to understanding of how

people in a particular setting think about health care (Kleinman 1980). He also affirmed no

one knows whether traditional health practices have had positive effects on public health,

since only their negative influences have been documented.

He identified three overlapping and inter-connected sectors of health care - the popular sector,

folk sector, and professional sector. He noted that each sector has its own ways of explaining

and treating ill-health, defining who is the healer and who is the patient, and specifying how

healer and patient should interact in their therapeutic encounter. Similarly, others’ studies in

Cambodia showed that health seeking behaviors contained three different types which are

self-treatment, treatment from local villagers (kru khmer), and lastly, the treatment from

modern health practitioners (van de Put 1992; DHS 2000; Yanagisawa et al. 2004). In

- 19 -
Cambodia, normally, the practice of self-treatment is influenced by the family, especially

senior relatives such as grandfather, father, grandmother, mother and so on. The senior

relatives are considered to be knowledgeable about disease treatment, specifically treatment

by home remedies.

As illustrated in Figure 2.1, all sectors can possibly coincide and influence each other. The

popular sector disseminates some of the beliefs of both professional and folk sectors and

borrows practices from them.

The professional sector is composed of the organized, legally sanctioned healing professions,

such as modern Western scientific medicine. It includes not only physicians of various types

and specialties, but also the recognized para-medical professions such as nurses, midwives or

physiotherapists. In Cambodia, this sector refers to the public and private health care system

run by persons with medically training, known as kru peet, such as primary nurses, secondary

nurses, primary midwives, and secondary midwives. In this sector pregnancy and delivery are

regarded as having intrinsic biological risks which require effective management by scientific

knowledge and technology. Medical complications are viewed as based on cause and effect

relationships (White 1996). Treatment in this sector is often influenced by western medical

practices, and often contradicts the local beliefs of villagers who maintain strong traditional

beliefs and practices.

The folk sector comprises individuals specializing in both sacred and secular forms of healing,

or a combination of the two. These healers are non-professional health care providers and are

not part of the official medical system. The common healers in this sector are known as kru

- 20 -
khmers (traditional healers, who treat all types of disease) and Yeay Mobs (traditional birth

attendants, who specialize only in delivery). The practitioners in this sector consider

pregnancy and delivery as a vulnerable time during which women must be protected from

dangerous spiritual forces, and harmony and balance must be maintained to ensure both

maternal and fetal health (Choulean 1982; Hansen 1988 cited in White 1996).

The popular sector is a non-professional, non-specialist domain of society, where ill-health is

first recognized and defined and health care activities are initiated. It includes all the

therapeutic options that people utilize, without any payment, and without consulting either

folk healers or medical practitioners. Among these options are: self-treatment or

self-medication, advice or treatment given by a relative, friend, neighbor, monk,5 and village

elders. In this sector the main provider of health care is the family. In addition, the main

providers of health care in the family are women, usually mothers or grandmothers. They

diagnose most common illnesses and treat them with the materials at hand (Chrisman 1977).

The popular sector is the biggest sector and provides other sectors with experience of

treatment based on cultural beliefs. In Cambodia, the treatment process in this sector

sometimes takes place as a collective activity. Senior people are thought to be knowledgeable

about disease treatment. When people are ill, they seek treatment from their relatives or try

their own home remedies. In case that illness is not cured, they seek further treatment from

kru khmer. In rural areas seeking treatment from the professional sector is the last resort that

they would consider (van de Put 1992).

5
Monk is a Buddhist follower; he is well-known among villagers in his village. He is expected to know
everything. Some monks can perform healing (i.e., provide spiritual incantation), and some can tell
fortunes.

- 21 -
Moreover, in Cambodia the popular sector preponderates over other sectors, as in most

developing countries. The professional sector has less influence in rural areas than the folk

sector. However, if the professional sector is strengthened, its influence may increase. The

popular sector shares some of the beliefs of both the professional and folk sectors and

borrows practices from both. Simultaneously, providers of the professional sector are affected

by beliefs of the popular and folk sectors.

In short, according to Kleinman, health care systems are the result of and conditions for the

way people react to illness in social and cultural settings and include beliefs and patterns of

behavior which are governed by cultural rules:

Closely related to the health value structure is the influence of culture on the
experience of illness. For, though disease occurs as a biological and psychological
phenomenon that may or may not have cultural determinants, illness is experienced
as a personal and social reality. That is, illness is in large part a cultural
construct…Culture may significantly affect symptom formation, as well as
psycho-physiological processes in and reactions to illness (1978:417)

According to Dooher and Byrt (2002), the concept of health is both difficult to define and

difficult to measure, due its complexity and the variations in perception from cultural, social

class and location perspectives. The World Health Organization considers health as a state of

complete physical, mental and social-well being and not merely the absence of disease or

infirmity (WHO 2002). Still, the perceptions of patients about health and context in which

occurs are not included in WHO’s definition (Dooher & Byrt 2002). However, Kleinman’s

model and arguments support the idea that health issues require attention to both

psychological and physiological factors.

- 22 -
White (1996) argues that pregnancy is not the absence of complications or disease, while

Kleinman’s (1980) model provides a way to view pregnancy as a physiological condition

whose meaning is shaped by the culture in which it occurs. The ways women view pregnancy

and its complications are cultural-related. For instance, a postpartum woman with high blood

pressure might still follow the general practice of ‘roasting.’ At the same time, she might

suffer from pre-eclampsia. Her relatives may not notice this; instead they think that the

woman has been defeated by spirits who made her ill, and therefore the first treatment they

would find is from kru khmer or yeay mob. Sometimes, kru khmer or yeay mob would be

able to cure the disease, and sometimes more commonly they were ineffective.

Figure 2.1: Health Care System Individual based

Family based
Socially based
Popular Sector
Community based

Run by public and

Non-professional health care
private health care
delivers, including
Professional Folk Sector traditional healers,
Sector traditional birth attendants
(TBAs) or yeay mob.

Source: Adapted from Kleinman’s model (1980).

2.3 Practical and Conceptual Factors Inducing Health Seeking Behaviors

Apart from the health care system adapted from Kleinman’s model, health seeking behavior is

another framework which expresses the preferences in finding health treatment. The

framework is adapted from van de Put (1992), an ethnographer who conducted a study in

- 23 -
Cambodia in 1992 to investigate Cambodian people’s behavior in utilizing health services, in

both urban and rural areas.

Drawing from figure 2.2, there are two factors influencing people’s behavior toward health

care: exogenous and endogenous factors.6 Exogenous factors refer to factors that have to do

with the characteristics of the various sectors. They comprise resources, health workers, and

location of public health service. They externally influence the behavior of people in seeking

health care. For instance, some health centers do not have enough health staff, or health staffs’

attitudes toward clients are unfavorable. Some health centers are located very far from

villages which makes it difficult for clients to reach them. Because of such exogenous factors,

thus, clients may decide to take home treatment or look for treatment from other sources

besides public health services.

Conversely, endogenous factors deal with characteristics of the population –the Cambodian

people in rural areas. It refers to demand for health services, distance to health center, cost of

services, reliability of services and lastly culture-bound attitudes. For example, some health

staff started to work at the health center only after the health center was constructed, and some

of them are assigned to work in the health center even though they do not know well about its

location. Moreover, some health staff, who have just started to work for the health center,

have less experience in providing services as they have just finished training. This poses the

barrier of reliability of service quality. Compared to those new practitioners, yeay mobs have

a wealth of experience in assisting birth and they are well-known in their villages.

6
For more details about the factors influencing health care behaviors of people, see van de Put (1992).

- 24 -
Analysis of the two types of factors should clarify the reasons for low use of health services

(particularly services regarding maternal health) among rural villagers, as well as ways that

health centers could improve their services. Many health centers were constructed as a result

of the health coverage plan of MoH in 1996. Yet each health center still faces great shortages

of materials and equipment. As a result, it is difficult to deal with cases from villages. Further,

health center staff refer women to referral hospitals which are very far from their own village.

The whole process of using public health services is slow, therefore, many people prefer the

local resources which they feel are sometimes helpful. Other reasons are interrelated with

cultural attitudes of people using the service. As van de Put mentions, a culturally bound

attitude, i.e. the preference of staying at home when ill, affects people’s behavior in accessing

assistance from public health services. In addition to the shortage of resources at health

centers, the characteristics of health service users can contribute to the low rate of utilizing

health services at health center level.

The study focuses on traditional practices still practiced by the majority of Cambodians.

Beliefs and practices regarding pregnancy, delivery and postpartum are seen as being

concurrently affected by both biomedical (professional sector) and socio-cultural (folk and

popular sectors) perspectives.

- 25 -
Figure 2.2: Factors Influencing Health Services Utilization

Health Services Utilization

Exogenous Factors Endogenous Factors

Equipment and materials Culture-bound

of health center
Socio-economic
Health workers’ skills problems
and attitudes
Unreliability

Coverage areas
Felt need of freedom
of health center

Cost, distance, waiting

Source: Adapted from van de Put 1992 time

2.4 Discussion and Conclusion

This chapter focuses on the identification of practical and conceptual determinants which may

contribute to persistent traditional health practices and beliefs adhered to by local villagers.

The determinants have been dealt with in light of the health care system model developed by

Kleinman (1980) and the health seeking behaviors model advocated by van de Put (1992).

Kleinman (1980) views health care systems as cognitive, affective and behavioral

environments7 which are culturally constructed. Individuals’ methods of treatment may vary

as they do not share the same perception of and response to their socio-cultural environment,

and their tacit knowledge and value-orientations may differ considerably.

7
Environment determinants include: geography; climate; demography; environment problems, such as
famine, flood, population excess, pollution; agricultural and industrial development; and so forth
(Kleinman 1980).

- 26 -
Beliefs and practices regarding health care during pregnancy, delivery and the postpartum

period could be influenced by both the biomedical (professional sector) and socio-cultural

(folk and popular sectors) perspectives. Kleinman’s model precisely provides an insight into

complex interactions of the three sectors (popular, folk and professional). The popular sector

is the most dominant domain within the system, while practitioners of the professional sector

are also influenced by beliefs of the folk and popular sectors.

The other focal point of this chapter is to consider the practical and conceptual feasibility of

incorporating traditional practices which are harmless and/or beneficial into modern health

care services pertaining to pregnancy, delivery and postpartum care. In order to examine the

possibilities of integration, it is necessary to have an extensive understanding of local

subjects’ health care. The health seeking behaviors model advanced by van de Put (1992)

describes ‘push and pull’ factors of public heath services utilization within the Cambodian

context. The exogenous and endogenous determinants afore-presented are deemed pivotal in

probing for approaches to turn beneficial informal health practices into formal ones as well as

to refine the formal health system to gratify indigenous needs in a more efficient and effective

manner.

All in all, this chapter prepares a solid theoretical ground for the present study to delve into.

Put another way, the current research questions fall within the conceptual framework of the

two models. While Kleinman (1980) illuminates to the grasp of the diverse sectors in the

intra-woven health care system, van de Put (1992) sheds light on exogenous and endogenous

elements to health seeking behaviors. Notwithstanding, it is crucial to comprehend the formal

health system of Cambodia. This is covered by the chapter to follow.

- 27 -
 Chapter Three

OVERALL HEALTH STATUS, REPRODUCTIVE HEALTH AND

CULTURAL PERCEPTIONS

3.1 Introduction

This chapter’s focus is threefold. First, it provides an overview of the health sector in

Cambodia, noting reforms in the sector over the past decade. Alterations within the overall

policy and budget framework of the sector are highlighted. Second, the chapter examines

Cambodian women’s reproductive health, discussing maternal health-related issues. Finally,

cultural perceptions concerning pregnancy, delivery and the postpartum period are analyzed.

In brief, this chapter offers insights on the reproductive health of Cambodian women within

the overall health sector, noting the roles of relevant cultural perceptions.

3.2 Overview of the Health Sector

Cambodia encountered more than two decades of disastrous civil war. As a consequence, the

health of the population is among the worst in the world. The country is severely short of

medical facilities and qualified professionals. During the Pol Pot regime (1975-1979), in

particular, hospitals were abandoned, medical equipment ruined and trained medical staff

were killed or died of hardship.

In the wake of the collapse of the regime, there remained only forty-five physicians in the

country of approximately six million people (Ross 1990; Heng & Key 1995). Ordinary people,

both literate and illiterate, were trained to be medical staff during the 1980s, but, their skills

and qualifications were highly questionable (Heng & Key 1995). The shortage of medical

- 28 -
staff and facilities has attributed to the poor health of the populace and in part encouraged

them to believe in supernatural powers in treatment of diseases.

During the 1990s, the government of Cambodia started to receive development assistance

from various international donors to improve the overall health of the people.

Non-governmental organizations (NGOs) have been one of the chief actors within this effort.

In 1994, for example, there were 71 NGOs (among 130 NGOs operational in Cambodia)

working on health issues, and they consumed 28% of the total budget allocated for health

sector development (Ngin 2000).

Notwithstanding, the government’s budget expenditure on health is low if compared with

such other areas as defense and education (MoH, WHO, DFiD & NORAD 1999). For

instance, the defense sector consumed 48.4% and 52.2% of the total budget allocation of the

government in 1994 and 1996 respectively, whereas the health sector received a mere 7.2%

and 8% respectively. Consequently, the bulk of expenditure on health care is shouldered by

individual households. Beaufils (2000) estimates that individual households are responsible

for 75% of total health expenditure. Though public health services are supposed to be free for

all, unofficial payment is demanded by many medical staff (Yanagisawa et al. 2004). Further

to the high fees, transportation cost is another barrier which deprives the poor of access to

services. Yanagisawa et al. (2004) and Wim et al. (2004) reveal that in some rural areas

transportation costs are higher than treatment fees charged by health centers.

- 29 -
3.2.1 Budget Expenditure on Health Sector

The Cambodian health system is financed by various sources, namely government, donors

and individuals. Referring to Figure 3.1, the health sector subsidy from the government

comprises a relatively small portion, while the majority of the expense is from people’s own

money (Tim 2002). In 1999, the government budget on health consumed only 1.1% of GDP,

which is about $2.858 per person (World Bank 1999; MoH 1999 & 2000; Espinoza & Bitran

2000; Mean et al. 2001).

There are various reasons behind the low allocation of government budget for the health

sector. According to Mean et al. (2001), firstly, the greater part of expenditure goes for

defense, which consumes more than 50% of GDP. Secondly, the tax revenue is low; therefore,

the government does not have enough budget to support the health sector. Thirdly, other

relevant ministries, such as the Ministry of Women’s Affairs and Veterans, have their own

budget for implementing health-related activities. Another subordinate reason is that the

government allocates a portion of budget for overseas medical treatment of high-ranking

officers, although there is no precise estimation of such allocation. To sum up, the state budget

expenditure on health is sparse. It is insufficient to improve the general health of the public,

and individuals have to spend their own pocket savings to access health care.

According to Beaufils (2000), the burden of health care expenses, as measured by the ratio of

cost of average health service contact to household non-food expenditure per capita, is greater

for the poor than the non-poor. Just one outpatient visit to a health center or referral hospital

consumes a third of a year’s non-food spending for those who are the poorest, whilst an

8
According to 1999 exchange rate, $1.00 = 3,800 Riels (Riel is Cambodian currency)

- 30 -
inpatient visit to a public facility costs more than twice as much as one year’s non-food

spending (MoP 1999). Consequently, some people prefer self-medication or treatment by

local resource people (such as traditional healers) to professional curing as the former way is

less costly, though it is at times ineffective.

The government must increase budget expenditure on health in order to provide sufficient

health care to all people, especially those who live in rural and remote areas. The increase in

government budget expenditure will help to lessen the cost of utilizing public health facilities

incurred by individual households and ultimately improve accessibility to public health

services in rural and remote localities.

Figure 3.1: Funding of Health Sector by Source of Finance

43 52 125 102
96
115
257
269
Riels (Billion)

884 968
1058
575

1996 (HDS) 1997 (SES) 1999 (SES) 2000 (DHS)

Out of pocket Donors GoC

Sources: Tim 2002

Notes: HDS: Household Demand Survey; SES: Socio-Economic Survey; DHS: Demography
Health Survey; GoC: Government of Cambodia

- 31 -
3.2.2 Health Sector Reforms

The Royal Government of Cambodia (RGC) has made tremendous progress in ameliorating

the health of the population since the Pol Pot regime was deposed (RGC 1997). Major

improvements in the well-being of the people have been made possible due largely to

committed and continuous assistance from the international donor community.

The government’s first achievement has been health sector reform. Before the health sector

reform took place, people faced more difficulty in accessing health care because of the long

distance to health facilities and high costs of using health care. In response to the poor health

of the populace, in 1996 the Ministry of Health launched a Health Coverage Plan to redress

infrastructure shortcomings of the Vietnamese-modeled system installed in the 1980s. This

plan is based on fundamental principles of equity through improved access to health care for

all of the population (MoH 1999a). It called for division of Cambodia’s 22 provinces into 69

operational districts, 67 referral hospitals, 8 national hospitals, and 935 health centers (MoH

2001). Thus, the entire people are to have rational and equitable access to basic health and

referral services. Each operational district (OD) covers a population of 100,000 to 200,000

habitants and contains one referral hospital and a network of 10-15 health centers which serve

a population of 10,000 people each. Every health center should be situated within a radius of

5 to 10 kilometers, equal to 1 to 2 hours walk (MoH 1996). It is staffed with 5 to 7 people and

provides outreach services to local community (MoH 1999a).

The Health Coverage Plan portrays the structure of health care at the operational district level

and sketches out the process of service delivery. It has included a Minimum Package of

Activities (MPA) provided by health centers. The MPA contains basic preventive, promotive

- 32 -
and curative care. The health centers provide services to local community. Another service

delivery is Complementary Package of Activities (CPA) provided by the district referral

hospital. Each referral hospital receives cases referred from the health centers and manages

complicated cases, operations, inpatients and serious illness requiring admission (MoH &

WHO 1997).

The reform requires a redefinition of roles, functions and criteria for location of each level of

health system, and a health financing policy to improve access and equity of services for the

poor (MoH 1999a). It also requires the incorporation of all vertical health programs at district

and commune levels, and the decentralization of authorities and responsibilities to

district-level health supervisors.

User fees for public health services were introduced by the MoH in 1997 (MoH 1996a). It

opened the way for cost-sharing and was a very important event in moving away from the

official policy of free health services, but in practicality the primary stakeholders have

received very limited services. One visit with 3 days of medication costs 500 riels

(approximately $0.139) (Yanagisawa 2004). This price is reasonable for most people in rural

areas, and there is also a fee exemption scheme for the poorest. The user fee scheme aims to

improve staff salary and expand of quality and quantity of services provided. According to the

national guidelines, the central rule is that 99% of revenue is kept at the facilities, of which

49% is included as the staff salary and 50% is used for operational items, while only 1% is

given to the treasury to ensure that a report of fees is received at the central level (Health

Economics Task Force 2000).

9
$1 = 4000 riels, according to 2003 exchange rate.

- 33 -
A Human Resource Development (HRD) plan (1996-2005) was developed by the MoH. The

implication of HRD activities with the process of health sector reforms involves three

important aspects, namely planning, training and management (MoH 1999a). A Health

Information System (HIS) has accordingly been established to support and maintain the

reform process, in areas such as implementation of a new drug distribution system, which is

essential for the functioning of the health system. The report from HIS is used for planning

health coverage, determining priority locations for development, resource allocation, and

wide monitoring of activities.

To sum up, the results of health sector reforms have had great effects on the health system.

However, the reform process has met with some criticism by both external observers of the

process and those working within this changing health system (Grove et al. 2002). The

practice of user fees has had a serious effect on the health of the poor. Although, the price is

considered affordable by all people, some poor people cannot access health care from public

facilities.

Another problem which has an important impact on use of health services, is the health center

staff’s salary. The salary of these government staff is very low, which makes it difficult to feed

their family. The overall monthly salary of a doctor working at a provincial hospital is US$24,

while that of a highly trained midwife or nurse is approximately US$12 (White 1996). This

insufficient salary of the staff is one reason for their negative and unfriendly attitude when

providing services to clients. Some staff run their own clinics and do not come to work

regularly.

- 34 -
This is another problem that the MoH should take into consideration in attempts to improve

the public health system. Put another way, the health sector reform per se will not culminate

in adequate improvement of the poor’s health unless the government increases the budget

allocation to the health sector and provides enough incentives to health staff at all levels.

As a result of the health sector reform, many public health facilities have been constructed,

yet the utilization of services is still low (MoH 2000a). According to a report on performance

of the health sector, many services have been made available to all people. Nevertheless, the

general usage of services is still unsatisfactory, in fact the percentage of clients employing

services at public health facilities has decreased, from 30% in 1997 to 23% in 1999 (MoP

1999).

Furthermore, the health sector reform focuses on the overall infrastructure and restructure of

management and gives little consideration to women’s health issues. Women and their

reproductive health conditions require greater attention from stakeholders at all levels. The

relevant stakeholders should better understand the actual health conditions of rural women.

Sound policies concerning women and their cultural beliefs in health care practices need to be

deliberately developed if we are to improve their reproductive health.

3.3 Women and Reproductive Health Conditions

3.3.1 Maternal Health and Mortality

According to the World Health Organization, maternal death is the “death of a woman while

pregnant or within 42 days of termination of pregnancy irrespective of the duration and the

site of pregnancy, from any cause related to or aggravated by the pregnancy or its

- 35 -
management” (WHO 1993 as cited in van der Paal & Chan 1999:3).

Maternal health conditions in Cambodia are among the poorest in the region. Moreover, the

statistical data system for recording the number of deaths during and after delivery is not

reliable, and the actual number of deaths is still very questionable (UNFPA 2000). Maternal

mortality rate is 473 per 100,000 live births (DHS 2000), while the average rate in the region

is 120 per 100,000 live births (MoH 1999b). This means that for every 1000 births there are

four women facing a high risk of death. Main causes of death are from illegal abortion,

eclampsia10 and haemorrhage (DHS 2000; UNFPA 2000). The other causes, like frequent

pregnancy, inaccessibility of health facilities and complications of births, are believed to be

common causes of death among the poor. Besides these major causes of death, malnutrition

caused by poor dietary practices resulting from poverty and cultural restrictions on many food

items during pregnancy is also another important cause which requires immediate

interventions (UNFPA 2000).

Health information regarding the levels and patterns of maternal mortality from health

facilities (i.e., health centers and referral hospitals) is extremely inadequate scientifically

(UNFPA 2000). Consequently, it is difficult to identify the exact causes of death and define

what sort of intervention is required, though many efforts have been made already to reduce

this high rate of maternal mortality. Community involvement in the Health Information

System is of importance to report more concrete health problems so that community health is

promoted in a more efficient and effective way.

10
Eclampsia is known as ‘Preay Kralah Phleung’ in Cambodian language.

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3.3.2 Maternal Health at the Primary Level

Availability of primary health care among rural women is very limited. Only around 38% of

pregnant women get antenatal care from trained midwives and only 28% are delivered by

these professionals (DHS 2000). In Cambodia, midwives are considered the main providers of

antenatal care services. In addition to trained midwives, traditional midwives or Traditional

Birth Attendants (TBAs)11 also play a crucial role in providing services regarding antenatal

care, delivery and after-delivery care. Almost 66% of babies are delivered by TBAs (DHS

2000; van der Paal & Chan 1999).

The great majority of childbirth (89%) happens at home; only 10% are delivered at health

facilities (DHS 2000). Childbirth at home takes place with the assistance of TBAs, trained

midwives, or both, or sometimes family members as well (UNICEF & WFP 1998). According

to DHS 2000, only one fourth of all delivered mothers receive postnatal care from trained

personnel.

Clearly, TBAs deliver more babies than trained personnel, but their skills in antenatal care and

delivery are very limited and very questionable in terms of hygiene. Some traditional

practices made by TBAs are potentially harmful, but many are medically beneficial to the

mothers (UNFPA 2000). Therefore, the skills of TBAs need to be upgraded as they are the

significant local resources which are already tapped.

11
Traditional midwife or traditional birth attendant is known as yeay mob in Khmer language. I use the
term ‘yeay mob’ very often in the next chapters.

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3.3.3 Abortion

Abortion is not recognized as a birth spacing method (MoH 1994). In 1997, the government

promulgated an abortion law, stipulating that abortion can be legally performed by trained

personnel under special circumstances. Prior to the adoption of the law, there was a shortage

of information about birth spacing services, and abortion was known to be generally practiced

to limit or delay births. In the meantime, the frequent practice of unsafe abortion has become

a common cause of maternal mortality and morbidity. An unverified estimate states that 25%

of death is caused by abortion (UNFPA 2000; DHS 2000). DHS 2000 depicts that about 3% of

women have at least one induced abortion, in which 85% get assistance from trained health

workers and 8% get assistance from TBAs (DHS 2000). It is believed, however, that because

of cultural and moral reasons women are reluctant to have abortion.

Illegal and unsafe abortion is thus another barrier for the improvement of women’s health.

More thorough and strict measures for dealing with illegal abortion should be taken. At the

same time, post-abortion care is also important to improve reproductive health of women.

3.3.4 Adolescent Fertility and Health Problems

Adults in Cambodia face a lack of health information, particularly information regarding

sexual and reproductive health. From the view of traditional culture, parents do not talk about

sexual and reproductive health with their children. Unmarried girls are not allowed to know or

ask about complications during pregnancy. Median age at first marriage of women in both

urban and rural areas is 20 years old (DHS 2000). This age marks the socially acceptable age

of childbearing. Women who get married so early will have a longer exposure to the risk of

pregnancy. Also, the early age of marriage implies an early age of childbearing which leads to

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a high fertility rate in the country. The government’s health policies do not deal much with

adolescent health. The only generic reference concerns how to improve maternal health of

‘future mothers’ (see NMCHC 1993).

In conclusion, situation analysis of Cambodian women and their reproductive health is needed

in order to better grasp indicators and relevant issues. The above critical issues have been

discussed in an attempt to link them with relevant traditional health practices which are

performed widely by the rural population. The most important issue, which should be tackled

immediately, is the accessibility of health care at primary level. Medically trained health staff

should be motivated to work in rural areas, and appropriate villagers selected for the training

to provide health education to all people in the villages. The health education should not be

done only with women but also with men and their significant relatives, and young adults of

both sexes should be encouraged to attend health education. Technical training to TBAs is

also an important factor to improve health of women in the villages as TBAs play an

important role, and they are resources which already exist in the villages.

3.4 Cultural Perceptions on Illness and Health Care

As mentioned above regarding budget expenditure on the health sector, the burden of public

health care expense is much greater for the poor than the non-poor. As a result, a large

proportion of the poor do not use public health services. They tend to apply traditional

practices to cure disease when they first fall ill. In case the disease is still not cured, their next

choice is often self-medication, by purchasing drugs at a village drugstore or grocery. If their

illness worsens, they will finally consider whether or not to visit a health center. It is difficult

for them to get services at public health facilities because of high cost of transportation and

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treatment fees.

Traditionally, people perceive that illnesses are caused by natural and supernatural forces (van

de Put 1992; Yanagisawa 2004). Illnesses from natural causes can be treated with supernatural

remedies (i.e., magical blowing), traditional medicines or physical treatment (i.e., pulling hair,

rubbing or coining on the body to burn it ‘to catch the wind’12); whereas, those from

supernatural causes can hardly be cured with natural remedies.

Figure 3.2 depicts the illness healing process according to a traditional decision tree. When

people have illness, they generally find the nearest resource which is less expensive and can

be sought within the village. After the first treatment, if there is no success, they try another

remedy. But if they believe the illness is caused by supernatural forces, they do not treat it by

trying natural remedies. Thus, providing medicines to the patient in such cases is believed to

awaken the anger of the spirit, which would cause greater damage to the patient as well as

their family. Instead, the patient seeks treatment from a traditional healer who would identify

the cause of illness and apply the right offerings and rituals to the spirit. If there is

improvement, they would celebrate the completion of healing with a meal or sometimes with

music.13 At this stage, the illness is believed cured. If the illness is not cured, another

treatment is tried. The patient may try to get treatment from another traditional healer, or, as a

last resort, access public health services.

12
The Khmer believe that illnesses is mainly caused by the wind. So the body is rubbed or coined in order
to catch the wind. To catch the wind in Cambodian language is known as Koh Khayol.
13
Music is offered to the spirit after the disease is completely cured. Normally, traditional healer is the
main actor to offer it to the spirit and dance to make the spirit happy. Offering music to the spirit in
Cambodian language is known ‘phleng leang a rak’.

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To conclude, it is clear that although under the impacts of globalization, Cambodian people,

especially those who live in rural areas, are still applying traditional health practices which

they consider cheap and effective. They prefer to treat themselves or seek treatment from

traditional healers on a trial and error basis. If the disease is treated without any side-effect, it

is considered successful treatment. But if the disease is not cured, this is considered

unsuccessful treatment; so they proceed to another method of treatment.

The traditional ways of practicing health care will be specifically discussed within dimensions

of reproductive health (i.e., pregnancy, delivery and postpartum) in the next chapter. However,

it is worthwhile examining here in the next section traditional views of Khmer people

regarding normality and abnormality during these critical periods of women’s health. These

overall perceptions are closely associated with traditional practices of reproductive health care

of rural women.

Figure 3.2: Illness Healing Process: A Traditional Decision Tree

Experiencing of Illnesses

Success: Cured
Traditional, natural
remedies

No success: Traditional Finding the cause (spirit)

supernatural remedies

Applying right
offerings & rituals

No success: Try again Success: Celebrate healing

with meal: cured

Source: Adapted from van de Put (1992)

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3.5 Cambodian Views Regarding Pregnancy, Delivery and Postpartum14

All traditional societies, including Cambodian society, have naturalistic views of the

functioning of the body (i.e., growth and decay). Similarly, pregnancy, delivery and

postpartum in Cambodia are viewed as natural phenomena that every woman encounters at

least once in her lifetime.

In a study in West Africa, for instance, women’s definitions of what forms a complication

during pregnancy vary from the biomedical definitions (The Prevention of Maternal Mortality

Network 1992). An early sign of pregnancy-induced hypertension is assumed to be an

indication of male fetus or twin babies. Moreover, spotting or small amount of vaginal

bleeding is not thought problematic, but recognized as an early sign of ante-partum

hemorrhage. Blood during delivery is believed to allow the renewing, the changing of the old

or ‘dead blood’; new, fresh blood provides strength and beauty and restores a woman’s health

(Chap & Escoffier 1996).

3.5.1 Views of Normality and Abnormality of Pregnancy

Pregnancy is believed to be caused by the mixture of sperm and ovule in female’s womb15

which is the location for the development of fetus (KAP Survey 1995).

From the points of view of people and health professionals, pregnancy is considered to be

healthy but it is also thought to be a state of vulnerability and danger. To protect the pregnancy,

pregnant women are advised to avoid doing physically hard work. Notably, the advice is

learnt from one another, i.e., from mothers, grandmothers, relatives and neighbors; it is not
14
Postpartum period, according to White (1996) and WHO (1998), is defined 42 days after birth.
15
Womb literally in Cambodian language is known as ‘sboun’. In the next chapter I will use the term
‘uterus’ which has the same meaning as ‘womb’.

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documented. In addition to self-protection from danger and vulnerability, there is a broad

variety of traditional practices and medicines for care of pregnancy and accelerating the birth.

Prohibitions include avoiding or decreasing hard work, avoiding eating hot foods and other

actions which may harm the fetus. Physically hard work, such as cutting wood, carrying water

and heavy things, and transplanting rice is strongly prohibited. Moreover, pregnant women

are not allowed to reach things which are high or above their head because in doing so the

fetus, which is believed to receive nutrition from the mother by sucking on the umbilical cord,

will be dislodged from the umbilical cord, causing miscarriage. There is a lot of advice for

caring for pregnancy, and it differs from one area to another. However, these prohibitions are

effectively abided by only by non-poor people; for the poor, they are hardly able to do so

because they have to work to support their family.

During pregnancy, women encounter some problems which are viewed as normal, such as

mild pain in the abdomen,16 swelling of legs and mild bleeding (White 1996). The problem of

mild pain in the abdomen is believed to be caused by wrong position of the fetus. Women who

have this problem consult with midwives or TBAs. In response to this, TBAs will massage the

abdomen in order to move the fetus to a straight position.

Another problem is swelling of legs which is believed to be caused by the baby. It is viewed

as normal during pregnancy or in five or seven months of pregnancy. Mild bleeding during

pregnancy is believed as bleeding to wash the baby’s face. The bleeding is less than menstrual

period; it lasts for one or two days without pain. This problem is caused by doing too much

16
Words describing some kind of pain and disease are difficult to translate into English. According to
White (1996), ‘siet sork pain’ is known as mild pain on abdomen.

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work or menstrual blood still left inside or women making sudden movement. In response to

these complications, some women drink traditional medicines or consult with TBAs or

midwives.

3.5.2 Views of Normality and Abnormality of Delivery

The majority (89%) of pregnant women deliver at home and some (70%) get assistance from

TBAs (DHS 2000). When women are in labor, the relatives or mothers send a family member

to call TBAs to their home. TBAs play an important role in delivery and after-birth care in

villages as they can be called at any time, and their houses are already in the villages, which is

easy to communicate.

The common complications occurring during delivery are stuck birth, the baby’s head not

coming out first, and stuck placentas (White 1996). When these problems occur, TBAs

massage the mother’s abdomen and use traditional medicines. In case the problems are

beyond their capacity to settle, they will refer women to a trained midwife or referral hospital.

Yet most TBAs try to settle the problems before they refer women to a referral hospital. When

women arrive at a referral hospital, in most cases the complication is almost too serious to

help. Moreover, there is difficulty in transportation, as they have to spend a long time to travel

to hospital. Also, sometimes there is no staff on duty at night time; therefore, it takes them

much longer to get treatment at a hospital. Furthermore, family members are worried about

the fee that they will pay trained health staff, which make them hesitant to send the women to

hospital. Hence, in the case of hemorrhage, women usually suffer badly and sometimes die

immediately after arriving at hospital.

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3.5.3 Views of Normality and Abnormality of Postpartum

After birth, women are taken very good care of by their family. The problems during this

period are related to physiological and psychological factors.

The most common problem during postpartum is ‘toah’17 which is literally known as ‘relapse’

in English language. There are many different types of relapse and they differ according to

conditions. Relapse from food, which is caused by eating certain foods which are prohibited

after birth, appears to be a very common problem for women. Several foods are prohibited,

namely pineapple, jackfruit, certain types of bananas, field cucumbers, buffalo meat, pig’s

head, Kray fish, Diep fish, Chdor fish and red-tailed fish (White 1996). Those foods and fruits

are considered to be dangerous for postpartum women. Some women believe that if they eat

many types of foods during postpartum roasting (for detail practice of roasting see chapter 4,

section 4.5.1), they will not suffer from eating them after they finish roasting. There are many

types of treatment for the relapse from food. Many kinds of traditional medicines which are

made from certain sorts of tree barks, shoots and roots are used for treatment. The most

common treatment is taking the food that women got relapse from, drying it or burning it and

boiling it with water or adding it to alcohol to drink.

Another common type of relapse is caused by emotional upset or thinking too much. The

symptom of this relapse is weight loss, lack of appetite and behavioral symptoms. This kind

of relapse is related to psychological problems which are hard to be completely treated. One

possible treatment is to make the women happy and stop thinking about their problems, and

convince them to use traditional medicines or injections.

17
‘toah’ is Cambodian language. Words which are used to describe problems and illness during pregnancy,
delivery and postpartum are very difficult to translate into English. White (1996) categorizes the word
‘toah’ as ‘relapse’.

- 45 -
Another problem which women encounter during postpartum period is ‘preay krala phleung’

or ‘eclampsia’. This problem is thought to be caused by a spirit (a supernatural cause) which

comes to hassle a woman while she is roasting. There are various symptoms for this problem.

The most common are seizures, fainting, losing consciousness, or acting crazily in some ways,

such as walking around nude, speaking nonsense, and becoming very angry or violent (White

1996). The causes of this problem are relevant to physiological and psychological issues.

Physiologically, many signs could be interpreted as resulting from pregnancy-induced

hypertension, anemia and postpartum hemorrhage, and high body temperature.

Psychologically, it can be a consequence of extreme anxiety and psychological trauma. The

treatment for this kind of problem includes injection, massaging to remove the left blood,

lowering the heat of the fire or removing the fire from beneath the bed, asking traditional

healers to blow, spit and recite incantations, burning incense and making offerings to the

woman’s ancestral spirits (White 1996).

There are many more practices and beliefs which are different from area to area. The

problems mentioned above are only the most common problems which can be encountered

everywhere in rural villages. The treatment processes are also different from place to place.

Some beliefs and practices associate with psychological problems. This clearly shows that

Cambodian people believe in both natural and supernatural forces. Some people prefer to get

treatment in both modern and traditional ways. Therefore, traditional and modern health

practices of people in rural areas, which are remote from the modern world, need to

supplement each other.

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3.6 Conclusion

In winding up, the Cambodia health sector is under-financed. The majority part of the health

expenditure falls on individual households, which hinders the poor from seeking treatment at

public health facilities. As a result, rural people prefer to practice self-medication and/or find

treatment from traditional healers. They visit a health center only when they are in serious

condition. Evidently, pre-delivery antenatal care among rural pregnant women is minimal, but

some may get care during pregnancy from traditional birth attendants in their own villages.

External assistance, both technical and financial, is needed to refine the health sector.

Technical support is helpful to improve skills of health center staff and traditional birth

attendants. Traditional birth attendants need to be trained in hygienic delivery in order to

reduce mortality and morbidity rates of mothers and children, as the bulk of women deliver at

home. Their skills need to be upgraded and followed up. Moreover, cooperation between

health centers and traditional birth attendants should be strengthened. Also, financial aid is

important for constructing or renovating health facilities which need to be equipped with

modern and hygienic materials. After several reforms, some health indicators have been

progressed, especially in maternal and child health. The user fee scheme sounds important and

necessary to better financial management of health centers and staff incentive. Yet, the real

poor should be taken into account in the fee exemption scheme.

Despite regionalization and globalization, Cambodians in rural areas as well as in suburban

areas continue to hold strong beliefs in traditional ways of health care. Thus, it is infeasible to

totally abolish their traditional beliefs and practices. Instead, health professionals should

encourage them to apply the ones which benefit their health. Health center staff, traditional

- 47 -
healers and traditional birth attendants should have coordinated cooperation in providing

health education to all, not only to women.

The next chapter illustrates both positive and negative effects of traditional beliefs and

practices in reproductive health in both physiological and psychological ways. The discussion

is based on findings of the field survey.

- 48 -
 Chapter Four

EMPIRICAL FINDINGS: THE FACTS OF TRADITIONAL PRACTICES DURING

PREGNANCY AND POSTPARTUM PERIOD

4.1 Introduction

‘It’s better for a father than a mother to die, it’s better to drown in a river rather than to have

house fire’ is a Cambodian proverb which shows the importance of women in the matrilineal

family system. The death of mothers is a great catastrophe for the whole family, especially

children, because mothers are housekeepers, food providers and also educators for children.

Maternal health draws great attention for the whole family particularly during pregnancy and

birth, when women are thought to be in a vulnerable state. Despite this attention, maternal

health in Cambodia is still among the poorest in the region. The maternal mortality rate in

Cambodia is 437 deaths per 100,000 live births mainly due to abortion complications,

eclampsia and haemorrhage (DHS 2000). Moreover, the causes of maternal mortality are

many, including factors influencing health service utilization (see Chapter Three for more

details).

This chapter discusses results of the questionnaire surveys conducted with health workers and

potential stakeholders (village women and TBAs). Its emphases are on identifying traditional

practices surrounding pregnancy, delivery and post delivery, and probing the positive and

negative impacts of those practices from the perspectives of health professionals and

villagers.

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4.2 General Information on Study Areas

The study was conducted in Angkor Chey district in Kampot province, which consists of 8

administrative districts. The fieldwork was carried out from July 21st to August 06th (13

working days), 2004. Kampot province comprises 4 Operational Districts (OD) under the

MoH organizational structure. The four Operational Districts (ODs) are Angkor Chey OD,

Chhouk OD, Kampong Trach OD, and Kampot OD. Angkor Chey is one of the four

Operational Districts situated in the south of Kampot province, with a population of 116,530

(NIS 1998). It consists of ten health centers, and each health center ranges from 8 to 15

villages. Four health centers were selected as target health centers, and 11 villages were

chosen randomly as target study areas.

The majority occupation of Cambodian people is farming and nearly 80% of the population

are dependent on the agricultural sector. About 84% of the total population lives in rural areas,

and 16% live in urban areas. Some areas are highly populated and some areas are sparsely

populated. The major occupation of Angkor Chey inhabitants is farming which is the main

livelihood for nearly 80% of the population. The majority of farmers grow rice and vegetables.

Rice grown is for family consumption, but vegetables may be sold at local markets. The most

popular vegetables in Angkor Chey are potatoes and pumpkins. Some farmers raise livestock

like pigs, cows and chickens for meat sold on at the market. A small number of the population

are fisherfolk, or run small businesses, and a few go to urban areas to work as garment factory

workers (mostly women), or run small businesses such as motordub (motorcycle) taxis

(mostly men). Generally, the people’s living condition is still poor in terms of sanitation and

hygiene. Far from the district town, only a few people can access safe drinking water and

toilets.

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4.2.1 Characteristics of Health Center

Health Centers have been constructed after MoH implemented its health coverage plan in

1996. Each health center has a team of 4 to 6 staff members to ensure all planned activities.

They are responsible for different activities, and they also have different level of ability such

as secondary nurse, primary nurse, secondary midwife, primary midwife and so on. Each

health center of the study area had 6 to 7 health center staff, in which all midwives were

primary midwives (see figure 4.1). Health centers are responsible for promoting the

relationship between the health center and the community, and outreach activities are one of

the tasks that health center staff have to do regularly (Health Center Manual 1997).

Each health center comprises 8 to 15 villages, and in each village there are two Village Health

Support Groups18 (VHSGs), member of which are selected by villagers. The health center

team conducts meetings with those VHSGs monthly. Yeay mops (traditional birth attendants)

from each village are encouraged to cooperate with the health center team technically. All

yeay mobs of the ten health centers had been trained by health center staff on sanitation

during delivery, management of complications during delivery, and referring women to the

health center or referral hospital. In order to ensure the capacity of training, all yeay mobs

have scheduled meetings with the health center team every three months to report about

delivery data and solve problems the yeay mobs have encountered during delivery.

Moreover, health center staff are encouraged to improve their technical skills. For financial

18
Village Health Support Group (VHSG) members are selected by villagers through a vote. Their main
tasks are to help health center staff during outreach activities, and provide health education to the villagers.
They work voluntarily. However, they are provided some incentive during training conducted by the health
center under financial and technical support of Racha (Reproductive and Child Health Alliance
Organization). They are required to attend meetings at the health center every month.

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management, the health center is in charge of implementation of patient fees, monitoring daily

and monthly income and expenditures, reviewing monthly reports of income and expenditures

and sending them to the operational district office, and discussing income and expenditures

during staff and management committee meetings. Only 1% of income from user fees goes to

the national treasury, and the rest is for motivating staff and covering other expenditures.

In an attempt to find out the traditional practices of inhabitants of Angkor Chey OD, 4 health

centers were selected as study areas namely Champey, Trapeang Sala, Dambok Kpos, and

Damkom. Trapeang Sala Health Center had been categorized as a leading health center in

terms of health indicators improvement and people’s participation in health center activities. It

was ranked as the best health center during a health center competition19 in early 2004. The

rate of delivery by trained midwives who are staff of the health center comprises 65% of total

deliveries, whereas only 35% of total deliveries were done by yeay mobs. This number is

thought to be high compared with other health centers where, in contrast, 66% of total

deliveries were done by yeay mobs (HC1 2004).

The number of deliveries by yeay mobs is much higher in villages located more than 8

kilometers from health centers and in areas where transportation to health centers is

problematic. For instance, Champey Health Center covers villages far from the health center,

and its rate of deliveries by yeay mobs is 80% much higher than the 20% of deliveries by

trained midwives.

19
A health center competition was held in Angkor Chey operational district in early 2004. Its aims were to
improve services and promote people’s participation at health centers. The competition, held annually, is
financed by Racha.

- 52 -
Figure 4.1 : Composition of Health Center Team

Health Center Chief

Secondary Primary Primary Other

Nurse Nurse Midwife Staff

Source: Health Center Manual, MoH (1997).

4.2.2 Characteristics of Villages in the Survey

The villages have an average population of 1,154 people. In administrative organization, there

is a village chief who is in charge of overall work in the village, two deputy chiefs, a village

development committee, and people’s representatives. Apart from administrative organization,

there are two VHSGs, three or four nuns and female elders, and several yeay mobs whose

work is to cooperate with health center staff who are organized according to health center

requirements. They are required to assist health center staff to gather villagers to participate in

the health center outreach and health education.

Moreover, they are to provide health education messages to their fellow villagers. All of them

except yeay mobs were voted upon by villagers, and recommended by the village chief for

their popularity and credibility in village. They work with the health center on a voluntary

basis, but during the short training course provided by health center staff, they are provided

incentives in the form of a per diem and support for transportation costs from home to health

center. They are encouraged to create close relationships between health center staff and

residents of their village. The tasks and responsibilities assigned to nuns and female elders are

different from those who are VHSGs.

- 53 -
4.3 General Characteristics of Informants

Fourteen yeay mobs and five trained midwives of target health centers were interviewed.

Moreover, a midwife in charge of the nursing division office at the National Maternal and

Child Health Center (NMCHC) was also interviewed. A community capacity building team

leader of Racha was also interviewed. These two were interviewed in order to obtain their

insights about traditional practices of rural people.

A total of 18 women participated in the focus group discussions, and 60 village women with

children less than 3 years old participated in individual interviews. Selected demographic

information and obstetrical histories were obtained from each focus group discussion and

individual interview.

Table 4.1 demonstrates that many demographic characteristics of women in the focus group

and individual interviews were similar. A high percentage of older women were included in

the focus group discussions in order to draw out their experiences and perspectives on

practicing traditional ways of health care.

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Table 4.1: The Number of Distribution of Sample by Age, Education, Number of
Pregnancy, and Number of Living Children
Background Focus group Village women TBAs Trained
characteristic (n=18) (n=60) (n=14) midwives (n=6)
Age
15-20 years 2 (3%)
21-25 19 (32%)
26-30 2 (11%) 18 (30%)
31-35 8 (13%)
36-40 7 (39%) 8 (13%) 2 (14%) 1 (17%)
41-45 2 (3%) 3 (21%) 2 (33%)
>45 9 (50%) 3 (5%) 9 (64%) 3 (50%)
Education
No education 2 (11%) 8 (13%) 2 (14%)
1st – 6th grade 16 (89%) 38 (63%) 8 (57%)
7th – 9th grade 12 (20%) 4 (29%)
> 9th grade 2 (3%) 6 (100%)
# Pregnancy
0 5 (28%) 2 (14%)
1 9 (50%) 18 (30%) 5 (36%) 5 (83%)
2 18 (30%) 1 (17%)
3 3 (17%) 8 (13%) 3 (21%)
4+ 1 (6%) 16 (27%) 4 (29%)
# Living children
0 5 (28%) 1 (2%) 2 (14%)
1 10 (56%) 22 (37%) 5 (36%) 5 (83%)
2 19 (32%) 1 (17%)
3 2 (11%) 6 (10%) 3 (21%)
4+ 1 (6%) 12 (20%) 4 (29%)

4.3.1 Target Women

Target women were selected on a voluntary basis. Their age ranges from 15 to 49 years. The

majority of women informants in this study were aged between 21 to 30 years, with this group

comprising 61% of total women informants. Register books of VHSGs were used to screen

the names of eligible women for the interviews.

The majority of the target women have little education; more than 50% of all target women

had 1 to 6 years of education. Nearly 12% of total women informants received no education

- 55 -
while only 3% had higher education (above grade 9). Daughters are heavily influenced by

their older relatives and mothers when they are in need of assistance regarding pregnancy and

childbirth.

After marrying the majority of women stay at home and do farm work. Some women go to

urban areas as garment workers and leave their children with mothers or relatives. Most

families in the survey areas earn occasional income by selling livestock, vegetables, preparing

a kind of local rice cake, and cutting timber and bamboo in the nearby mountains. The

exceptions are two informants in Sdoc village, Champey Health Center, who have a more

regular income derived from selling groceries. Some women with children under three years

of age could not be reached for interviews because they were away working in Phnom Penh.

Several families do not have any income at all.

Because of the changes in family planning in Cambodian society, the number of family

members is decreasing. The average number of children of the respondents in this study is 2.5.

Average fertility rate of women decreased since Racha started a birth spacing program in

1997 focusing on community based services,20 beginning with community education on

family planning. VHSGs were trained to provide birth spacing messages to all women of

reproductive age (15-49 years old), and were allowed to sell birth spacing pills and condoms.

Cambodian families are mostly extended families with many members. However, only 8% of

informants live in extended families, while the rest run their own families (nuclear family)

20
Community based service is a program which was developed by MoH and USAID to educate village
health volunteers and grocery sellers about selling birth spacing pills and condoms which are the primary
methods of birth spacing for villagers. This program was implemented by the cooperation of Racha with
Angkor Chey OD in 1997, and it was considered as successful according to the result of annual evaluation
which was done by evaluation unit of Racha in 2000.

- 56 -
after marriage. Because many informants live in nuclear families, they do not have family

members to assist during postpartum practices and they have less opportunity to rest after

birth. Still, they are influenced by their senior relatives or neighbors about health care

practices.

4.3.2 Traditional Birth Attendants (yeay mobs)

Fourteen yeay mobs were selected for study. They were visited occasionally without making

any appointment beforehand. The majority of yeay mobs in this study are rather old yet

popular in their villages. Besides providing delivery assistance, they do rice farming and

raising livestock. Almost all yeay mobs have been trained by health center staff, except for

two who live very far from health centers and are rather elderly. A few of them cannot read or

write.

All yeay mobs in the study learnt their skills from mothers, grandmothers and senior relatives

in their own villages. They said that they wanted to provide delivery assistance so they tried to

learn from others before they received training from the health center. One yeay mob said that

a ghost spirit told her to assist births, otherwise she would be cursed by ill fate for her whole

family.

The health center training focused on improving hygiene during delivery, referring women

with danger signs to the health center or referral hospital, and educating women to get

antenatal care services from the health center. In addition to improving their skills, yeay mobs

were asked to bring information from their villages to the health center. Each health center

conducts meeting with yeay mobs every 3 months to discuss problems yeay mobs

- 57 -
encountered during delivery and to allow them to provide delivery reports to health center

staff.

Remarkably, the older the yeay mobs the more popular they were. Elderly yeay mobs were

thought to be knowledgeable about delivery and have extensive experience in assisting birth.

Women informants said they preferred to get assistance from yeay mobs who have practiced

for a long time and have never had any problems during delivery.

4.3.3 Trained Midwives of Health Centers

Five health center midwives were interviewed. In each health center, there are one or two

primary midwives. They were interviewed after they finished providing services. All health

center midwives in the study also run their own clinics at home and provide delivery service

both at residents’ homes and their own homes. They started to work at the health centers after

they were established in 1996 according to the MoH health coverage plan. Thus, some of

them are relatively new to the villagers. This makes them different from yeay mobs who live

and work in their own village for a long time.

According to the health coverage protocol of the MoH, each health center is required to

conduct monthly outreach activities to every village of the health center’s catchment areas.

This activity does not only aim to provide basic services to every villager, but also aims to

create good communication between health center and villagers. Health center outreach

activities include: vaccination services for children, women in reproductive age (15-49 years

old), and pregnant women; antenatal check ups for pregnant women; and health education.

Some health center staff were not known very well in villages, and villagers felt that health

- 58 -
center staff’s capabilities were somehow questionable. Through the outreach activities,

villagers were getting to know health center staff much better than before, but they still felt

that health center staff were difficult to communicate with.

4.4 Delivery Status

In Cambodia the maternal mortality is high, at 473 per 100,000 live births (DHS 2000). This

means that among 1000 births, there are around 4 maternal deaths. Furthermore, the death of a

mother is a tragedy for the whole family because she is considered a caretaker and food

provider. The causes of maternal mortality are complex, and the MoH must pay more

attention to promoting maternal health and taking serious action to lower the high rate of

maternal death.

In 2000, 70% of total deliveries in rural areas were assisted by yeay mobs (DHS 2000). In the

target areas of the study, 80% (n=60) of women got assistance from yeay mobs during

delivery, 15% of deliveries were assisted by trained midwives and only 5% of deliveries were

done by both trained midwives and yeay mobs. The deliveries assisted by both a trained

midwife and yeay mob were special and rare cases. They happened only when there were

signs in danger pregnancy. One woman who participated in an individual interview stated that

during her last delivery she got assistance from both yeay mob and a trained midwife. She

said that at first she called yeay mob for help, but when her delivery became more complex,

yeay mob sent a family member to call for a trained midwife.

According to data drawn from health center reports in 2004, the number deliveries by yeay

mobs outnumbered the number of deliveries by health center midwives (table 4.1). In one

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health center there are one or two primary midwives, but there are more than four yeay mobs

in each health center area (i.e., Champey health center has 13 yeay mobs, Damkom health

center has 7 yeay mobs, Dambok Khpos health center has 8 yeay mobs, and Trapeang Sala

health center has 4 yeay mobs). All yeay mobs were said to be accessible at any time, and

their fees are much lower than health center staff. In addition to the reasonable fees, yeay

mobs were admired for their personal characteristics and interpersonal relations with villagers.

They were reported to take care of the women they delivered and visit them spontaneously

until a week after delivery or longer if they live closeby.

Yeay mobs are required to have good communication with trained health center midwives,

and they are obliged to have meetings with the health center to report about delivery practices

every three months. They are not allowed to deliver a woman with danger signs on her

antenatal check-up card. If there are delivery complications, yeay mobs have to refer the

woman to a health center or referral hospital. In this case, transportation fees for the woman

will be paid by the referral hospital, and yeay mobs will be paid a small amount of money for

referring the case. Consequently, some yeay mobs mentioned that after the training, they

rarely deliver women with danger signs because they are afraid that they may cause the

woman’s death. However, before the training, they did not have any idea about hygienic and

safe delivery.

“I did not deliver a woman who was marked as having danger signs on her antenatal
check-up card. I did not deliver her, even though her family insisted me so much. I
told her to deliver with a trained midwife or deliver at a referral hospital. If they
don’t do what I told, I just keep them away.” ( a 60 year-old yeay mob in Robak
Ktom village of Dambok Khpoh health center)

“I did not dare to deliver a woman with danger signs crossed on her antenatal
check-up card. I am afraid to cause her death. If I cause a death to a woman, I will

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 lose face21 and no one will ask me to assist delivery again. I refer her to deliver with
a trained midwife of health center. Some women are stubborn, they don’t agree, so I
have to accompany them to referral hospital, or if they want to deliver at home, I
work together with a trained midwife of the health center.” (a 57 year-old yeay mob
in Robak Khtom village of Dambok Kpoh health center)

Some women from the study compared the attitude of yeay mobs and trained midwives, and

said that yeay mobs are much more helpful and are accessible at any time. They said that they

considered trained midwives as outsiders and they hesitated to consult with them about their

health problems as they don’t know them well. Some women delivered all of their children

with the yeay mob who lived nearby their house, so they got used to this situation. They gave

birth many times so they did not worry about their last birth. What is notable is that almost all

the women said that they were worried only about their first birth, which was considered to be

dangerous. During their last birth, they thought it should be normal and should be less

problematic. If they did not encounter any problem during their first birth, they preferred to

get assistance from yeay mob.

The preference for delivering by yeay mobs is related to the Khmer word ‘Kob’. Kob

describes as a state of not having any problem, or safety. Khmers use this word with yeay

mobs who have never encountered any problems during assisting delivery. If a yeay mob is

kob, she is well known and often called for assistance. Thus, some yeay mobs are afraid of

assisting delivery with danger signs. Generally, they referred the woman in question to the

health center or referral hospital.

“I know that to be delivered by a trained midwife is safe, but still I was delivered by
yeay mob because I know that I have no health problem. I have delivered all my
children by the same yeay mob. The yeay mob is nice and helpful. She is kob
21
The word ‘lose face’ is an expression which is translated direct from Cambodian language. This
expression has similar meaning to ‘ lose reputation.’

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 (skillful) with delivery in this village. Everybody likes to ask her to deliver their
babies. I got assistance from her since my first child. I have never had any problem
during delivery, I believed in her capability to deliver my last child.” (35 year-old
mother in Robak Ktum village of Dambok Kpoh health center)

“I have to deliver at home because my house is very far away from health center. It is
also difficult to call the midwife to come to my house during night time because I
don’t have a motorbike to take her here. The only way I can do is to call yeay mob
who lives near my house. She does not mind whether or not I have motorbike to take
her to my house. My husband takes her using the old bicycle.” (a 22 year-old woman
in Trapeang Kamnob village, Dambok Khpoh health center)

“Yeay mob is nice and helpful, she does not mind walking to my house at night time
or any time of need. I am afraid to call a trained midwife at night time because I
think that she was sleeping.” (a 22 year-old woman in Trapeang Kamnob village,
Dambok Khpoh health center)

Working hours of health center staff are limited which turn the preference of clients to yeay

mobs. Due to the low salary and irregular payroll of government staff, most of the health

center staff work only in the morning (however, there are a few exceptional cases where

health centers are supported by NGOs to motivate the staff). Obviously, it is very problematic

for women to travel a long distance to a health center and then not meet the staff. Therefore,

they decide to choose an alternative, which is available and accessible such as getting service

from yeay mobs. Thus, to deliver at home is the first resort, and most of the time yeay mobs

are called for assistance. Only occasionally, trained midwives of a health center were also

called for assistance.

Most of the informants prefer home as the place for delivery, under assistance of either yeay

mobs or trained midwives of health center. The initial reason for staying at home was that

when they are at home they are able to take care of their children and house. If they deliver at

a health center, there will be no one to take care of their children and house. Another reason

for preferring to deliver at home was that their children are still young, so they could not be

- 62 -
responsible for all the household chores. Their husbands are busy with their rice farming.

Some women said that when there seems to be no complication or danger signs, they prefer to

deliver at home. However, women with danger signs still prefer to deliver at home because of

the above major concerns. Among the 60 informants, 45 (75%) women mentioned about their

preference for staying at home when giving birth, 10 (17%) informants mentioned delivering

at health center or referral hospital, and only 5 (8%) informants said that they did not know

whether to deliver at health center or home.

Referring to Health Center Report 2004 and results of the study, the number of women getting

delivery assistance from yeay mobs is higher than the number getting assistance from trained

midwives during the first semester of 2004. The main reason is the price of service. Yeay

mobs were reported to charge less than trained midwives of the health center. Yeay mobs

reported to accept fees from clients no matter whether in kind or in cash. Most commonly,

some yeay mobs are given an offering in return for their service. The offering depends on the

resource of each household, and may or may not include cash. Normally, things included in

the offering are a bottle of traditional rice wine, one or two milk-bottles of rice, betel and nut

(slar malu).

It is believed that if the women delivered by yeay mob and did not give any offering back to

her, in the next birth she will become a house maid of yeay mob and live in poor condition.

Some yeay mobs mentioned giving the rice to families considered poor. The price for delivery

by yeay mob ranged from 5000 Riels to 20,000 Riels ($1.30 to $5.0022). In contrast, the price

of delivery by trained midwives ranged from 20,000 Riels to 50,000 Riels ($5.00 to $13.00).

22
$1.00 = 4,000 Riels

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The price of delivery by trained midwives is included injections.

“I get paid for the service as yeay mob, but the amount is left to the patients. I don’t
demand the payment because some of my patients are poor people. If they don’t have
the money, how are they going to pay me?” (55 year-old yeay mob, Dambok Kpos
village, Dambok Kpos health center).

All of the yeay mobs in the study reported that they rarely provide antenatal check-up to the

women, and they also know nothing about women’s pregnancy until the women are ready to

deliver their baby. All of them mentioned to provide great assistance during delivering the

baby and they support the women in labor physically and psychologically.

“Mostly women don’t come to me until the baby is ready to be born. If they need
help before that- perhaps because they have pains in their belly, or something like
that- then their husband will come to get me. Sometimes if the baby is lying in the
wrong position it can be very painful, and backache is sometimes another problem.”
(55 year-old yeay mob, Dambok Kpos village, Dambok Kpos health center).

“When a woman is ready to give birth, her husband or family member will come and
get me. The first thing I do is to touch her abdomen so that I can tell when the baby is
going to be born. I massage her and wait for the white liquid to flow out. I stay with
her the whole time, give her massage, encourage her to take hot water, eat food as
much as she can in order to be strong, say good things to her to help her through the
pains. Immediately after the baby is born, I put it on the mother’s chest and tell her to
breastfeed her baby.” (45 year-old yeay mob, Angcheay Cheung village, Champey
health center)

According to the study, 80% (n=60) of total deliveries were done by yeay mobs. Figure 4.2

illustrates the relationship between the preference for getting assistance from yeay mobs with

level of education.23 The number was calculated based on the survey of sixty interviewees

(n=60). Women with low or no education tended to get assistance from yeay mobs (75%)

while women with some education or higher education tended to get assistance from trained
23
The basic level of education started from first grade until ninth grade(MoEYS 1999), but some women
in rural areas received only six years of schooling, which could be considered basic education because they
can read and write.

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midwives. Although women with some education or higher education (from grade 9 and

higher) tended to choose delivery by trained midwives, women with one to six years of

education chose delivery by yeay mobs. The rate of delivery by yeay mob decreased when the

level of education increased (n=60). Women with no education tended to get less assistance

from health center staff than those with a few years of schooling. Although the relationship

shown in is not so significant, it does reflect the relationship between education and the use of

health services.

Evidence from other studies in Cambodia also clearly depicts the correlation between use of

health services and levels of education and living standards (Collins 2000; DHS 2000). Level

of education has a positive effect on type of delivery (DHS 2000). The result of this study

supports the finding of DHS 2000, which indicates that mothers with no education tended to

get more assistance with delivery from yeay mobs than those with less than 6 years of

education. A few uneducated mothers delivered their children with trained midwives as they

were marked having complicated pregnancies and were referred by yeay mobs to trained

midwives. Figure 4.2 shows that the bulk of uneducated women delivered their children with

yeay mobs, while a low percentage of women delivered their children with trained midwives.

The living standard also factors in the preference for accessing health services. Nearly 36% of

the population live below the poverty line (Beaufils 2000). Obviously, the level of individual

income of target informants of the study, in which about 20% of women informants do not

earn any daily income at all, is unlikely to strongly influence on public health services

utilization. After the reform in 1996, each health center applied fee exemption scheme for the

poor, they can benefit from the scheme. Yet, the public services are still under-utilized.

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Culturally, Cambodian women prefer to think about the health of their beloved ones before

they think about their own health. Therefore, level of income or individual poverty alone

cannot strongly affect the preference of getting services from public health services, but other

factors such as gender-preference, distance of health centers, means of transportation, etc.

directly and indirectly influence their behavior in using public health services.

Notwithstanding, the services provided by yeay mobs is thought to be cheaper (or sometimes

free) than that provided by health staff. They are viewed to be closer to women than health

staff who are usually located at a distant health center.

The finding of this study reinforces the necessity of strengthening capability of yeay mobs in

developing countries through continuous training as it will result in reduction of harmful

practices and thus decrease maternal mortality (Levitt 1998). Yeay mobs are among the scarce

local resources which prove effective in reducing maternal deaths (Goodburn et al. 2000). In

addition, yeay mobs provide essential social and psychological support for pregnant and

postpartum women in their care. Yeay mobs at the health centers in the study areas have been

trained and cooperated with health center staff technically. Consequently, there has been a

major increase in maternal health service utilization and decrease in death rate during delivery

(Racha Annual Report 2004).

Moreover, improving girls’ education is another important factor which can contribute to the

reduction of maternal death rate. To educate girls means to educate future mothers. It is clear

from the survey that all of the woman informants were influenced by their senior relatives,

especially their mothers, in terms of reproductive health beliefs and practices (see the sections

to follow). If girls’ education improved, harmful beliefs and practices would decrease

gradually.

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In brief, the main barriers to use of public health services by rural women are the relatively

costly fees and the doubtfulness about the quality of care. Further to upgrading the technical

and professional quality of medication, the price of delivery by trained midwives and other

health practitioners should be reduced in order to allow more pregnant women to use their

services. Another important factor is that owing to poverty and culture, Cambodian women

put the health of their loved ones over their own. Therefore, their initial option is to utilize

available indigenous resources, such as yeay mobs prior to seeking treatment from health

professional.

Table 4.2: Assistance during Delivery of 10 HCs in Angkor Chey District,

Kampot Province in the First Semester of 2004.
Month Midwives TBAs
January 71 102
February 91 109
March 78 106
April 78 89
May 97 99
June 71 80
Total 486 585
Source: HC1 2004

Figure 4.2: Linkage between Level of Education and

Assistance during Delivery (n=60)

80%

60%

40%

20%

0%
no education 1st -6th grade 7th-9th grade

Yeay mobs Trained Midwives

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4.5 Traditional Practices

Traditional practices are those which are not modern, and are taught, learned and adapted

from one generation to the next, not by books or researches. In Cambodia, there are many

traditional practices regarding health care and treatments. The traditional practices

surrounding pregnancy, delivery and post delivery are widely followed, especially among

those who live in rural areas. However, those practices have not been fully documented,

although and several researches concerning their impacts have been done. When people get ill,

firstly they try to treat themselves or get traditional treatment. Similarly, senior villagers are

considered to be knowledgeable about what to do during pregnancy, delivery and post

delivery. Therefore, senior people are considered the main factor to influence the younger

generations.

The traditional practices surrounding pregnancy, delivery and post delivery explored in this

study are: the practice of ‘lying by fire’ or ‘roasting’ (Ang Phleung), use of traditional

medicine during pregnancy and post delivery, the use of hot rocks, the practice of body and/or

face steaming, injections, etc. These practices are considered to be popular among old people

in the study.

Injection is not considered a traditional practice, but it was raised in this part because some

injections were not done according to real need, but rather according to the beliefs and

demand of the clients. Mostly, injection was done by either trained health staff or untrained

health staff who can be nurses or midwives and who have some knowledge about how to

inject. From the result of the study (figure 4.3), all target women informants used traditional

medicines during pregnancy and after delivery. Ninety five percent of informants practiced

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roasting, which ranged from one day roasting to 10 days roasting, and 85% used hot rocks to

put on their abdomen or to sit on after delivery, 73% practiced body and face steaming, and

60% got injections after delivery.

Those practices have correlation with standard of living. Among the poor households,24 the

level of practice is lower than those who are non-poor or better off households. The number of

days was also reduced. For instance, those who are poor can manage ‘lying by fire’ for only 3

days. Some women did not practice body and/or face steaming because of money and time

constraints. However, the practice of using traditional medicines was maintained. All of the

informants in the study used traditional medicines during pregnancy and after birth. Some

very poor women did neither ‘lying by fire’ nor injection. Those who did not roast long

enough after birth due to danger signs after delivery and the shortage of firewood complained

about their health problems. Because of the social norms, most women have limited

autonomy to seek their own health care and make their own decisions; they may be further

disadvantaged if they are poor.

Table 4.3 depicts the 14 practices which were reported by all informants in the study. More

than 50% performed 11 activities. Three activities were practiced by fewer than 50% of

women. Five of the most popular activities will be discussed further and include traditional

medicines, ‘lying by fire’, putting hot rock on abdomen, body and face steaming, and

injection. What is worth noting is that the most influential person regarding those practices

was the mother, then relative, midwife and lastly husband. The husband, who was considered

24
The poor is defined as those who earn less than a dollar a day. They house is in the shortage of rice and
have only an acre of rice field. The very poor is defined as those who live less than a dollar a day, the
couples do have have work besides rice farming, they don’t own rice field. Both category of people have
similar condition of the house, roofed and walled by palm leaves.

- 69 -
influential regarding household finance and farming work, has low power to influence the

birth practices of his wife.

In Khmer society, wife or mother was considered a house keeper and a house leader. Thus,

she was responsible for all the household chores and specifically taking care of the health of

her family members. This is the reason that most postpartum women in the study mentioned

their mothers as the most influential person in managing health care. Those who mentioned a

midwife were those who got antenatal check-ups (ANC) at a health center and consulted a

midwife during services. Yeay mobs are also potentially influential regarding traditional

practices of health care after delivery, but they have been instructed to encourage women to

get service from health center rather than perform traditional remedies.

Overall, the main argument here is that education either informal or formal (for influential

person and women themselves) is of importance and effective to reduce duration of traditional

practices, rather than level of income alone.

Figure 4.3: Traditional Practices (n=60)

100 100
95
85
73

60
%

Lying by fire

Injections
TM during

TM after
Pregnancy

Use hot rock

Spong
birth

TM= Traditional medicine

- 70 -
 Table 4.3: Summary of Activities and Practices Mentioned by Women
Activity n (%) of women Range day of Influential person
practicing activity practice First Second
1.Traditional medicine 60 (100) 1-365 Mother Relative
2. Lying by fire 57(95) 1-15 Mother Relative
3. Hot rock 51(85) 1-7 Mother Relative
4. Steam 44(73) 1-15 Mother Relative
5. Brolei (mixed with rice wine) 44 (73) 3-15 Mother Relative
6. Injection 36(60) 1-8 MW Relative
7.Sexual abstinence 60(100) 7-150 Mother MW
8. Hot bath 39(65) 1-90 Mother Relative
9. Avoid taking bath 55(92) 1-30 Mother Relative
10. Restrict from doing hard work 20(33) 7-90 Mother Relative
11. Rest at home 23(38) 7-60 Mother Relative
12.Cover with thick cloth 35(58) 2-90 Mother Relative
13. Ice bag on abdomen 9(15) 1-7 MW Mother
14.Food restriction 45(75) 1-150 Mother Relative
MW= Midwife

4.5.1 Maintaining Body Heat

According to traditional medicines after birth, women are considered to be ‘cold’ and

therefore vulnerable to many kinds of diseases. In order to return the health of postpartum

women to normal, women are advised to maintain their body heat. The activities to maintain

body heat were listed in table 4.3, namely ‘lying by fire’, body and face steaming (spong),

taking hot bath, injections, taking hot drinks (consuming traditional medicines), covering the

body with a thick cloth from head to toe.

In this section, the practice of ‘lying by fire’ is raised for the discussion. Literally, ‘lying by

fire’ is known in Khmer language as ‘Ang Phleung’, or ‘roasting’. The term ‘lying by fire’ is

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used very often in this section instead of the term ‘roasting’.

Almost all the women who were interviewed practiced ‘lying by fire’ during every birth. They

believed it effective to heal the woman postpartum. This practice is still followed widely in

rural areas. In urban areas this practice has been replaced by the practice of injections.

This practice, according to the focus group discussions and result from individual interviews,

is thought to be beneficial for the health of the new mother, though they found it difficult to

lie above fire. Other women told that they have joint pain if they don’t roast long enough

because their sawsaye (it literally means fiver and serves as a classifying word for strings,

threads and hairs, and it is also refers to long, string-like structures in the body including

blood vessels, nerves and ligaments) was not well cooked. They feel that they are vulnerable

to many diseases if they don’t roast long enough.

“Roasting makes a woman have energy. When a woman roasts, it cooks her sawsaye.
She can then do work and not relapse like when transplanting, harvesting, and
carrying rice seedlings on her shoulders.” (50 year-old elder in a focus group
discussion, Dang Tong village, Damkom health center)

“Ang Phleung prevents your body from coldness during the rainy season or cold
season. You don’t have pain in the joints of your arms or legs. A woman who does
not roast feels weak and has no energy, gets thin and cannot do hard work like
others.” (46 year-old woman, Ang Kchey Cheung village, Damkom health center)

“We are farmers and we have to do hard work to survive. It is different from those
urban people who do only light work. We have to roast in order to prevent relapse.
Ang Phleung can also make the skin healthy.” (39 year-old pregnant woman with 3
grown-up children, Dang Kom Cheung village, Damkom health center).

“ I roasted for a week after I delivered my son. My mother told me to roast, I don’t
know about its effect on health. She said that if I did not roast I would not be able to
do hard work such as sowing, transplanting, harvesting, etc. I am poor; I don’t have
money for injection, so Ang Phleung can be used instead of injection to make the
body warm.” (24 year-old woman, Trapeang Tnot village, Dambok Khpos health

- 72 -
 center)

Besides the advantages mentioned above, ‘lying by fire’ was also reported to provide mild

disadvantages. Women described it as inconvenient or unpleasant, and suffered minor burns

and heat rashes. They also reported breathing problems during roasting. The majority of

complaints were about roasting by firewood, while roasting by charcoal is likely to have been

less unpleasant. Several women told that they were almost unable to breathe when lying down.

Another woman said that she felt she was choking or had something big and heavy on her

chest. Although they faced those difficulties during roasting, they kept practicing it. While the

delivered woman is on the fire, she is not allowed to complain about the heat. If she

complains that it is too hot it will make spirits angry with her, and then it will cause preay

kralah phleung (eclampsia) which could lead to death. At the same time, visitors are not

allowed to say ‘too hot’ in front of the delivered woman.

“When roasting, a woman is not allowed to complain about the heat of the fire,
otherwise, she will get much hotter. A woman has to try to be in a high temperature
of the heat in order to make her body gets enough heat and to have her sawsaye cha
en (well-cooked).” (65 year-old elder in a focus group discussion, Ang Chuourt
Village, Champey health center).

“It was difficult to breathe in the first day of roasting. I told my mother about this but
she chided me and told me to try to breathe. Later, I tried to get off the bed by myself.
Then, my husband reduced the heat of the fire because it was too hot. I continued to
roast until a week but with low heat. I believe that when the heat temperature is low,
roasting is good for health because I didn’t feel pain while I was roasting.” (30
year-old woman, Trapeang Tnot village, Dambok Khpos health center)

“It is very hot to lie on the fire, but I have to try otherwise I cannot do hard work. I
have to take care of the children and do all household chores; therefore I have to
believe what my mom said. My mom is so healthy. Though she is old (65), she can
do all hard work. I can’t do like her because I did not roast as long as she.” (35
year-old woman, Trapeang Kamnob village, Dambok Khpos health center).

A trained midwife of a health center said that if the woman has health problem she told the

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family members especially mother not to ‘roast’ the woman. Some households obey her

advice but some keep practicing but reduce the number of days of ‘lying by fire.’

“I told the woman who I found to have pre-eclampsia signs or any danger signs after
delivery not to roast. I told them the threat of death if they keep doing so. They fear
dying, so they obey my advice. However, some women did not obey because their
mothers force them to practice it, but they roasted only for one or two days. It is hard
to tell them not to practice it, but I have to tell them to reduce the heat of the fire in
case they still want to roast.” (A midwife of Damkom Health center)

4.5.1.1 How ‘Lying by Fire’ is Done

Immediately after the delivery, a fire is lit either underneath the hut or the bamboo bed of the

mothers, or directly under the bed of the mother where she has to lie and roast for several

days, sometimes for weeks. A small bamboo hut was built and was attached behind the house.

A delivered woman and her child were kept in the hut. The delivered woman and her little

child lie on the bamboo floor. There is a fire under the bamboo hut. The hut is for the woman

and her child, and others stay in the house. The fire is lit 24 hours, day and night, until she

stops roasting. Women turn their body around like when roasting fish to make sure they get

full benefit from the heat. During that time and after roasting is finished, the woman is

covered from head to toe with heavy cloth and a cap to avoid wind entering into her body.

Before the fire is lit, Kru khmer (traditional healer) is called to give incantation and light the

fire. Sometimes, yeay mobs also helped to light the fire. Then, they called the kru khmer

again to put out the fire. While ‘lying by fire’, the newly-born child is also ‘roasted’ but is put

on a thick wooden floor in order to reduce the heat. In the first day of ‘lying by fire’, the

woman is advised to lay with her face down as much as possible, which is said to contribute

to a faster process. After a few days she can turn around.

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4.5.1.2 Why ‘Lying by Fire’ is Done

Traditionally, immediately after delivery, a woman is considered to be in cold state which is in

contrast to the state when she is pregnant, when she is thought to be in a hot condition. Thus,

she is said to be vulnerable to all kinds of diseases, and her health condition needs more

attention from her family. She is believed to lose a lot of strength during labor and to have

shared part of her blood with the baby. During that time, the uterus and sawsaye are believed

to be tender. Women interpreted that their sawsaye are new, unripe and breakable after using it

forcefully during delivery.

Also, the body has suddenly changed from a hot condition during pregnancy to a cold

condition. Accordingly, roasting is believed to help to restore balance and strength as it heats

the body and make the sawsaye chass (old sawsaye) or cha en (well-cooked sawsaye). It

means that roasting is to cook the sawsaye kjey (the new sawsaye). This is considered to be

very important to help the mother regain strength and energy in order to be able to work hard

again in the future. All women expressed their great fear of not being able to work hard in rice

fields after delivering the baby. Almost all old women in the study have problems with their

sawsaye.

“New sawsaye is when your body is weak. When you work, you feel shaky. When
you stay one or two months after birth you feel like your energy increases gradually.
When you do hard work, you feel the shakiness in your body increases. Then you
have to avoid hard work during that time. Later you feel better if you stay longer.
When you have old sawsaye, you have energy. You don’t feel shakiness in your body
anymore. You are strong enough to resume your hard work.” (Yeay mob, 60 years old,
experienced in assisting birth for more than 30 years. The mothers delivered by her
have never had any problems. Champey health center)

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‘Lying by fire’ is also believed to prevent toah if the woman follow all the roasting procedure

and avoid eating some foods which are considered to cause toah. Toah is literally known as

‘relapse’, it may occur immediately or several years after a woman has given birth. There are

many kind of toah, but the most common cause of toah is from food. Immediately after

delivery, the woman is not allowed to eat certain kind of foods. All informants mentioned toah.

A few of them experienced toah which they believed to be caused by food such as pig’s head,

buffalo meat, soup and uncooked vegetables. Another reason for the practice includes the

need to prevent the skin looking old and dry, to increase appetite, and improve sleep.

Table 4.4 shows the percentage of target women who practiced roasting after birth. Fifty

seven mothers with children under 3 years experienced ‘lying by fire’ immediately after birth.

The duration of ‘lying by fire’ is different from one family to another. In families which can

afford to buy charcoal or wood they can roast for a longer period, while poorer women roast

for a shorter period. Some wealthy women combined the practice of ‘lying by fire’ with

injections which are believed to produce heat in the body. But injections could be done only

when the practice of ‘lying by fire’ is finished. The duration of ‘lying by fire’ ranged from 1 to

10 days. However, the elders expressed that they used to roast nearly a month during their

time.

According to the study only 3 delivered women did not roast. One of them delivered at

hospital in Phnom Penh, and she was not allowed to practice ‘lying by fire’. Another 2 have

serious health problems, a symptom of high blood pressure, and they are strictly prevented

from ‘lying by fire’. Almost all women in the study believed that the practice of ‘lying by fire’

is good for their health. Women with some education also tended to be influenced by their

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senior relatives about the advantages of ‘lying by fire’.

There is no significant relationship between ‘lying by fire’ practices with level of education.

However, women with primary or high education are less likely to be influenced by their

senior relatives, and duration of ‘lying by fire’ of those women tends to be shorter than those

who are uneducated or less educated. Figure 5.6 shows this relationship. The women with less

than 6 years of education tend to roast more than those who have more than 6 years of

education and tend to roast less than their counterparts who have no education at all.

The practice of ‘lying by fire’ is widely done not only in Cambodia but also in almost all

Southeast Asian countries influenced by traditional Chinese beliefs. Kaewsarn et al. (2003)

have researched an example from Thailand about the Chinese concept of ‘Yin and Yang’ (hot

and cold) which makes women, particularly postpartum mothers, follow the practice of ‘lying

by fire’ or ‘roasting’. In Cambodia, there is no in-depth research about the possibility of its

advantages to health of the new mother. The Khmers also believe in the concept of hotness

and coldness of food which makes the body hot and cold. Therefore, the consumption of food

and some practices are considered to contain substances which could make the body hot or

cold.

The reason for practicing ‘lying by fire’ is that it heats the body. The modern health sector is

trying to change the behavior of people towards practicing modern health care and improve

the utilization of public health services at health centers and operational districts. The sound

policies cannot be achieved unless the public health services at health center level and attitude

of health staff are improved. It seems to be impossible to totally eliminate what the people

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have believed since they were young, and health services provided by trained health staff are

still questionable. Some researchers found that the practice of ‘lying by fire’ is harmful for

women with health problems (Goodyear 1995; White 1996). The advantages of the practices

have not been clearly identified. From the perspective of women informants, those who

experienced child birth at least once in her reproductive life perceived that the practice ‘lying

by fire’ can make their health good and is beneficial in their later life.

Traditional practices during delivery and postpartum period which were practiced by women

and yeay mobs were viewed to be potentially harmful and are likely to contribute to the

development of postpartum morbidity by many researchers (Amin and Khan 1989; Bhatia

1981). However, some beneficial and harmless practices were unlikely to be taken into

consideration by many modern health practitioners. Some yeay mobs also provide useful

practices which can provide psychological support to the new mother. For example, yeay

mobs massage women’s back and shoulders softly. Although, this practice is not effective to

reduce labor pain, it could make women feel better psychologically.

My argument here does not totally support the practice of ‘lying by fire,’ but sees that to some

extent, it may be useful for the new mother who does not have health problems after birth.

Charcoal should be used for the fire, and the place for roasting should be clean enough to be

sanitary. ‘Lying by fire’ could make the body of the new mother warm if the heat is not too

high. According to my observation of poor households, many are cold, especially in the wet

season. Most of the houses are covered by palm tree leaves, and their walls are also from tree

leaves. Only a few better-off households have better housing. A new mother could easily

suffer from the cold because she lost a lot of strength when giving birth. The warmth of the

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fire could help her to feel better after birth. The practice is important in cold season. However,

women with health problems should avoid roasting.

Table 4.4: The Practice of ‘Lying by Fire’

Number of days No. (n=60) %
1 day 3 5
3 days 19 32
More than 3 days 35 58
Total 57 95%

Figure 4.4: Relationship of 'Lying by Fire' and Level of

Education (n=60)
100%
95% 93%

5% 7%
0%

no education 1st-6th grade 7th-9th grade

Not practice Practice

4.5.2 Traditional Medicines

There are various types of traditional medicine. The kind of medicine used depends on type of

disease. Traditional medicine is also used by pregnant women and postpartum women. But

the ones used for disease treatment are different from the ones used by pregnant and

postpartum women. The medicine used by pregnant women is called tnam

ka pea ptey poah,25 tnam kdao (hot medicine) or tnam bok.26 Most pregnant women (55 out of

60 informants) started to drink the traditional medicine when they were around five months

25
Tnam ka pea ptey poah : medicine to protect pregnancy. Mostly, the medicines made from herb
combined with many types of trees’ bark.
26
Tnam bok is very common. It was drunk like tea. People who are not pregnant women can also drink it. It
is believed not having joint-pain if they drink it a lot. See appendix A and B for Khmer traditional
medicines which are used during pregnancy and postpartum.

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pregnant. The traditional medicine used during pregnancy is believed to keep the baby small

inside and to ensure easy deliveries, smooth deliveries, and clean babies.

All of these medicines are boiled with water and served after each meal and whenever

pregnant women are thirsty. All pregnant women as well as postpartum women are advised to

avoid drinking cold water or un-boiled water. They add some amount of the tnam bok into hot

water and drink it like tea. This medicine can be bought from kru khmer or at the market.

Usually, yeay mobs are not instructed to sell traditional medicines, but there are a few yeay

mobs who also sell some traditional medicines for pregnant and postpartum women. Some

medicine can be found by the family members without buying from kru khmer. Old people or

senior villagers are supposed to be knowledgeable about this kind of medicine. Moreover, the

boiled water mixed with traditional medicine is used to serve the whole family, not only

pregnant women.

“Pregnant women are advised to boil traditional medicines which are mostly made
from dried plants and can be found by the women’s family in the forest or around
their house. Some women buy it from kru khmer or in the market. It is used to
accelerate the birthing process and reduce pain during labor. Some women drink it
since they were 3 or 4 months pregnant and some take it only when they are 5
months. The whole family can also drink it. They use it like tea.” (59 year-old and 55
year-old elder, in a focus group discussion, Trapeang Rong village, Dambok Khpos
health center ).

The ingredients of traditional medicine used during pregnancy and after birth are reported to

have been collected from far and wide, particularly from forest and mountainous areas. There

are sometimes rituals associated with the collection of medicine. However, according to

villagers, some childbirth-related medicines are available locally. The main ingredients are

said to be plant products and/or different animal products, such as ground bones, claws and

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lung. Dried plant medicine can be seen to contain plant materials, even if the individual plants

cannot be identified, and it would be difficult to add non-plant material to this type of

medicine without the knowledge of the person boiling the medicine. Some ingredients are

reported to be given by the ghost or magic spirit who comes to kru khmer and tells them about

the ingredients and how to use them to help people in need. Some women mentioned that they

bought the traditional medicine from kru khmer who said that he was given the knowledge of

assembling the medicine and ingredients by spirits during dreams.

“When I was sleeping, a ghost came and told me about the ingredients of traditional
medicine during pregnancy. He told me to give it to pregnant women in order to
protect their pregnancy.” ( 69 year-old yeay mob, O maka village, Dambok Khpos
health center).

“I think traditional medicines are good for health. During my first child’s pregnancy I
did not drink it, and I had a difficult delivery. Then during my second pregnancy I
drank it, and I did not have much pain and had a short time.” (35 year-old woman,
Leap village, Trapeang Sala health center).

“I have drunk it since my first pregnancy; I have never had a problem during labor.
My children are healthy. My husband went to the forest in the mountain to find them
for me. During pregnancy, I can not drink cold water, thus I boiled water mixed with
tree bark to drink. I kept drinking traditional medicines until I delivered. After
delivery I drank different kind of medicines to prevent toah and to be healthy. My
mother boiled it for me. I don’t only drink boiled traditional medicines but I also
drink the traditional medicines mixed with rice wine. During my last delivery, I had
severe pain in my uterus. So when I drank wine mixed with traditional medicines I
felt much better. I can eat and sleep well after drinking wine. I heard my mother said
that if I drink wine I will not have joint pain when I am old and I will have good
looking skin as well.” (29 year-old woman, Dang Tong village, Damkom health
center).

“ Delivery is very important for a woman’s life. I have to save money for using
during delivery. I have to buy wood for roasting, traditional medicines during
pregnancy and after delivery, etc.” (19 year-old woman, Sdoc village, Champey
health center).

The medicine which is used for postpartum women is different from the one used for pregnant

women. There are various types, and they can be found by family members or bought from

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kru khmer. This kind of medicine is called ‘tnam toah’ (medicine to prevent relapse). It can be

used to mix with boiled water or steeped in alcohol (rice wine). Some herbal medicines must

be prepared in advance. It is believed that by the time a woman gives birth, the medicines will

have their full strength. These medicines are believed to be ‘hot’, thus they function in a

similar way to the practice of ‘lying by fire’. Some women drink both kinds of traditional

medicine (boiled with water and steeped in alcohol). It is served after meals. This kind of

traditional medicine is used only after delivery and can be used until one year or more.

Most women realize that their body loses a lot of liquid during roasting because of the heat.

Some mothers reported to have salty diets during ‘lying by fire’ in order to increase

consumption of water. They also said that they had to pass much more urine during the

roasting period than usual. The major drink consumed during this time is the traditional

medicines, which is a tea-like beverage. The postpartum women are advised to drink it as long

as possible. At first they drink just a small amount, and this amount is increased day by day. It

is believed to prevent relapse and joint-aches, to promote good looking skin, to promote

strength and to foster good sleep and appetite. The steeped medicine is believed to be better

than the one mixed with boiled water.

“Traditional medicine is used to protect the fetus and to reduce pain during labor.
Many women buy the medicine and steep it in rice wine long before the birth in order
to make the wine and medicine stronger. Sometimes, not only postpartum women
drink it but their relatives or husband who is supposed to take care of the woman also
drink it. Some women drink both boiled traditional medicine and the one steeped in
rice wine. Usually, they drink it after they finish roasting.” (65 year-old man in an
informal talk, Kea Tha Vong Leu village, Trapeang Sala health center).

“I felt unwell after drinking the wine but I try to drink a cup after every meal because
after drinking it I can eat a lot and I can sleep long.” (23 year-old woman, Sdoc
village, Champey health center).

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Tnam toah is reported to be difficult to drink because of its bitterness. Some women reported

to drink more than a month. Many mothers stated that even if they felt dizziness or headache,

they drink it because they believed that it makes them healthy. The effects of it are considered

the same as those boiled traditional medicines. All respondents stated that they try to drink it

because they don’t want to be unhealthy. This kind of medicine can be bought from kru khmer

or found by the family members. The details of traditional medicine used during pregnancy

and postpartum can be found in appendix A and B.

“Tnam toah is bitter and difficult to drink but it is good for mother’s health. A woman
has to try to drink it. If a woman can drink it a lot she will not have health problems.”
(40 year old-woman, Robak Ktum village, Dambok Khpos health center).

Effectiveness of those traditional medicines on mothers’ health or babies’ health was not

clearly known among young mothers in the study. Most of young mothers did not know the

effect of taking the remedies, but they told that they believed in its effectiveness because of

their mothers’ advice and their own experience. They were advised to drink the wine as much

as they could after each meal. When asked about side effects, all informants stated that they

did not recognize it, and they were optimistic that there were no side effects at all when

drinking it. All respondents from informal talks, group discussions and individual interviews

viewed that the traditional remedies steeped in rice wine and traditional remedies in boiled

water were good for health.

Traditional remedies steeped in rice wine are sold in every grocery store of all villages. A

glass of the wine cost from 100 riels to 300 riels ($0.025-$0.08). The wine is sold to all

villagers, but the remedies steeped in the rice wine were different from those which were used

by postpartum women. However, it was believed to reduced join-aches and increase appetite.

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The positive effects of drinking rice wine were thought to be greater than the negative effects,

according to the result of focus group discussions.

“The wine that I drink does not have any effect on the baby, but we need the wine to
keep us warm. The heat helps the body to get its normal condition back and it
prevents the blood from getting stuck in the veins.” (25 year-old mother, Chak
Chrum village, Dambok Khpos health center).

“When I drink a glass of rice wine, I feel strong and can eat and sleep well. Usually, I
drink the wine before I go to farm in the morning and one more in the evening after I
am back from the farm. If I did not drink it a day, I feel so exhausted and have
joint-aches. I can not sleep well. It costs 100 riels ($0.025) a glass.” (65 year-old man,
in informal talk, Trapeang Kamnob village, Dambok Khpos health center).

There are a lot of kinds of traditional remedies which are used to treat almost all kinds of

diseases. Some traditional remedies used during pregnancy are believed to protect the fetus,

and these remedies are boiled in water only. The traditional remedies used during postpartum

period are believed to prevent from disease which could be caused by many types of activities

such as various kind of food, hard work, etc. The traditional remedies used to treat diseases,

especially HIV/AIDS, were researched by Khana and Alliance (2001). The traditional

remedies specifically used during pregnancy and postpartum period have not been deeply

explored. A trained midwife of NMCHC mentioned that the national health program of MoH

did not prevent women from using traditional remedies. They allow their clients to use them

in a limited way. A moderate quantity of traditional remedies either in boiled water or steeped

in rice wine was advised. Herbal medicines are made from tree roots, trees barks, bones of

animals, and many kind of grass, which are not substituted by chemical substances. Some

traditional medicines, for instance the ones pregnant women used, are said to have been

introduced by spirits who want to improve the life of villagers. Senior people are thought to

be the most knowledgeable persons about the medicines.

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The cheap price and local availability of traditional remedies affected the user’s preference.

The remedies used during pregnancy cost 1000 riels to 2000 riels ($0.25 to $0.50) per pack,

similar to the price for the remedies used during postpartum. Herbal remedies are important in

places where public health services are limited and where people’s standard of living is low.

For instance, when a villager gets ill, they wish to visit a health center. But in the wet season it

takes time to travel to the health center, and often the staff do not come to work in the

afternoon or on a rainy days. Therefore, the patient will miss meeting any staff of the health

center. In this case, if they know how to use local resources such as yeay mobs or kru khmer

who are trained in providing effective health care or traditional remedies to treat their

problems, they will not have to waste time. As a result, instead of spending time traveling

very far to the health center, they could spend time doing other important jobs, such as

housework or farm work. It may be true that the poor prefer self-treatment as suggested by to

van de Put’s model in chapter 2, but, herbal medicines are also ubiquitous in market in the

capital, Phnom Penh. The present study found no difference between the poor and the

better-off about the preference for using herbal medicines, and there was no linkage with level

of education.

Almost all the informants mentioned that the longer they drink traditional medicines the better

health they will have. The consumption of hot water during and after pregnancy is thought to

be advantageous for the mother’s health and the production of breast milk (Fok 1996; Du

1998). However, the effect of boiled and brewed alcohol of traditional medicines on the

infant’s health should be taken into considered for further research. Remarkably, not only

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women with no education or some education, women with high education also drink

traditional medicines during pregnancy and postpartum period.

The most influential person for this practice is the grandmother who experienced using it and

told her daughters about her belief on its effect. The wine is prepared in advance (during

pregnancy) in order to make the medicines strong. It is worth considering the impact of wine

on the health of the baby because all postpartum women in the study breastfed their children.

Thus, the practice of drinking traditional rice wine mixed with herbal medicines may

adversely affect the health of the babies, and this topic needs further research. The belief that

drinking rice wine mixed with herbal medicine could reduce pain should also be studied more

deeply in order to identify what is good for health and what is bad.

In conclusion, the effects of remedies used during pregnancy and postpartum have not been

deeply studied. Further research is very necessary to identify positive or negative effects in

order to improve maternal and baby health. The practice of using traditional medicines

during pregnancy and after delivery requires more attention and cooperation from the

professional sector, the folk sector and the popular sector in health provision (see detail of the

sectors in chapter II).

4.5.3 The Use of Hot Rocks

Another way postpartum mothers regain body heat is through the practice of putting hot rocks

on the abdomen after delivery. This practice is done one or two days after birth. It is also

commonly known in rural villages as well as the practice of ‘lying by fire’. There are two

ways to perform it. The first one, which is commonest, is putting the hot rock on the abdomen,

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and the second practice, which is less common among the informants, is sitting on the hot

rocks. This practice is believed to space birth as it makes the uterus tender, and reduces uterus

pain and hemorrhaging. It is also believed to heal the perineal wound quickly. The most

influential person in this practice is mothers and the person with second most influence are

relatives.

How the practice is done: A rock weighing 2 to 3 kilograms is heated to a high temperature.

Then, the rock is covered by a blanket and put on the woman’s abdomen. The rock is placed

particularly on the uterus area. Some women reported to ask yeay mob to assist in placing the

hot rock on her abdomen. The second way of using a hot rock is to heat a very heavy rock to a

high temperature, then covering it with a blanket and having the woman sit on it. The second

practice is less common than the first, and only one woman in the study reported to have

followed it. The duration of the practice ranged from 1 day to 7 days for thirty minutes to

ninety minutes once a day. This practice can be done coincidently with the practice ‘lying by

fire’.

According to the result of the study, 50 out of 60 informants practiced placing a hot rock on

the abdomen, and one informant reported sitting on hot rock.

“I don’t know the benefit of using a hot rock. My mother and aunt told me their
experiences and they advised me to do so. My mother heated the rock for me because
during that time, I could not stand. She stayed with me until I was strong enough to
do everything by myself.” (19 year-old mother while she was breastfeeding her 2
years old son at her house in Dankom village of Dankom health center)

“ I heard elders say that putting a hot rock on the uterus can help to space birth. I
don’t use any kind of birth spacing methods but I have only two children. I put a hot
rock on my abdomen when I delivered my last child.” (36 year-old woman, in focus
group discussion, Dang Tong village, Dankom health center).

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The practice of putting a hot rock on the abdomen could be replaced by putting an ice-bag on

the abdomen. About two to three kilograms of ice were put in a plastic bag, tying its cap

firmly, covering it with a towel, and putting it on the woman’s abdomen. It is believed to

reduce uterus pain. But ice is expensive. Some women who delivered in hospital they were

advised to use ice, but when they returned home they used a hot rock instead. According to

the interview with the midwife at NMCHC, ice is provided by the center to a delivered

woman. The woman is advised to put the ice bag on her abdomen for 24 hours only. However,

some women insisted on using it longer, so they have to buy it by themselves. At health center

level ice was not provided. The most influential person on this practice was the trained

midwife, and the second most influential person was the mother. This practice ranged from

one day to seven days for 24 hours or whenever a woman is free. According to the study, only

9 (15%) women used ice-bags instead of hot rocks.

“ I used ice to put on my abdomen while I was at hospital because the midwife
advised me to do so. She allowed me to put ice only for one day, but I did not feel it
was enough, so when I returned home, I used a hot rock. I put a hot rock on my
abdomen for 3 days. I think it is cheaper than ice.” (19 year-old woman, Dankom
cheung village, Dankom health center).

Some practices have hidden effects on health which do not appear immediately, but may

appear in the future. For instance, in terms of the practice of placing too heavy a hot rock on

the abdomen, immediately after birth women have painful uterus cramps, and when they

place a hot rock on their abdomen, they feel relief, and conclude that the rock is good in

reducing pain. However, one midwife explained about the future side effect of placing too

heavy a hot rock on the abdomen, in that it could cause uterus prolapse (Srot sbuon) when the

women gets older. Trained health staff did not explain this to women, but they just advised

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women not to perform the practice. No one from the study mentioned about uterus prolapse

caused from the practice of using hot rocks.

The practice of using hot rocks or ice-bags on the abdomen has not been explored so far, and

its effects require investigation. Almost all women favored practicing it though mild

side-effects had been reported by several women. It could be helpful according to the

suggestion of a trained midwife, who explained her experience. She mentioned that

immediately after birth, she had severe uterus cramps. When she put her abdomen against a

hot rock (this is different from the practice of most informants here because they placed a hot

rock on their abdomen), the cramp reduced gradually. According to a study of Thai women’s

postpartum practices, the practice of heating a lamp on the perineum was recommended by

modern health staff instead of the practice of placing a hot rock (Kaewsarn 2003). It sounds

applicable to the Cambodian situation; however, due as the living conditions of most women

in rural areas are still in sanitary, the recommended practice should be done hand in hand with

sanitary education.

4.5.4 The Practice of Body and Face Steaming (Spong)

Spong is a steam bath method that Khmer women usually follow to clean their bodies during

the confinement period. Several types of herbs are boiled with water in a big pot. The hot pot

is placed on the bed or the floor. The woman sits on the bed or wooden chair without any

clothes, or a minimum of clothing on and a blanket covers both her and the hot pot. She is

told to open the pot’s cap gradually and inhale the vapor.

The other type of practice of spong uses a hot rock. A big rock is heated to a high temperature.

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Then, the rock is put on the floor or bed. The practice is similar to boiled water in pot in

which the woman is told to sit on the bed or wooden chair without or with a minimum of

clothing on and a blanket covering her and the hot rock. When in the blanket, the woman puts

a few drops of salt water on the hot rock in order to inhale the vapor from the rock.

The duration of this practice ranged from 1 day to 15 days for more than two hours a day or it

is done as long as the woman could until the water or the rock is cold. This second type of

practice is rarely done. The most common practice of spong which is widely known is boiling

varieties of herbs in a pot.

Spong is believed to help sweat out ‘poisonous’ water in the body so that the body may absorb

‘good’ water. This is said to make the woman have healthy and pretty skin, particularly on her

face. It also helps to protect against blurred vision, dizziness, headaches and fatigue in later

life. In addition, it helps to get rid of the smell of lochia, which is believed to have bad odor.

Another reason to practice it is to increase the consumption amount of water by the new

mothers. The most influential person in this practice is mother and the second most influential

person is relative.

Fifty one out of 60 informants (73%) practiced spong. The practice of spong consumes both

money and time, therefore, only the non-poor households can perform it, or the poor perform

it for a short time. Notably, spong cannot be done coincidently with ‘lying by fire.’ Spong is

done only after ‘lying by fire’ is finished.

“After I finished roasting, I practice spong for a few days. I was told that spong is

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 good for health because it can prevent having headache and jorm mok 27 ”. (39
year-old woman, Chak Chrum village, Dambok Kpos health center).

“Some women after giving birth, they did not work a lot, so they did not release
sweat. It is good for them to spong because they can release sweat and also be thirsty.
My mother told me to spong as much as I could. But I spong one three days, because
I have to take care of the household chores.” (37 year-old woman, Robak Ktum
village, Dambok Khpos health center).

Another nine women informant who did not practice spong stated that they could not afford it

(4 informants), and they thought that injections could heat their body enough so they did not

need to spong (5 informants).

“I also wanted to practice steaming but I could not because there is no one to help me.
I was busy taking care of children, and my husband was busy with rice farming.” (34
year-old woman, Ang Kcheay Tbong village, Dankom health center).

The practice of spong is appreciated by most women in the study because of the restriction on

doing hard work and taking bath during postpartum period which made their body smell.

After delivery, the majority of women restrain themselves from doing hard work for at least

two weeks or more than a month. All women mentioned not taking a bath for a month.

Usually, they said that the first bath they took is the first day that their babies opened its eyes,

which is one month after the delivery. Due to not taking a bath for a long time, the mothers

were recommended to practice spong to reduce their body odor. Further, the soots twigs which

are boiled with water can make them feel comfortable.

“I did not take a bath for a month, until my son opened his eyes. I did not do hard
work such as harvesting or farming, so my body smelled badly. Thus I was told to
practice spong because it reduced bad smell from my body. Also, the substances
which are used to boil with water can make my body smell good. I think spong is
27
Jorm mok a kind of disease of having scars on face. Usually, Cambodian women have this kind of
problem after giving birth. Most of them thought that it causes from worrying too much, and did not take
enough sleep habit. They believed that face steaming can reduce the scars on their face.

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 similar to taking a bath, but it is better than taking a bath for delivered mothers.”
(29 year-old woman, Keatha Vong leu village, Trapeang Sala health center).

The practice of body and face steaming is somehow important for the health of new mothers

and it requires more attention from the professional sector. According to the individual

interviews with midwives of health centers and the midwife from the NMCHC, they agreed

that they do not mind clients practicing it because there is no restriction protocol from the

MoH and also they thought that the practice could be beneficial to health.

“I don’t mind clients practicing body and face steaming because if we look at the
modern practice there is the practice of steam at beauty salon. So I think it must be
advantageous to do it though it is not documented. And if we look at Thailand, they
also have body steaming in order to reduce the body’s toxic substances. And several
researches have shown its importance.” (43 year old trained midwife, Champey
health center).

This practice seems to be accepted by the modern health staff. All modern health practitioners

in the study believed that this practice is harmless, and indeed has some benefits for

postpartum women. Postpartum women were restricted from taking a bath for at least two

weeks. Consequently, spong could help women to sweat out what they thought as poisonous

substances and it also helps to reduce body odor. This practice has been introduced in modern

practice to care for women’s beauty. The practice of herbal steaming is advertised for women

of all ages. The practice of spong should be further researched in order to identify its benefits.

In an attempt to promote beneficial local practices, the advantages of this practice should be

noted in the health education curriculum.

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4.5.5 Injections

Apart from traditional practices, most of the informants also mentioned use of injections.

Usually, in villages injections are given by either trained health staff or untrained health staff.

The practice of injection is raised for discussion for several reasons. Firstly, injection in rural

areas can be done by either professional health staff or non-professional health staff who have

some knowledge about how to inject.

Notably, since the integration of people who stayed in refugee camps,28 many people who

were trained in nursing and midwifery returned to their own villages. Although they were not

recognized as having modern health training, some of them run their own clinics in the village,

providing services such as injections, disease consultation, and treatment for all kind of

disease of both women and men, young and old. Even though they are the health center staff,

they work independently with villagers in their villages. They are called private peet.29

Secondly, there are various medicines used for injections. The most common medicines used

by women are summarized in table 4.5. Often, injections are believed to provide good health

to postpartum women. Another reason for injections is to reduce pain during labor and to heal

the perineum was cut while delivering (for difficult birth). The effect of the medicines is to

heal the wound. Trained health practitioners seem to agree with the last reason and stated that

if women were not injected with certain medicines they would suffer from fever.

28
During 1980s, many people wished to migrate to live in other countries rather than in Cambodia. They
traveled across the Thai-Cambodian border and were kept in camp sites along the border. Some people with
some level of education were trained to be nurses or midwives. They were not considered as professional
health staff, although some of them have been working for the government hospitals. They have to upgrade
their skills at vocational training school or university.
29
Peet is used to call a person who is medically trained in disease treatment. Peet can be doctor, nurse and
midwife.

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When asked about what would happen if a woman did not practice ‘lying by fire’, all

respondents said that women should replace ‘lying by fire’ by injecting ‘hot’ medicines.

Injections are popular not only among postpartum women but also unmarried women, but

those who can afford injections are considered better-off villagers. Injections are much more

expensive than traditional ways of health care. A variety of medicines are used to inject

postpartum women and the number of needles range from one needle to 8 needles for a

postpartum period. The variety of medicines used to inject postpartum women is shown in

table 4.5. Often, injections were given by untrained and trained health care deliverers who

have no idea of the medicines’ mechanism or potential side effects. Some women bought

medicines by themselves and call for private peet or nurses to inject them. Some women were

injected by either midwives or nurses of a health center. Further, deliveries by trained

midwives were induced by injections.

Injected medicines are costly, especially in rural areas where modern and new medicines have

hardly arrived. Medicine can be bought at village drug stores or at private peet clinics. The

effect of those medicines is questionable as there is no proper check-up from trained

pharmacists. The cost of injections is diverse. If a woman was delivered by a trained midwife,

the cost of the injections will be included in the service of delivery. On the other hand, if she

was delivered by yeay mob, she must call a private peet or nurse of a health center to inject

her. The cost of medicines ranged from 20,000 riels to 60,000 riels ($5 to $16). And the cost

of injection per needle is 500 riels to 1,000 riels ($0.13 to $0.25). In rural areas, people can

earn only less than half a dollar (2000 riels) a day.

According to the interviews, 60% of informants had injections after birth. The amount

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injected ranged from 1 syringe to 8 syringes. Some women who could afford to buy more

medicines, preferred to inject more syringes because they think that medicine not only makes

their body hot, but it also makes their skin beautiful. Most respondents in the study stated the

benefits of injections as promoting good skin, making the body hot and regaining energy after

birth, boosting breast milk production, and promoting good appetite and sound sleep. The

influential person for this practice is trained midwives and the second most influential person

is relatives.

“I received injections for a week, one syringe per day. The peet30 injected me. If I did
not inject I could not sleep well after birth because I still had pain. But when I had an
injection and together with drinking rice wine with traditional medicines, I could
sleep well. I have no health problems.” (35 year-old woman, Trapeang Sala village,
Trapeang Sala health center).

“Women prefer injections after birth because they believe it makes their skin
good-looking and helps them regain energy after birth. Some women get injections
just when they have fever because of uterus pain. Some women buy medicines in
advance, and then ask me to inject them. In this case, I charge them for only injection
service. However, some women did not buy drugs and I inject them using my
medicines. The injection and the delivery fee are charged together. But I suggest
them to inject only a few needles because of its high cost, and I know that my
villagers are still poor. I advised them to use the money to buy food which provides
better nutrition for their health. A few women still want to get more injections.” (A
health center midwife, 39 year-old, Dankom health center)

Although injections provide some benefits, they are not advisable. Some of the medicine does

not have any effect on health. The injections should be done only by trained health staff

because they would be able to manage potential complications. Moreover, in response to the

lack of trained health staff at health center level and also at district level, people who were

trained at camps should be encouraged to work at health centers. During health education

women should be informed about the actual effects of ‘medicines’ and the waste of money

30
The peet here she mentioned about trained midwife of health center who assisted her during delivery.

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caused by injecting. Instead of injection, women should be encouraged to eat nutritious

locally available foods, and they should be educated about the importance of nutritious diets

during the postpartum period.

Table 4.5: Medicines Used by Postpartum Women

Name of Medicine Reason Women Used it
(Generic Name)
Becozine To make skin good/hot, increase energy
(Vitamin B1, B2, B5, B10, and B complex)
Bepontene To make skin good/hot, increase energy
(Dexpanthenol, DL gamma lactone,
P-hydroxybenzonate methyl hydroxypropyl)
Vitamin B6 For postpartum hemorrhage
Vitamin B12 To increase blood pressure, increase
energy
Vitamin B Complex To increase energy
Vitamin C To make the sawsaye soft
Lactate IV fluid To increase blood pressure
IV with glucose For fever
Calcium To make skin hot, decrease pain,
increase energy
Ampicillin To heal the uterus
Penicillin To heal the uterus
Utine (unknown generic name) To make skin hot, increase energy
Strychnine To make skin hot, increase energy
Atacriline (unknown generic name) To lower blood pressure
Heptamyl (heptaminol HCl) For postpartum hemorrhage
Source: White 1996

4.5.6 Other Practices

There are many other practices during pregnancy, delivery and postpartum which differ from

area to area. For example, regarding postpartum diet, some women believed that they have to

refrain from eating certain foods, and some women believed that there is no need to be on

restriction. In addition to roasting, drinking traditional medicines, steam, using hot rocks and

injections, there are various types of practices.

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- Sexual abstinence and restricted activity

A period of sexual abstinence was reported by all women, with the duration varying from

7 days to 150 days. The most common reasons for avoiding sexual intercourse were the

involution of uterus and the health of women. A few women said that they observe the

practice by the habit, tradition, or because their mother or old people told them to do so,

the majority of women mentioned that they think their health is the main reason to avoid

sexual intercourse. Trained midwives of health centers also reported to advise women to

observe sexual abstinence. Several behaviors are also common for postpartum women.

They avoid many activities in order to rest particularly in the first few days after childbirth.

They were advised not to do strenuous works which required large amount of energy such

as transplanting, harvesting, carrying heavy loads of water, squatting or kneeling, and

exercising. These activities were believed to lose energy, to cause relapse, and cause the

uterus to slip from the normal position, to cause joint aches in the old age (because the

sawsaye is still young).

- Taking hot bath

Hot baths were recommended by a few women. Most of the postpartum women did not

take any bath for a period varying from two weeks to one month. Mothers and senior

relatives were the most influential. After two weeks or one month of restriction from

taking bath, they reported to start to take a hot bath afterward. The duration of taking a hot

bath continued until three months after birth. However, some poor rural women reported

taking a hot bath for a very short period which ranged from two weeks to six weeks. They

believed that taking a hot bath could maintain their body heat and accelerate the healing

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 process.

- Food restriction

The consumption of a high salt diet is encouraged; often women eat mainly rice with large

qualities of salt and pepper or accompanied by salty fish and meat. When a woman is

roasting, she is required to eat certain kind of food such as borbor (porridge) with pepper

and salt. All kind of vegetables are strictly prohibited for postpartum women, the

prohibition lasting until 20 weeks after birth.

The reason for the consumption of a salty diet is partly to help heat the body and partly to

encourage women to drink more boiled traditional medicines or rice wine mixed with

traditional medicines and to make the women urinate more often. There is no food

restriction during pregnancy but some women (n=30, 50%) said that they did not eat

banana shoot soup, because they were afraid that it could cause stuck birth and unhealthy

baby. All women (from focus groups and individual interviews) mentioned avoidance of

eating spicy foods, as they believe that spicy foods affect the baby’s health and uterus

involution.

- Brolei

Brolei is the name of a wild tree. Brolei shoots are sliced and steeped in rice wine. Usually,

pregnant women prepare this since the time they are one or two months pregnant. The

brew is used to paint the body of delivered women. This practice is done daily after

delivered women finished steaming. The number of days practiced is similar to that for

steaming, varying from 1 to 15 days. Some women reported that they practiced it as long

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 as possible and they thought that the longer the better. However, as this practice consumes

time and money not all the women in the study practiced it.

- Hot salt pot

Another traditional practice during postpartum period is hot salt pot. Sea salt is heated

with a clay pot until it is quite hot. The salt pot is then placed on the woman’s body,

especially on her abdomen, back, legs and arms. This practice is believed to ‘loosen’

tendons and blood vessels in the body so that the blood and ‘wind’ will not be obstructed.

It is believed that childbirth blood is ‘poisonous’ and it may remain in the back part of the

body, particularly in the backbone. If this happens, the woman will experience body aches

and pains in later life.

“Pregnancy period is very important for all pregnant women, so all pregnant women
have to follow the rules in order to be healthy and have the baby healthy. When I was
pregnant I did not do hard work and I followed all the rules my mother told me,
unlike this young generation. When I told my daughter not to do something during
pregnancy, she did not believe me and kept doing it. But you see the young
generation girls do not have good health like the elders. The old people were very
healthy and they live very long.” (49 year-old woman, in focus group discussion,
Ang Chuort village, Champey health center).

4.6 Reasons behind Practices

Results from the study demonstrate that participants’ postpartum practices followed the

beliefs originating from the yin and yang of Chinese medicines and that they practiced a

number of activities to maintain their body heat. Women accepted that Ang Phleung or ‘lying

by fire’ during postpartum period is believed to reheat the mother’s body.

Almost all the respondents in the study were influenced by their senior family members,

- 99 -
especially mothers, to practice traditional ways of health care. It is very common that

Cambodian families have close relations because most of them live in extended families. In

addition, because of many years of civil war and political instabilities, many people heavily

rely on self-treatment or seek treatment from these who experienced a similar disease.

In the informal talks with senior villagers, the practice of ‘lying by fire’ has the following

cultural reason:

“Long time ago, there was a story about roasting. There was a couple, a husband and
wife. His wife got pregnant. They ran away into the forest. Then she delivered the
baby in the forest. After that she was cold. Then her husband made a fire for his wife
to lie on to prevent coldness. Since then, all Khmers believe that roasting cooks the
sawsaye.” (An old man, 60, of Ang Kcheay Cheung village).

“My wife was cold immediately after giving birth. I did not know what to do. The
TBA told me that she suffered from losing a lot of blood during delivery. Then, she
told me to find kru khmer who can give incantation to avoid ghosts who follow every
delivered woman and ate placenta. I called Kru Khmer to help my wife and light the
fire for roasting. After roasting, she felt better because she was no longer cold. Kru
Khmer is knowledgeable about the practice.” (The quote was taken during informal
talk with senior villagers, Damkom Tbong village).

Some reasons were forgotten because they were not properly documented, and some became

unclear as they were passed on from person to person. Thus sometimes the truth has been

changed and sometimes something has been added to the truth make the story more attractive.

This happens in every country which is weak in documentation and where the people have a

low level of education. In 1975, Cambodians came under a genocidal regime which

completely destroyed all documents kept in the country. After Cambodians were freed from

the regime in 1979, they were in great hunger which caused them not to think about any thing

but survival. A layman of one pagoda in the study area said in an informal talk

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 “There were some documents about the cultural reasons for Khmer beliefs but most
of them were destroyed during Pol Pot regime. The old people died because of old
age and because of disease, therefore, some reasons are not known. And young
generations were not educated about those reasons, so day by day, they are
forgotten.” (A layman, 65 year old, Ang Chout village, Champey health center)

There are many cultural practices related with beliefs about ghosts which will affect the newly

delivered mother if she does not respect the rules developed by ancestors, during pregnancy,

delivery and after delivery (Eisenbruch 1992). A major cause of illness during the postpartum

period is believed to relate to ghosts and also to supernatural causes.

Women are expected to observe particular codes of conduct associated with

pregnancies and childbirth. If women violate these codes, their bodies are invaded by
ancestors or spirits. They suffer from a ‘Ckuet’ (mental illness), known as ‘Ckuet
Kralaa pleung’(eclampsia), that reflects a catastrophic disruption in the mother’s
spirit world and her body. This ckuet is caused by what is regarded as unripe bad
blood remaining in the mother: after the birth, the placenta, umbilical cord and
umbilical blood should descend, and the woman can become ckuet if they do not and
she then acts wrongly in some way (Eisenbruch 1992:284).

The practice of taking a hot bath, lying by fire, spong and using a hot rock, have similar

reasons. The main preference during post birth period is heat to make the body of the new

mother warm as she suffers from cold after birth.

Cultural reasons coupled with spiritual reasons make women strongly obey what they have

heard from their senior relatives and mothers. All relations in the family are hierarchically

ordered along the elder-younger dimension (Jan et al. 1996). Culturally, Khmer women are

not expected to ignore what their elders say. They are not allowed to go against elders;

otherwise, they will be cursed with bad fate in the future.

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4.7 Concluding Analysis of Traditional Practices Impact on Health

Amongst the 14 traditional practices, the practice of drinking hot water with traditional

medicines is the most common practice held during pregnancy and postpartum period, while

the practice of ‘lying by fire’ stands as the second most common practice among rural women

during postpartum period. The most influential person for the practices is the woman’s

mother and the second is relatives, who may be grandmother or aunts. Some study informants

reported following the practices as they do not want health problems during their old age. For

instance, the practice of taking a hot bath is reported to be beneficial for postpartum women.

Some women also preferred to practice moderate heat of lying by fire as it could warm them

during the cold period after birth.

Since all of the studied villages have experienced the interventions of Racha, ranging from

Family Planning (starting in 1996) and Reproductive Health Program (which includes Safe

Motherhood Program, TBA training Program, Health Promotion and Health Education

Program and Child Health Survival Program), all informants are likely knowledgeable about

health care issues and have changed their health care utilization behavior. However,

traditional practices are still favored among the women informants of the study.

Traditional practices are believed to offer not only physiological but also psychological

support, which is vital for women’s health during pregnancy and postpartum. For instance,

relapse is believed to be caused by the wrong practice of women such as too early resumption

of coitus or eating some prohibited food. Relapse cannot be treated unless women observe

some special prohibition and drink traditional medicines.

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Ideally, from the perspective of trained health staff traditional practices are harmful when

women practice them too much. There is a difference in perspective between trained health

staff and local people who perform the practices. To bridge the gap by incorporating harmless

traditional practices into modern health practices would be crucial to improve the health of

women for the time being.

Results of the study reveal that level of individual income did not have strong influence on

health care behavior of respondents. Health centers have a fee exemption scheme for those

recognized as the poorest in the village and approved by the village chief. Although the

scheme has been implemented, people’s health care utilization has not changed so much. An

informant with a moderate level of income still prefers to give birth with yeay mob whom she

trusted to solve complications. Persistence of traditional beliefs affects the way people view

their health and complications in pregnancy and birth. Women believed that, for instance,

their health would be good in the future if they followed the advice of senior people and

ancient spirits.

However, level of education played an important role in influencing health care behaviors of

women in rural areas. Women with some education or those who could read or write tended to

perform traditional practices less than those who could not write or read. Obviously, women

who have a low level of education were generally influenced by their senior relatives and they

tended to believe in them much faster than those who were highly educated or had a few years

of schooling. Educating old people and training them to be health educators for their children

and other young relatives is one crucial intervention for behavior change among Cambodians.

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Chapter 5 reviews persistent traditional practices and beliefs concerning reproductive health

from other developing countries in an attempt to compare these with common Cambodian

practices. Moreover, it aims to discuss the impact of the identified practices from the point of

view of trained health staff and local women and identify which practices are harmless or

harmful. Lastly, it also gives recommendations for improvement of women’s health situation

and suggests areas for further scientific research.

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 Chapter Five

BRIDGING THE GAPS BETWEEN MODERN HEALTH CARE AND

TRADITIONAL HEALTH CARE FOR DEVELOPMENT

5.1 Introduction

This chapter is divided into three sections. The first section contrasts the empirical findings of

the present study with the literature to date so as to derive insights into the issues under

discussion. The second section considers possible approaches to incorporate the harmless and

beneficial traditional practices into modern healthcare policies. Finally, the chapter suggests

policy recommendations for relevant stakeholders (i.e. the Ministry of Health, IOs, NGOs and

the community) to improve the overall reproductive health of rural Cambodian women.

5.2 Traditional Beliefs and Practices Concerning Reproductive Health in Developing

Countries

In many cultures of developing countries, the pregnancy and postpartum period is seen as a

time when mothers are vulnerable to all kinds of diseases. During this period, a certain

number of physical and emotional activities are restricted and certain traditional practices are

followed in order to avoid ill health (e.g. Manderson 1985; Fok 1996; Townsend & Rice

1996; Holroyd et al. 1997).

In order to avoid ill health, women in many cultures are advised to refrain from doing

physically hard work and eating certain kinds of food (e.g. Goodburn 1995; Rice 1999;

Kaewsarn 2003a). In the cultural context of Cambodia, White (1996) and Kuhlmann (2004)

- 105 -
describe restrictions about food intake and strenuous work practiced by rural women during

the pregnancy and postpartum period. However, they argue that food restriction is not

physically advisable; in fact, it would lead to malnutrition of both mother and infant. In the

present study, more than 50% of women mentioned restriction on some particular food, such

as pig head and bamboo shoots. Nevertheless, the very poor women were unlikely to observe

any food restriction as they could only afford locally available vegetables. The study among

Bangladeshi women also revealed that the restriction of food intake has relation with poverty

and cultural beliefs (Goodburn 1995). Bangladeshi poor women could not manage to buy

nutritious foods, although they were not restricted from food intake; on the other hand, they

were not allowed to eat meat for cultural reasons.

Another restriction during this critical period is on sexual intercourse. Lee (1972) studied

among Vietnamese women, Wilson (1973) and Laderman (1982) studied among Malay

women, Muecke (1979) studied among Northern Thai women, Chalmers (1993) studied

among Indian women, Escoffier-Faveau et al. (1994) studied among Laotian women,

Goodburn (1995) studied among Bangladeshi women, and Kaewsarn (2003 and 2003a)

studied among Thai women. The study among Thai nurses about their perception of the

practice showed they found it acceptable and beneficial (Kaewsarn 2003). The similar study

conducted by Goodburn (1995) among Bangladeshi women also found the practice beneficial

for women’s health. A study by Chap (1996) reveals sexual abstinence among Cambodian

women, from the last trimester of pregnancy until the end of the postpartum period. It is

believed that having sex within this period would have bad effects on health of both mother

and infant (Chap & Escoffier 1996). Mostly, this restriction is imposed by trained health

staff and women’s mothers.

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The concept of hot and cold states during pregnancy and postpartum is also observed by

women in many developing countries. The idea of pregnancy being a hot state and postpartum

being a cold one necessitating dietary change has been described in studies of Indian women

(Chalmers 1993), Vietnamese women (Manderson and Mathews 1981), Taiwanese women

(Pillbury 1982), Malay women (Laderman 1982; Wilson 1973), and Bangladeshi women

(Goodburn 1995). The common belief is that body heat must be maintained during

postpartum. The concern about maintaining balance by providing extra heat for postpartum

women has been documented in studies of Hmong women (Jambunatha 1995), Rolai tribal

women in Vietnam (Lee 1972), Korean women (Kendall 1987), Lao women

(Escoffier-Faveau, Souphanthong and Pholsena 1994; Robertson 1984), Malay women

(Laderman 1982; Wilson 1973), Northern Thai women (Muecke 1976). In Cambodia, the

practice of ang phleung or ‘lying by fire’ has been studied by White (1996), UNFPA (1999)

and Kuhlmann (2004).

Rural Cambodian women believe in staying in a hot state in order to keep the body balanced

and enhance health in the future. But, non-poor or urban women prefer injections to ‘lying by

fire’ in order to make the body hot after giving birth, as this is more convenient. According to

White (1996), trained health staff do not advise women on this practice. The present study

discloses that the mother is the most influential person to make women follow the practice. In

addition, eating hot diets (e.g. ginger, pepper, chilli, etc.) is prevalent among postpartum

women in Cambodia, as these foods are also believed to heat the body. Women participating

in the present study reported refraining from having such cold foods as cold soup and raw or

unboiled vegetables during postpartum. By contrast, hot foods are avoided during pregnancy

- 107 -
as women think that they are harmful to health of both mother and fetus (Kuhlmann 2004). It

is believed that during this period the body must be kept cool, as a precondition for a healthy

mother and baby.

Besides these traditional beliefs and practices adhered to by rural women in many developing

countries, another common feature is that the majority of deliveries are handled by TBAs

(yeay mobs) (see Goodburn 1995; Jennifer 1997; Kaewsarn 2003; Bang et al. 2004). Since

TBAs play such an important role in rural birth deliveries, there is a consensus to strengthen

their capacity so as to make their practices safer. The Ministry of Health (MoH) of Cambodia,

for example, has conducted trainings for yeay mobs to upgrade their technical skills and to

educate them to refer pregnant women with danger symptoms or complicated births to health

centers or referral hospitals (Racha Studies 7 & 16). Upon completion of each training course,

yeay mobs are provided with delivery kits (Neumann et al. 1986; Nessar 1995; MoH 2001),

and health center staff maintain regular contact with them through supervision, refresher

training or meetings every three months (MoH 2001).

Assessment results of yeay mob trainings prove that improvement of yeay mob qualifications

is extremely necessary in rural areas where public health services are quite limited (Racha

Studies 7 & 16). The two studies recommend taking into consideration whether the practices

of yeay mobs are medically harmful or harmless. According to the findings of the present

study, the majority of women were delivered by yeay mobs, and thus improving skills and

knowledge of yeay mobs is necessary to reduce maternal mortality, because they are physical,

psychological and emotional supporters for many women (Collins 2000).

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5.3 How Can Traditional Beliefs and Practices Concerning Reproductive Health be

Integrated into Modern Healthcare Policies?

As presented in Chapter Four, women of the present study held a broad variety of traditional

practices during pregnancy, delivery and postpartum. To determine what traditional practices

can be incorporated into modern healthcare policies, it is crucial to comprehend how women

and health practitioners perceive these practices. The sections to follow outline perceptions of

these stakeholders regarding particular practices, offering reasons and explanations from

diverse perspectives.

5.3.1 Women’s Perceptions of Traditional Practices

The present study found that the majority of women desired to continue their traditional

practices (e.g., lying by fire, using hot rocks, drinking traditional medicines, etc.). Only a

small number of women, particularly the non-poor, preferred to practice both traditional and

modern methods of health care. Perceptions about the effects of and reasons for these

practices expressed by the women are summarized in Table 5.1, which represents a synthesis

of findings from the focus group discussions and individual interviews with target women and

yeay mobs.

The judgment regarding the practice’s bad or good effects on health was drawn from the

overall judgment of target women and yeay mobs. Notably, some practices were marked as

having dual effects which are either good or bad on health because women gave ambiguous

responses. Some women judged some practices as potentially harmful if performed too long

or too forcefully (e.g., too hot, for the practice of ‘lying by fire’).

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After many years of birthing experience, many women observed that they did not have any

health problems applying some of the traditional practices during pregnancy and after birth,

thus they thought that those practices were good for their health. As explained in Chapter Four

about the practice of ‘lying by fire’, the majority of women believed that when they take

enough time to lie by fire they will avoid future joint-ache, and be able to work very hard. In

contrast, they reported feeling uncomfortable when they did not perform each practice for

long enough. A woman from a focus group discussion, for instance, complained that her

ill-health was because she was not allowed to ‘lie by fire’ after birth as she had had high blood

pressure. Despite some minor side effects caused by the heat, they believed that the heat is

important for their health and to maintain the body’s strength. A sixty five year old elder

stated that during her time since there was no nearby public medical facility, she used only

traditional ways of health care for all of her nine childbirths, and she has never had any health

problems because she adhered to the practices very well.

Experiences of senior relatives who practiced traditional practices and enjoyed good health

influenced the behavior of the young generation. Drawing from the discussion in Chapter Two

about theoretical framework of the study, health care behavior was influenced by the popular

sector which includes the family. New mothers learned that their mothers have good health

because they adhered to many traditional practices after birth. However, new mothers still

complained that they could not perform all the practices advised by their mothers because of

time and money constraints, and they perceived that they have poor health as a result.

Superstition and ritual are also important in health care beliefs. Many informants believed that

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if they don’t follow their ancestors’ instructions, they will suffer bad health. For instance,

yeay mob reported that a ghost spirit came to her in a dream, told her about traditional

medicines during pregnancy, and advised her to give these medicines to pregnant women,

otherwise, she would be cursed with ill-fate or ill-health. The medicines are tested through

trial and error. If it successfully cures the problem, it is thought of as effective medicine. In

contrast, if it is unsuccessful, users will change to other medicines. Some pregnant women

visited kru khmer (traditional healer) or yeay mob to receive incantations and amulets to avoid

evil spirits and birthing obstacles.

The last finding regarding utilization of traditional practices is related to inaccessibility of

modern health services. Public health services were perceived by the majority of villagers as

poor quality (in term of quality of care, attitude of health staff, shortage of prescribed drugs)

and unaffordable (service charge imposed by Health Centers). Villagers are rarely able to find

health center staff if they visit after 11 o’clock in the morning. More precisely, the long

distance to health centers and poor working discipline of health center staff also contributed to

the unfavorable perception of public health services (Collins 2000; van de Put 1992). Some

informants reported spending more than one hour to travel from house to health center by

walking and nearly another by bicycle, only to find no staff at the health center. An example

drawn from the research by White (1996) showed that women were not happy when health

center staff did not understand the language they used to describe their condition. This shows

the staff’s careless attitude to clients’ complaints, which made clients feel marginalized.

Therefore, the clients turn to consult with yeay mobs or kru khmers whom they know very

well. Women described yeay mobs and kru khmers as good listeners.

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In an attempt to advocate indigenous knowledge and enhance beliefs which could be a

supportive factor, it will be critical to gain the cooperation of both orthodox or modern and

traditional health practitioners to work with one another.

Consequently, in the search for adequate and effective health facilities and the provision of

these facilities for a majority of women, the government needs to look into the possibly of

having both modern health practitioners and traditional birth attendants working together in

the health centers.

Table 5.1: Traditional Practices from Women’s Perspectives

Effect
Practices Obstacles Reasons
Good Bad
1.Traditional medicine X -Difficult to drink -Prevent from being relapse
-Duration of practice -Accelerate birth
is long -Small infant and easy birth
-Reduce pain during labor
2. Lying by fire X X - Skin rash -Regain strength
-Smoky and lack of -Bad blood flows out
oxygen - Cook sarsaye
3. Hot rock X X -Too big -Reduce uterus cramp
-Too heavy -Space births
4. Steam X -Takes time -Good skin
-Prevent headache, dizziness
5. Brolei X -Takes time -Good skin
-Good body smell
6. Injection X -Expensive -Good skin
-Reduce pain (antibiotic)
-Regain strength
7.Sexual abstinence X -Difficult to avoid -Involution of uterus
husband’s sexual -Maintain health
desire
8. Hot bath X -Take time -Maintain body heat
9. Avoid taking bath X X -Bad smell -Maintain body heat
-Avoid young/raw sarsaye
being touched by cold water
10. Restrict from doing X -No one to take care -Avoid relapse
hard work of the house -Sarsaye is young
11. Rest at home X -No one to take care -Avoid relapse
of the farm work --Sarsaye is young
12.Cover with thick X X -Difficult in dry -Avoid being touched by the
cloth season wind, cold air
13. Ice bag on abdomen X -Expensive -Reduce uterus cramp
14. Food restriction X X -Not enough nutrition -Avoid relapse
Source: Based on the individual interviews and focus group discussions with the target
women and yeay mobs.

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5.3.2 Health Staff’s Perceptions of Traditional Practices

According to seven individual interviews conducted with trained health staff, some traditional

practices were not supported by professional health staff and some practices are still

questionable. A summary of adaptive and maladaptive practices from perspective of

professional health staff is given in table 5.2. Professional health staff were asked to give their

perspectives on the fourteen practices raised by informants. The table was synthesized from

individual interviews with 5 trained midwives of four health centers on the perception of

which practices should be adapted into modern health care practices and which are harmful

for women health. The judgments were made based upon experiences and perceptions of

those health staff. Although the number of interviewees in this study is not large enough to

represent all trained health staff, it could be used to examine the current perceptions of

traditional practice from the point of view of health professionals who work closely with rural

women.

The perspectives of professional health staff contradict those from villagers for several

reasons.

Firstly, health staff argued that some practices may have bad effects on health later in life.

One health professional argued that the practice of ‘lying by fire’ should not be done by all

women. However, so far there is no scientific research on effects of the practice of ‘lying by

fire’, and good and bad impacts of this practice remain obscure. Prohibition without evidence

is a barrier for women trying to decide whether to follow traditional practices or modern

practices.

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Another point of disagreement from health professionals is the practice of injection. Most of

the injections are carried out by trained midwives of health centers soon after the woman

delivers her baby. Some medicines injected proved to have no effects on health. Instead of

injections, professional health staff recommended women to get enough food. The practice of

food restriction which could cause malnutrition to both mother and infant should be

prohibited.

The practice of spong and brolei have been recognized and are believed to provide no bad

effect on health. Spong and brolei could reduce body odor caused by avoiding bathing. These

practices were acceptable.

The practice of placing an ice-bag on the abdomen is not contradictory with modern practices.

This practice is recommended by trained health staff. Yet it was not widely done as it required

money to buy ice, and in rural areas ice is difficult to get. Therefore, although this practice is

recommended by many trained health staff, it is not commonly done in rural areas.

Table 5.2: Traditional Practices from Health Practitioners’ Perspectives

Practices Adaptive Maladaptive Questionable
1.Traditional medicine X
2. Lying by fire X
3. Hot rock X (modify practice)
4. Steam X
5. Brolei X
6. Injection X (medicine should X (waste of money
be the right one) for useless
medicines)
7.Sexual abstinence X
8. Hot bath X
9. Avoid taking bath X
10. Restrict from doing X
hard work
11. Rest at home X
12.Cover with thick cloth X
13. Ice bag on abdomen X
14.Food restriction X
Source: Base on individual interviews with trained health staff

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5.3.3 Synthetic Discussion of Traditional Practices

The findings of the study reveal many traditional practices pertinent to reproductive health

issues persisting in Cambodia, especially in rural areas. Fourteen traditional practices have

been identified through individual interviews and focus group discussions. From the

perspectives of the target women, seven practices should be incorporated into modern health

care policies.

Initially, this study supports the view that cultural rituals are important in pregnancy,

childbirth and postpartum. According to the results of the study, postpartum care is a cultural

construct made of a collection of knowledge and experiences not only of mothers, but also of

their senior relatives and neighbors. Individual people view diseases based on their own

cultural knowledge and also interpret their experiences of treatment based on their cultural

knowledge and assumption about traditional customs regarding postpartum care.

The results of the study demonstrated that more than 50% of women informants continued to

follow a number of traditional practices in postpartum period, particularly related to self-care,

rest and the consumption of ‘hot’ foods and fluids as well as certain other foods. Khmers

believe that childbirth leaves the mother in a cold state, so that she must do something to

restore the balance of the body. The practice of taking hot foods during the postpartum

period also proved to be beneficial, for example, in Thailand this practice proved to be

necessary for postpartum women (Kaewsarn 2003; Rice et al. 1999). Hence, this practice

should be recommended and should be encouraged.

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Another reason to support harmless traditional practices is that traditional practices of health

care are less costly compared with modern practices.31 From the findings of the study, the fee

for delivery by yeay mob is much lower than the fee for the same service from a trained

midwife. Moreover, traditional medicines, which can be found locally or in the nearby forests,

are more available and cheaper than modern drugs prescribed by health professionals. It is

also believed that traditional medicines have fewer side-effects than modern drugs (Sargent &

Marcucci, 1983). As explained in Chapter Three, the burden of health care expenditure falls

on individual households, and it is extremely expensive for the poor. Therefore, I argue that

trained health staff should take advantage of traditional practices to serve people’s needs in

order to reduce the cost of getting health care and at the same time to supply modern health

services if not in contradiction with their beliefs. It is important to explore local resources to

serve the basic needs of local people.

Synthesizing the results from Tables 5.1 and 5.2, nine practices were perceived as beneficial

to health, while five practices were said to be partly beneficial and questionable. However,

comparing the perspectives of elders and young people, elders tend to think well of all

practices, while young people are less sure.Young people often complained about problems

with the practices. Reasons for perceiving the practices as beneficial are personal experience

and observing effects after practicing. The practice of using traditional medicines during

pregnancy and postpartum period was perceived as beneficial from the perspective of

villagers and some health staff.

In contrast, the practice of ‘lying by fire’ had dual effects. It could be harmful if the heat is too

hot and there is not enough sanitation in the house. The behavior of this practice should be

31
Modern practices are defined as the practices done by medically trained health staff.

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modified, to use charcoal, and women should take enough nutrition in order to get best effect

from this practice. Trained midwives should educate women that the use of too hot fire is

useless and can be harmful, and there is no known advantage to such activity. There is greater

risk than benefit if the practice of ‘lying by fire’ is too hot or too long. Another practice,

placing hot rock on the abdomen, could be advisable if the heavy rock were replaced by a

light one or hot water container.

The practice of spong or ‘steam’ and the practice of brolei are accepted as good practice

among local villagers and trained health staff. This practice should be recommended and

encouraged among postpartum women.

The practice of injection after birth is questionable; this practice should be done by medical

trained health staff. The medicines for injection should be appropriate, and women should

avoid wasting money for useless medicines, as mentioned by White (1996).

The practice of sexual abstinence was found adaptive, and should be recommended by trained

health staff during health education to all women. The practice of avoiding a bath should be

placed by the practice of having a warm bath during the postpartum period. This is widely

accepted by trained health staff and is acknowledged as providing good effect on health as

well.

The practice of restriction from doing hard work and rest at home should be adaptive, but

these practices have been performed by better-off villagers while the poor cannot afford to

rest. However, this practice should also be recommended by trained health staff.

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Another practice, that of covering postpartum women with thick cloth from head to toes,

should be avoided in some circumstances, such as during the hot season. However, this

practice did not prove to have any bad effect on health. Putting ice bag on the abdomen is

recommended by many health staff, but few rural women can afford to buy ice.

Lastly, the practice of food restriction should be considered whether it is adaptive or

maladaptive as food consumption is often thought to be of nutritional importance (Rizvi 1976;

Goodburn 1995). However, some foods recommended to be taken during pregnancy and

postpartum such as meat and fish are unlikely available in poor families. The study’s findings

about food avoidance suggests that emphasis on the general harmfulness of food taboos in

health-education messages may not be necessary, and that such messages should be confined

to practices of proved relevance.

Older women and those who are less educated are more likely to practice traditional ways.

Thus, it is significant to provide traditional support to these people. Traditional practices may

act as a barrier for postpartum women getting care from professional health staff, because

professional health staff may disagree with their practices. Midwives who were interviewed in

the study always criticized the practice of ‘lying by fire’ and the use of hot rock. In order to

develop and provide effective care to women, trained health staff need to be aware of and

sensitive to the cultural needs of local people (White 2002).

White (2002) studied the perceptions of pregnancy and postpartum among Cambodian

women. She found that local villagers described diseases according to their own language;

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while trained health staff used technical language to describe diseases, using terms influenced

by French language. Therefore, if the trained health staff do not carefully consider and

investigate their clients’ complaints, women may choose to seek care from elsewhere, because

practitioners in the traditional system (yeay mobs or kru khmers) do pay attention to and treat

these cultural conditions. Although, I did not study women’s language to describe diseases,

the findings clearly identified the importance of local knowledge in perception of diseases and

the dominance of traditional practices in influencing rural women. The findings show that

yeay mobs still play an important role in improving women’s health in rural villages.

Consequently, TBA training is necessary to reduce maternal mortality. Studies from elsewhere

proved that TBA training is unlikely to be discontinued because yeay mobs are scarce

resources to support health policy (Goodburn 2000). Training yeay mobs is a relatively low

cost intervention, but one that has acknowledged limitations (Fortney & Smith 1997).

Although the training may not be cost-effective, it could be diverting the attention of donors,

governments, NGOs and others from interventions for which there is some evidence of

effectiveness in reducing deaths and support for referral and essential obstetric services at

first-level referral facilities (Maine 1996).

Similarly, in Cambodia, yeay mobs were trained to improve technical skills and refer

complicated births (Racha studies number 16). Yeay mobs should be trained and encouraged

to give appropriate services in their own community. Yeay mobs cannot reduce maternal

deaths directly, but they can be indirectly influence the practice of health care, reduce harmful

practices and unclean and unhygienic delivery (Racha studies number 16; MoH 2001). Hoff

(1997) claimed that incorporating TBAs in Primary Health Care programs can be cost

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effective and provide culturally relevant services to communities.

5.4 Synopsis of Major Research Findings

The qualitative analyses of primary and secondary data produce the following main research

findings:

(1) Fourteen main traditional practices were identified by villagers in the study areas. Only

five traditional practices were explained in detail in chapter four while the rest were

briefly explained because less than 50% of informants performed them.

(2) Harmless traditional practices should be incorporated into modern health practices.

Traditional practices derived from the summary tables 5.1 and 5.2 are viewed from

perspectives of trained health staff and local people. Nine practices were considered as

adaptive, and it was not clear whether the rest were good or bad for health, adaptive or

maladaptive. For example, the practice of putting too heavy a hot rock on the abdomen is

dangerous for women’s health, thus an alternative should be introduced. According to the

study among Bangladeshi women, trained health staff recommended postpartum women

to put hot water containers on their abdomens (Goodburn 1995). The study by White

(1996) recommended that the practice of putting hot rocks on the abdomen is beneficial to

women’s health. Similarly, drawing from this study, the practice of putting hot rocks using

a light rock, should be recommended. Or the practice of heating a rock then placing the

abdomen on it, as mentioned by a midwife of the health center about her own experience

of delivery, should also be introduced.

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 Though the practice of drinking traditional medicines during pregnancy and after birth had

no clear effects on health, according to the results from the survey, the amount drunk

should be reduced, specially the amount of rice wine which traditional medicines were

steeped in.

The practice of ‘lying by fire’ is unlike to be eliminated because majority of informants

preferred this practice against the advice of health staff. Therefore, the modification of this

practice (i.e. lower the heat, reduce the duration of practice, women should get enough

nutrition, sanitize house or living condition) should be introduced through health

education during outreach activities and through village health volunteers. The possible

modifications of practices should not contradict the people’s beliefs.

(3) The popular sector plays an important role in influencing health seeking behavior of

women in the study areas. The main actor in the popular sector in this study is the family

and the mother in particular. The popular sector was also influenced by the professional

sector and folk sector. However, from the perspective of villagers, they prefer to maintain

beliefs which already existed in the village.

(4) Yeay mobs categorized as folk sector, are resources existing in the village. They are in a

crucial position in reducing maternal deaths. Thus, further training courses and follow up

for yeay mobs are greatly needed to ameliorate health of women and their infants. In spite

of many arguments about advantages and disadvantages of TBA training, the results from

the study areas disclosed that yeay mobs are important to improve health of women by

strengthening their technical skills of delivery and improve their ability to recognize and

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 refer high risk clients.

(5) Professional health staff do not pay enough attention to cultural issues. Midwives from the

study mentioned that traditional practices performed by women are useless and could be

harmful. Some midwives criticized the wrongdoing of putting hot rock on the abdomen.

(6) Lastly, level of individual income is unlikely to have strong effect on health seeking

behavior, but other substitute factors such as heath staff’s attitude and discipline, location

of health facility, persistence of traditional beliefs and practices etc. have influence on

health seeking behavior of women. An informant from the study mentioned about her

dissatisfaction with the attitude of health staff providing health services. She said that the

health staff did not listen to what she thought about her problems, but just tried to judge

her condition. This did not happen when the woman got service from yeay mob, and she

added that she considered yeay mob as one of her own relatives. More significantly, the

fee exemption scheme for the poor which was imposed by the MoH in 1997 has been

applied to some health centers; yet, the level of health center utilization has not shown

significant improvement. Yeay mobs and kru khmers remain people’s counselors and

guidance.

5.5 Recommendations

There are many positive traditional practices surrounding pregnancy, delivery and postpartum

in rural Cambodia, but there are also some issues for concern. Based on understanding of the

Cambodia’s actual health context, several policy implications are noted.

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(1) Local beliefs and practices should be recognized by professional health practitioners:

Knowledge of the beliefs of local women should be incorporated in the training of health-care

providers if the health services are to be made relevant to local women. Some practices have

shown to be harmless, like the practice of spong, taking hot bath after birth, drinking hot

water (contains traditional medicines), etc. These are local knowledge about the practices and

they have adapted from one another through the ages. It is impossible to prohibit these

practices. Instead, the practices which are considered harmless should be encouraged. In

contrast, the practices which are considered harmful, like the practice of lying by fire with too

much heat, putting too heavy hot rock on abdomen, etc., should be modified or banned for

women with health problems. Health staff should educate women about those harmful

practices with evidence-based explanations. Since those practices were learnt from elders,

education for senior villagers and yeay mobs are important to influence their daughters’

decisions.

Furthermore, older women and those with little or no schooling are more likely to practice

traditional ways; therefore, it is important that additional support is given to this group.

Cultural beliefs and practices can act as barriers to modern practices, and rural women may

undertake postpartum practices with which health professionals may not always agree. Thus,

cultural sensitiveness and awareness should also be added in the curriculum for training

health care providers. Perceptions of clients about traditional practices should be respected by

trained health staff. If some practices prove harmful, trained health staff should try to educate

women based on scientific explanations. Trained health providers should understand the

perceptions of their clients and listen to their complaints. Instead of criticizing clients, health

staff should explain reasons based on actual facts that clients could understand and accept.

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The identification of beneficial local customs that could be reinforced in community health

education or in community health worker training should certainly be given equal importance

as the identification of harmful practices. Respect for reinforcement of beneficial local

customs is likely to improve the relationship between local communities and formal medical

services. The reinforcement should be done through community participation in health center

activities. Essentially, the staff should encourage people’s participation in health center

activities such as during monthly outreach activities, health promotion campaigns, etc.

Moreover, professional health providers should respect and support traditional beliefs and

practices, and a good relationship should be developed between trained health staff and yeay

mobs. Yeay mobs are expert in massage for women during labor, and kru khmer are expert in

spiritual protection which gives women psychological support. Encouraging those skills and

reinforcing relations between the professional and folk sectors are crucial for the development

of women’s health. Ultimately, training of TBAs should be continued on the basis of a good

understanding of traditional beliefs and practices. The TBA training program should be done

nation-wide.

(2) Improve Reproductive Health Through Informal Education:

The most immediate intervention is the improvement of informal education. Actually, women

in rural areas received lower formal education than men, and some of women have never been

schooled for various reasons (Beaufils 2000). Thus, informal education in rural areas has

proved to be important to disadvantaged groups. However, drawing on results from the study,

both formal and informal education are important to improve reproductive health of women in

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Cambodia. In formal education, health education should be included in school curriculum.

Government should continue to promote girl education in rural areas and encourage them to

finish education to at least primary level.32 School committees should also encourage parents

to send their daughters to school and explain to them the hidden advantages of education.

Furthermore, results from the study demonstrate that level of education affects health care

practices more than level of individual income per se. Although some health services

provided by trained health staff are unaffordable, the health centers have a scheme for service

fee exemption for the poor. Still, public services utilization is low if compared with the

services provided by folk sector, namely kru khmers and yeay mobs. Hence, health service

marketing through informal education, i.e., health education by village volunteers, campaigns

to improve health services utilization, is needed to improve services at health centers. On the

other hand, improvement of services at health centers focusing on women reproductive health

should stress not only the users’ perspective side, but also health service providers. Trained

health providers should educate women while providing services (during outreach activities,

or when women come to get antenatal check-up at health center) about which practices could

be harmful for their health. In addition, negative effects of traditional practices with

supporting evidence, should be informed to all women and men.

Although level of individual income is unlikely to have strong influence on heath seeking

behaviors, public health service fee exemption should be maintained, and it must be ensured

that the real poor are allowed benefit from the scheme. The program of health service fee

exemption for the poor should go hand in hand with the program of health center marketing

32
Primary level of education starts from 1st grade to 9th grade (MoEYS 1999). It is considered basic
education which enables students to read and write.

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which aims to improve service utilization by people in the health center’s catchment area.

Furthermore, health education messages should include awareness of risks and complications

related to delivery to all related person, yeay mobs, women, women’s families and their

husbands. This education should also focus on senior people as they have strong influence in

their daughters’ decision to seek health care.

(3) Improve Accessibility of Modern Health Facilities and Improve Attitudes of Health Care

Staff:

In term of accessibility, transportation is the major obstacle. Because of the physical

demanding journey, it is not common to take people with severe diseases to health center by

traveling a long distance of road. Sometimes there is no road available. One informant in the

study mentioned her preference for getting assistance during delivery by yeay mob, because

the yeay mob lives in her village and is nearby her house. Yeay mobs can be contacted at any

time of need, which is in contrast with the trained midwife because of the long distance to the

midwife’s house. In other words, there are one or two midwives working in one health center,

while there are nearly ten yeay mobs serving villagers.

Consequently, in order to increase women’s access to modern reproductive health services, it

is vital to increase the number of trained midwives at each health center. The TBA training

should also be expanded. In addition, the government should consider building roads from

each village to the health center. Some villages which are very far from provincial towns do

not have accessible road. Building roads is important to improve not only people’s health but

also their economic situation.

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The shortage of trained health staff and irregular pay-roll is another problem of public

services. Obviously, after health sector reform, many health centers have been constructed in

order to make health services are more accessible to all people. Still, there is a problem of

shortage of health staff working at health centers, particularly the shortage of primary and

secondary midwives. On the other hand, health staff’s salary is inadequate to feed their family,

and the irregular pay-roll of the salary which discourages health staff from working full time

at the health center. The increase in budget health expenditure is necessary to solve the current

condition. Nonetheless, the budget should be spent appropriately to meet the most urgent

needs. Meanwhile, there is critical need of outside assistance from NGOs and IOs to support

health development program in Cambodia.

In order to encourage health staff at health center level to better serve people in their

catchment area, staff motivation should be considered. The motivation should be done by two

ways, firstly by motivating health staff to attend short training courses or workshops, and

secondly health staff could be motivated by exchange programs with other health centers and

offer field visits to the staff to visit other health centers in the province or outside of the

province. If motivation of health staff could be achieved, attitude of the staff toward clients

could also be improved. They could learn from successful health centers or they can

compare the improvement of their daily work with other health centers. Although informants

of the study did not mention about attitude of health staff, some of them expressed

dissatisfaction when getting services from health staff (i.e., some informants complained

about spending long time waiting for service, words used by health staff). Foster (1982)

argued that professional health care providers tend to think the problem of low services

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utilization is caused by the users rather than with those who provide services. However, one

should note that the problem is actually caused not only by users but also by health providers.

Therefore, the gaps between health providers and services users should be bridged by

improving communication between health staff and community and motivating health staff to

work closely with community.

(4) Delivery and Postpartum Care:

The program of delivery and postpartum care should be taken into consideration. During this

critical period, women are constrained not only by their cultural mores, but also by their own

existing beliefs and knowledge.

Most women who got assistance from a trained midwife during delivery reported that they

were not given postpartum care, they had no idea about the importance of postpartum care,

and reported that they called yeay mob if they had problems. According to the interview with

trained midwives from the health centers, there is no postpartum care in health center outreach

activities. Thus, such a program should be added. Messages about postpartum care and its

importance should be added to current health education programs.

The results from the study reveal that yeay mobs practiced postpartum check-ups for at least

three days after delivery. As the three days after delivery are very crucial for women’s

health, this practice is essentially adaptive, as noted by White (1996). However, some yeay

mobs reported not visiting women whose houses were located far from their own. The

program of postpartum care and check up should be supported and introduced to trained

health staff.

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5.6 Recommendation for Further Research

The chief scope of this study covered the main traditional beliefs and practices of rural

Cambodian women during pregnancy, delivery and postpartum from the perspectives of

relevant stakeholders. Yet, the study did not scientifically examine the specific details of these

practices. Thus, further scientific/medical research into these individual traditional practices

should be conducted in order to better integrate them into the overall reproductive health

policies of the government and other stakeholders.

Moreover, although both traditional and modern practices of reproductive health care are an

important part of Cambodia’s comprehensive health care strategy, there has been little effort

to assess the perceptions of traditional and trained midwives regarding these issues in-depth.

Systematically exploring their perceptions may therefore foster greater understanding and

respect between these health care providers and consequently contribute to the development

of collaborative health care strategies for improving rural women’s reproductive health

5.7 Limitations of the Study

First of all, the study of traditional practices and cultural perceptions concerning reproductive

health encompasses a variety of broad dimensions. This study examined the perceptions of the

villagers about traditional practices versus modern practices surrounding pregnancy, delivery

and postpartum only from the community level.

Due to the qualitative nature of the study, the findings cannot represent the perceptions and

experiences of all Khmer women. Qualitative research does not provide generalizable

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findings. Qualitative data do, however, provide readers with a better understanding of

women’s subjective experience of practicing traditional culture of health care concerning

reproductive health matters, since the information can be gained through the informants’ own

voices (Rice 1996; Daly et al. 1998).

The relatively small sample size of informants and the short period of time for the field survey

also limited the methodological scope of the study. The length of the actual fieldwork was 13

days, and only 60 informants were individually interviewed. Because of the time constraint

each individual interview was shortened. July and August is the time when farmers begin the

year’s work on their rice fields, transplanting and ploughing, so local women were not able to

spend much time for the interviews. The rice field work is a collective activity in which they

helped each other; therefore, it was difficult to spend a long time talking with them except

during day break, lunch or before they went to fields.

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Chap, P.R., and Escoffier, C.F., (1996). Cambodian Women Perceptions of Fertility and
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Chhun, L., et al., (1995). KAP Survey on Fertility and Contraception in Cambodia. National Birth Spacing
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REPORTS
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MoH, WHO, DFiD, NORAD, (1999). Health Sector Reform Phase III.

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INTERNETS
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Appendix

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Khmer Medicine Used During Pregnancy
Name in Cambodian Language Name in English Language
Kapok Bark
sMbk K
Proclorb tree
edIm Rbkøb
Kanthuk leaves
søwkknÞÜt
Jackfruid leaves
søwkxñúr
Mean leaves
søwkman
Deyenreh plant
édGERg
Tbalkenn
t,alkin
Baykdang
)aykþaMg
Rangphnom flower
páaraMgPñM
Meas vine
v½rmas
Ripe coconut
dUgTMu
Very green coconut
kþibdUgx©I
Coconut water
TwkdUgx©I
Red coconut root
b£sdUgePøIg
Red coconut bark
sMbkdUgePøIg
Lemongrass leaves
søwkéRK
Maam leaves
søwkm¥m

-1-
 Bay chreung leaves or bark
søwk rW sMbk)ayRCWg
Black sesame
l¶exµA
páaQUk Lotus flower
Reang sot flower
páaraMgsUt
The old bark of tamarind tree
sMbkGMBil
Chuntol pong moen
CnÞúlBgman;
Basil plant
CInagvg
Ripe banana
eckTMu
The heart of jack fruit
bNþÚlxñúrTMu
Kong treang bay saw
kRnÞaMg)ays
Ktov bark
sMbkfáÚv
Ktum bark
sMbkxÞúm
Sney leaves or bark
søwk rW sMbksñay
Nonung crung
nenagRCug
Trabeik prey
RtEbkéRB
Angkia bos bark
sMbkGgÁabus
Preng vine
vløieRbg
Kakhopprey
kxubéRB

-2-
 Doh kun vine
vløiedaHKun
Lapeak root
l<ak;
Dangkiap kdam tree
edIm degáo bkþam
Ciiang kaam
CIG gáam
Kuuchay
Kuqay
CIsaMghum Ciisanghum
Kandiearkmoot
keNþo xµÜt
Qastork tree
edIm GasÞk;
Bark kramaa poo tree
sMbkedIm RkmeBa
Tmagntreybaat
eFµjRtI) at
Rorngveelkorm plant
edIm regVIlk¥m
Prorkplae plant
edIm RbkEpø
Forest guava flowers
páaRtEbkéRB
Rumsayesok
rMsaysk;
Roka
rka
Mistletoe or parasitic plant which grow on
beBaØIrEk¥k kapok, guava, kandov trees
Rukantok
rwskn§úk
Bark of guava tree
sMbkRtEbkrebH

-3-
 Mkak leaves
søwkmáak;

Khmer Medicine Used after Delivery

Name in Cambodian Language Name in English Language
Ktom bark
sMbkxÞúm
Pepper and alcohol
eRmc nig Rsa
Soot
ERmgePøIg
Guava leaves
søwkRtEbk
Black sesame
l¶exµA
Chii sanghom
CIsaMghum
Maam
m¥m
Kakhop
kxub
Triel tree
edIm eRTol
Dah kum
edaHKun
Voal thnung
vløiFñúg
Poo dambook
eBaFidMbUk
Kravaanh chruk
RkvajRCUk
Honey
TwkXµMú
Chkac sraeng
EqáERsg

-4-
 Mook chnieng
muxQñag
Kantor root
rwskMNr
Bay kdang
)aykþaMg
Day angrae
édGERg
Tbal ken
t,al;kin
Kandap cangey
kNaþb;ceg¥r
Churpleung
eQIePIøg
Kdul bark
sMbkkþúl
Kahopprey tree
edIm kxubéRB
Treal sva tree bark
sMbkedIm RTalsVa
Bark oomuuy tree
sMbkedIm eGamYy
Bark sdav tree
sMbkedIm esþA
Bark korkob prey tree
sMbkedIm kxubéRB
Sdav wood
xøwm esþA
Mengpoodambook
fñaMgeBaFidMbUk
Leaf of bamboo which doesn’t grow in forest
søwkbJsSIR suk
Leaf of forest bamboo
søwkbJsSIé RB
White kray root
bJsRkays

-5-
 Red kray root
bJsRkayRkhm
Tasaeng bark or leaves
sMbknigsøwkEsg
Nyanh tree
edIm jaj
Chur pleung root
bJseQIePøIg
Leaf or bark of custard apple tree
søwk rW sMbkeTob
Mdeng meas
emþjmas
Kamteah
kaMTH
Shield of a sword
eRsamdav
Rattan roots
bJsepþA
Beytun
)ayTn;
Beynyanh
)ayjaj;
Kontuitproung
knÞÜteR)ag
Sandeyk tuak
sENþkTUk
Root or tuber of grass (generic)
emIm esµA
Musk deer grass
esµAQøÚs
Tngan bark
sMbkf¶an;
Kanhcurdach leaves
søwkkeBa©Irdac
Angquny vine
vløiG gÁúj

-6-
 QUESTIONNAIRE SURVEY
FOR TRAINED HEALTH CENTER MIDWIVES

Informant Name: Date of Interview:

Informant Age: Health Center Name:
Position: District Name:
Year of working: Village Name:
Year of Education:
# Pregnancy:
# Living Children:
# Family Member:

A. Common Issues:
1. How long have you been practicing midwifery?

2. What is level of training?

2.1 Primary Midwife?
2.2 Secondary Midwife?
2.3 Primary midwife and continue to secondary midwife?

3. How many deliveries have you done?

4. Do you see women during their pregnancy? Where do you provide ANC service to women?
4.1 At home
4.2 At village during outreach activities
4.3 At health center

5. Do you provide delivery services?

5.1 How many deliveries were done at health center? How much?
5.2 How many deliveries were done at patients’ house? How much?
5.3 How many deliveries were done at your house (in case the midwife runs her own clinic)? How
much?

6. After delivery how long do you stay with the woman? When do you return and what do you do after
you return?
7. What advice do you give to women during
7.1 Pregnancy

-1-
 7.2 Delivery
7.3 After Delivery

8. Do you provide postpartum care service?

9. How much does it cost for postpartum care if you provide at
9.1 At health center
9.2 At home
9.3 At village during outreach activities
9.4 At your own clinic

10. Do you provide injections to women during

10.1 Pregnancy
10.2 Delivery
10.3 After Delivery

11. Please tell me the reason of injections and what kind of medicines do you inject women?

12. How many needles usually women get the injections from you during
12.1 Pregnancy
12.2 Delivery
12.3 After Delivery

13. How much does it cost of each time of injection?

B. Cooperation between TBAs and trained midwives

14. Have you had an opportunity to work with TBAs?

15. If yes, what was the reason and how did you interact together?

16. What do you think if women are delivered by TBAs?

C. Advices and Practices:

17. How do you know that a woman is healthy or unhealthy?
18. What advices do you give to women during
18.1 Pregnancy
18.2 Delivery
18.3 After Delivery

-2-
19. Please list the name of the practices that women in your village did during
19.1 Pregnancy
19.2 Delivery
19.3 After Delivery

20. What care do you give to women during labor and after birth?

D. Problems and Treatments:

21. What kind of complaints do you often hear from
21.1 Pregnant Women
21.2 Delivered Women
21.3 Postpartum Women

22. What kind of problems or dangers do women face spiritually and physically?

23. What is Toas? What causes Toas?

24. How many kinds are there?

25. What are the symptoms? What is the treatment?

E. Common Practices:
26. Tell me about roast

27. Why do women roast?

28. What are the advantages of roasting?

29. What are the disadvantages and side-effects of roasting?

30. What would happen if women did not roast?

31. What should be done to replace the practice of roasting?

F. Substitutes for roasting and other practices:

-3-
32. Besides roasting, what else do women do?

33. What are the impacts of those practices?

G. Perceptions and Recommendations:

34. What do you think about practicing traditional methods of health care done by people in village?

35. What kind of traditional practices should be kept and provide good effect on health?

36. How to improve health center services to better meet the needs of people in your catchment area,
according to your opinion?

37. What should government or NGOs do to improve reproductive health or reproductive health services at
local level?

Thank you very much for your cooperation!

-4-
 QUESTIONNAIRE SURVEY
FOR TRADITIONAL BIRTH ATTENDANTS (YEAY MOBS)

Health Center Name: Date of Interview:

District Name: Informant Name:
Village Name: Informant Age:
Year of Education:
# Pregnancy:
# Living Children:
# Family Member:

A. Common Issues:
1. How long have you been practicing midwifery?

2. How did you learn your skills?

a. _From mother or other relative
b. _From a midwife I knew
c. _From NGO or government sponsored training course
d. _From my own experience
e. _Other, Specify

3. How many deliveries have you done?

4. Do you receive payment for delivery and how much do you usually receive?

5. How do you know that a woman is health or unhealthy?

B. Advices and Practices:

6. What advice do you give to women to protect their pregnancies?

7. What advices do you give them?

8. Do you advise any kind of medicine to a woman in pregnancy? Labor? Delivery?

9. If yes, what kind?

10. Do you see women during their pregnancy?

-1-
 (Check as many as apply)
a. _Do not see women during pregnancy
b. _Check for anemia
c. _Check position of baby
d. _Massage
e. _Treat complaints
f. _Give advice
g. _Discuss plan for delivery
h. _Other, specify:

11. What care do you give to women during labor and after birth?

12. After delivery how long do you stay with the woman? When do you return? What do you do when
you return?

13. Have you had an opportunity to work with a midwife?

14. If yes, what was the reason and how did you interact together?

C. Problems and Treatments:

15. What kind of complaints do you often hear from pregnant women?

16. What kind of problems or dangers do women face spiritually and physically?

17. What cause problems for pregnant women? When? And what kind of problems?

18. What can you do to help the woman? What kind of treatment?

19. What is Toas? And what causes Toas?

20. How many kinds are there?

21. What are the symptoms? What is the treatment?

22. How do you prevent Toas?

23. Tell me about roasting.

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 24. Why do women roast?

25. How long should women roast?

26. What are the benefits and disadvantages of roasting?

27. What would happen if women did not roast?

D. Substitutes for roasting and other practices:

28. Besides roasting, what else do women do?

29. Please list name of the practices women do during pregnancy, delivery, postpartum?

30. What are the impacts of those practices?

E. Perceptions and Recommendations:

31. How do you feel about health center services? What kind of traditional practices should be kept
and provide good effect on health?

32. How to improve health center services to better meet your needs?

33. What should government or NGOs do to improve your reproductive health or reproductive health
services at local level?

Thank you very much for your cooperation!

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 QUESTIONNAIRE SURVEY FOR TARGET WOMEN

Informant Name: Date of Interview:

Informant Age: Health Center Name:
Years of Formal Education: District Name:
# Pregnancy: Village Name:
# Delivery:
# Family Member:

A. Household Characteristics:
1. Type of House

2. Material Ownership
__Radio
__TV
__Bicycle
__Motorcycle

3. How many household members do you have?

4. How often do you talk about reproductive health (sexual health, pregnancy, delivery and after birth
problems) with your patents? Relatives? And husband?

5. Who was the principal decision-maker in selecting the planned location for the birth?

B. Common Knowledge and other practices during pregnancy, delivery and after birth:
6. How do you know that a woman is healthy or unhealthy?

7. What practices women do to protect their pregnancies and during pregnancy? Who tell you?

8. What practices women do during delivery? Who tell you?

9. What practices women do during postpartum? Who tell you?

10. Please tell me why you follow those practices.

10.1 Pregnancy
10.2 Delivery

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 10.3 After Delivery

11. Please tell me the advantages of the practices during:

11.1 Pregnancy
11.2 Delivery
11.3 After Delivery

12. Please tell me the disadvantages and side-effects of the practices during:
12.1 Pregnancy
12.2 Delivery
12.3 After Delivery

13. Do you get antenatal care during pregnancy? __1.Yes __2.No

13.1 If yes, why? How many times? How much does it cost?
13.2 If no, why? From whom else?

14. During your last pregnancy, did you deliver at health center? __1.Yes __2.No
14.1 If yes, why? How much does it cost?
14.2 If no, why? Where? How much does it cost?

15. Who helps you to deliver birth during your last pregnancy?
__Trained midwife; __TBAs; __ Trained midwife and TBAs; __No one; __other

16. How much does it cost to get assistance from:

16.1 Trained midwife
16.2 TBAs
16.3 Both of them

17. After delivery, from whom do you get care? How many times? How much does it cost for each time?

18. How do you go to health center? How much do you spend for transportation to health center?

19. How much do you spend for getting health center services for general problems?

20. Do you get injections during:

20.1 Pregnancy
20.2 Delivery

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 20.3 After Delivery

21. Why do women get injections during

21.1 Pregnancy
21.2 Delivery
21.3 After birth?
22. From whom do women get injections? How much does it cost for each time of injections?

C. Common Practices:
22. How long did you rest after birth?

23. Do you roast? __1.Yes __2.No

23.1 If yes, why? Who tell you? How long do you roast?
23.2 If no, why? Who tell you?

24. What are the possible advantages of roasting?

25. What are the possible disadvantages and side-effects of roasting?

26. What would happen if women did not roast?

27. Besides roasting, what else do you do?

28. Did you drink traditional medicines during pregnancy, after birth?
28.1 If yes, what Khmer medicine did you drink during pregnancy, after birth? How much does it
cost?

29. What specific activities should pregnant women do/not do? Give me the reason.

30. What things should pregnant women eat/drink and not eat/drink during pregnancy, after birth? Give
me the reason.

D. Problems and Treatments:

31. What kinds of problems can pregnant women have/heard about?

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32. Did anything else happen during pregnancy? Delivery? Postpartum?

33. Who helps and helps for which problem?

34. What should women do for these problems and to prevent the problems?

E. Perceptions and Recommendations:

35. How do you feel about health center services? What kind of traditional practices should be kept and
provide good effect on health?

36. How to improve health center services to better meet your needs?

37. What should government or NGOs do to improve your reproductive health or reproductive health
services at local level?

Thank you very much for your cooperation!

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