Determinants of the continuum of maternal health care in Cambodia: an analysis of the Cambodia demographic health survey 2014

Cambodia has achieved significant progress in the area of maternal and child health, meeting Millennium Development Goal 4 (MDG) to reduce child mortality and MDG5a to reduce maternal mortality [1]. Based on the 2014 Cambodia Demographic Health Survey (CDHS), under-five mortality has decreased from 124 deaths per 1000 live births in 2000 to 35 deaths per 1000 live births in 2014 [2]. Within this period, there was also a decline in maternal mortality from 206 to 170 deaths per 100 000 live births. However, Cambodia remains in the group of countries with the highest maternal mortality ratio in South-East Asia [3]. Therefore, extra effort is needed to achieve the new health target of Sustainable Development Goal (SDG 3.1) to lower the maternal mortality ratio to less than 70 per 100 000 live births by 2030 [4].

To achieve this target effectively, adequate and high-quality care for maternal health (MH) is required along the continuum of care (CoC). The coverage of MH services is regarded as one of the main contributions to the reductions of maternal mortalities [5].

Previous studies have largely focused on individual components along the continuum of care separately, especially Antenatal Care (ANC) [6‐8] and to Skilled Birth Attendant (SBA) [9, 10], but that Post-natal Care (PNC) has received less attention until recently [11]. Coverage along each component can be measured by counting ANC which pregnant women should have adequate and high-quality ANC during pregnancy with at least optimum four visits as recommended by World Health Organization (WHO) [12] or eight visits following the new WHO 2016 guideline [13]. Women should have SBA which refers to delivery care provided by qualified and experienced health professional (a midwife, doctor or nurse) [14, 15]. After delivery, PNC, especially within the first 48 h after birth, is critical to the management of postpartum complications [16].

However, targeting the coverage of MH services separately does not ensure that every woman receives all essential MH services throughout pregnancy, childbirth and postpartum periods [17]. There is an increasing focus on applying a CoC approach, which indicates the continuation of care throughout the lifecycle and implies that MH services are closely linked and action must be taken in an integrated manner [18]. The CoC is widely divided into two key dimensions: time and place. The time dimension addresses the situation where women receive MH services from pre-pregnancy to post-delivery and it addresses the importance of continuity of packages of MH service over time at different stages of pregnancy, childbirth and postpartum [18‐20]. The place dimension measures various components of services provided at health facilities, communities and home and addresses the coordination among family level, community-level and health facility-level [18, 20].

In this paper, we focus on the time dimension in the CoC because it reflects Cambodia’s policy goal that every woman should receive key packages of services across the pregnancy to postpartum continuum. Our study advances findings from previous continuum of care studies by uniquely considering whether the care components along the continuum were ‘optimal’ based on the recommendations of National Strategy of Reproductive and Sexual Health Cambodia [21]. These include four or more ANC visit with the first visit at the first trimester of pregnancy (optimal ANC), delivery assisted by SBA and at least 2 PNC visits within 41 days or six weeks of childbirth with the first PNC check is within 48 h after birth (optimal PNC).

Improving coverage along the continuum of care relies on a better understanding of factors contributing to gaps. Despite progress in MH indicators during the last decade in Cambodia, substantial coverage gaps remain [22] and more efforts are still needed to improve life-saving MH services. In this study, we aim (1) to investigate coverage along of the continuum of care, and (2) to identify determinants that are associated with mother’s continuation of service use along the continuum, and (3) to identify determinants of achieving a complete continuum of care.

Ensuring optimal service use along the continuum of maternal health care is a critical part of Cambodia’s national strategy to improve the health of mothers and newborns. This study contributes important knowledge to understanding the gaps, where women are lost from one service to another, and why women are unable to achieve the complete CoC.

Our findings indicated that more women dropping out from the continuum of care between optimal ANC and delivery than between delivery and optimal post-delivery. Less than half of women in our study received optimal coverage of the full continuum of care. This reflects the progress of the government in the past years; however, extra efforts and effective fill-the-gap intervention from the government and relevant organizations are still needed to accelerate the level of optimal coverage through connecting the three services (optimal ANC, SBA and optimal PNC) together.

Women dropping out from one service to another due to some influential factors. Our finding that indicated the significant association between the use of optimal ANC with higher level of education, household wealth quintile and any exposure to mass media was consistent with previous studies which found that maternal education, husband education, household income, and media exposure were factors affecting ANC uptake in Pakistan [29], Uganda [32] and some developing countries [33].

Moreover, the finding that the higher levels of education of husband, and women from wealthier household positively associated with the continuity of using SBA among those had optimal ANC is in line with the result of an analysis of the Ethiopian Demographic and Health Survey which found that women whose husband completed at least secondary school were more likely to use skilled birth delivery assistant [34]. However, our study did not show a significant effect of women’s education on the continuity of having SBA among those had optimal ANC. Among married women who have both optimal ANC and SBA, over 60% were educated and came from at least medium income family. In this context, was wealth quintile became the most influential factor associated with the continuity of using SBA among those who have optimal ANC.

Received all different elements of ANC care is found to be a significant predictor of continuity of having SBA among those who had optimal ANC and continue to use optimal PNC among those who had optimal ANC and SBA. The elements of ANC care receiving during ANC visit make women better aware about their pregnancy condition and more likely to understand the importance of safe delivery and post-delivery care. A similar findings from a multi-country study of Africa indicated that the element of ANC care has a positive impact on delivery assistance and PNC use [35]. This demonstrate the importance of maintaining the quality of ANC care through enriching its content. WHO 2016 New ANC model also mentioned that “ANC should be delivered in term of both timing and content of each ANC contact” [36].

From the analyses, women’s decision-making power in the household was associated only with the use of optimal ANC care and the continuity of using of optimal PNC care for those had optimal ANC and SBA. This aligns with previous studies in Indonesia and Bangladesh which found that decision-making power had a positive effect on ANC and PNC coverage [37, 38]. In our study, decision-making power had no association with the continuity of using SBA after receipt of optimal ANC care. This is similar to another study in Indonesia in which women’s decision making power had no effect on the use of a skilled birth attendant [28], but different from the systematic review which found that women’s empowerment was positively associated with the use of maternal health service including skilled birth attendance in developing countries [39]. The difference in results from one to another study may be explained by the different measurement approaches to capturing women’s decision-making power [40]. One plausible explanation for why decision-making power is not a significant predictor on the continuity of using of SBA was that in delivery context, decision-making is not necessary and SBA is a usual event which a choice cannot be decided by only women and her family.

Our study also showed the predictors on the achievement of complete CoC. Decision-making power was also found in our study to be a significant predictor of achieving a complete CoC. This confirms a previous study in Nepal, using the same three outcomes, which found that women’s autonomy in decision-making had a positive effect on the use of all three maternal health services [41]. This suggests the new MH programs should refocus to empower women in making their own decision which in turn might accelerate the use of maternal health service. From our study, the cultural factors especially decision-making factors is an important determinant in achieving continuum of care. We have reflected the importance of social science research in pin-pointing the cultural factors that influence on barriers to access maternal health care. Future research should incorporate wider scope of social science into their study to better identify the barriers or gaps related to gender issue and health care utilization.

The educational levels of both women and husbands were significantly associated with achieving the complete continuum and thus offer a promising strategy for improving maternal health services in the country. The significant association between health insurance coverage and the complete achievement of CoC might due to the expansion of health-equity fund or mother health voucher schemes by the Ministry of Health Cambodia could also constitute a promising avenue. This reflects the coverage of social health protection program could encourage women to use services. Surprisingly, jobless husband was found to have greater odds for married women to achieve complete CoC. This could be the case since over 86.0% of the jobless group were from at least medium income family which they can afford the usage of services regardless of employment.

Consistent with many other studies, household wealth strongly predicted service use and achievement of the continuum of maternal care. A study in Gabon also found that maternal health service utilization was higher in women from wealthy households [42]. This implies that wealth can also be barrier to assess to care if the government has no strategies in removing financial barriers or financial hardship for women in using the services. Multi-sectoral actors and different attentions are needed to improve the continuity of care in Cambodia.

Even with high coverage of each individual maternal health care service, Cambodia has achieved only a moderate proportion of women who complete the Continuum of Care from pregnancy to post-delivery with optimal care. This coverage would have been higher had only the count on the number of visits for ANC and PNC been considered, but our study further considered whether the visits were at the recommended time to help identify potential gaps of care. This is the ever first analysis examining optimal service use along the continuum and what factors should be taken into account or invested to improve the coverage of care. Policy makers should not only focus on the routine or common factors across all three services separately but also study the continuum in an integrated manner to identify how problems differ along the continuum. Social science research in Cambodia is limited; therefore, government should invest more in social science in order to widen the opportunities in identifying the influential factors of barriers accessing to health care especially on gender inequality. Future maternal health intervention should address this issue by consider including a component to empower women in decision-making and engage their spouse as well as other family member to understand the importance of using maternal health service as a continuum.