Ghazaleh Samandari

The role of social support and parity on contraceptive use in Cambodia

Cambodias health infrastructure was all but destroyed during the Khmer Rouge regime and the Vietnamese occupation of the 1970s, rendering the countrys family planning programs virtually inoperable for more than 20 years. 1–3 In 1994, an internationally supported, government-led effort to reinstate family planning campaigns was launched; 4 however, efforts were considerably hampered by the coun-trys poor infrastructure, leading to very low contraceptive prevalence rates and concomitantly high rates of fertility and maternal mortality. 5 Over the past decade, renewed efforts of government and nongovernmental agencies have contributed significantly to improved reproductive health outcomes. Between 2000 and 2005, the contraceptive prevalence rate (CPR) among all Cambodian women increased from 11% to 34%, and the total fertility rate (TFR) dropped from 4.0 to 3.4. 6 Despite these gains, shortcomings in family planning service delivery and acceptance in Cambodia remain. The most recent Cambodian Demographic and Health Survey (DHS) from 2005 reports that the CPR among currently married women is only 27%, and one in four married women have an unmet need for family planning. 6 As a result of the low use of family planning, Cambodias TFR remains high relative to other Asian countries, and its maternal mortality ratio—estimated at 450–540 deaths per 100,000 live births—is among the highest in the region. 6–8 Moreover, Cambodias CPR is the lowest in Southeast Asia—ranking 130th out of 177 countries around the world 8,9 —and its infant mortality rate (97 deaths per 1,000 live births) is above the regional average. 6 These measures are not only indicative of the risk to women and children, but have wider implications for the population as a whole. Women with a high number of births are less likely than others to complete their education , participate in the labor force and have high levels of income; 10,11 on the other hand, women who use contraceptives tend to have a better quality of life, higher social status and greater autonomy. 11–15 The health care costs associated with complications of pregnancy and childbirth can strain families with limited resources. 16,17 In countries where resources for health care are low, high fertility can further encumber fragile health systems. 16–20 Conversely, increased availability and use of family planning has been linked to improved economic and social development of families and broader communities. 11,16–20 The common determinants of contraceptive use (i.e., age, education, socioeconomic status) apply in the Cam-bodian context: 21–29 For example, …

“Souls of the ancestor that knock us out” and other tales. A qualitative study to identify demand-side factors influencing malaria case management in Cambodia

BackgroundAppropriate case management of suspected malaria in Cambodia is critical given anti-malarial drug resistance in the region. Improving diagnosis and the use of recommended malarial treatments is a challenge in Cambodia where self-treatment and usage of drug cocktails is widespread, a notable difference from malaria treatment seeking in other countries. This qualitative study adds to the limited evidence base on Cambodian practices, aiming to understand the demand-side factors influencing treatment-seeking behaviour, including the types of home treatments, perceptions of cocktail medicines and reasons for diagnostic testing. The findings may help guide intervention design.MethodsThe study used in-depth interviews (IDIs) (N = 16) and focus group discussions (FGDs) (N = 12) with Cambodian adults from malaria-endemic areas who had experienced malaria fever in the previous two weeks. Data were analysed using NVivo software.ResultsFindings suggest that Cambodians initially treat suspected malaria at home with home remedies and traditional medicines. When seeking treatment outside the home, respondents frequently reported receiving a cocktail of medicines from trusted providers. Cocktails are perceived as less expensive and more effective than full-course, pre-packaged medicines. Barriers to diagnostic testing include a belief in the ability to self-diagnose based on symptoms, cost and reliance on providers to recommend a test. Factors that facilitate testing include recommendation by trusted providers and a belief that anti-malarial treatment for illnesses other than malaria can be harmful.ConclusionsTreatment-seeking behaviour for malaria in Cambodia is complex, driven by cultural norms, practicalities and episode-related factors. Effective malaria treatment programmes will benefit from interventions and communication materials that leverage these demand-side factors, promoting prompt visits to facilities for suspected malaria and challenging patients’ misconceptions about the effectiveness of cocktails. Given the importance of the patient-provider interaction and the pivotal role that providers play in ensuring the delivery of appropriate malaria care, future research and interventions should also focus on the supply side factors influencing provider behaviour.

Dimensions of child punishment in two Central American countries: Guatemala and El Salvador

OBJECTIVE Severe physical punishment of children is an important issue in international child health and welfare. This study examines such punishment in Guatemala and El Salvador. METHODS Data came from nationally representative surveys of women aged 15-49 and men aged 15-59 residing in Guatemala (2002) and El Salvador (2002-2003). The surveys included questions about punishment experienced during childhood, with response options ranging from verbal scolding to beating. In Guatemala, parents were asked how they disciplined their children; questions allowed them to compare how they were punished in their childhood with how they punished their own children. Bivariate and multivariate analyses are presented. RESULTS In Guatemala, 35% of women and 46% of men reported being beaten as punishment in childhood; in El Salvador, the figures were 42% and 62%, respectively. In both countries, older participants were relatively more likely than younger participants to have been beaten as children. Witnessing familial violence was associated with an increased risk of being beaten in childhood. In Guatemala, having experienced physical punishment as a child increased the chance that parents would use physical punishment on their own children. Multivariate analyses revealed that women who were beaten in childhood were significantly more likely in both countries to be in a violent relationship. CONCLUSIONS The use of beating to physically punish children is a common problem in Guatemala and El Salvador, with generational and intergenerational effects. Its negative and lingering effects necessitate the introduction of policies and programs to decrease this behavior.

Homicide among pregnant and postpartum women in the United States: a review of the literature.

Eighteen articles that examined the extent of homicide among pregnant and/or postpartum women in the United States are reviewed, documenting the studies’ methods and findings. Results from proportional mortality analyses (studies that examined only deaths, rather than deaths within a larger population of living individuals) showed a modicum of support for the contention that homicide may account for a greater proportion of the deaths among pregnant/postpartum women than among other women of reproductive age. However, results from more comprehensive analyses that estimated homicide risks/rates (studies that examined deaths within the context of living populations) did not find any evidence to suggest that pregnant/postpartum women experience a greater risk/rate of homicide compared to other women of reproductive age. This difference in findings is discussed in light of the different methodological approaches.

Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia

BackgroundAlthough abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation.MethodsAn intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country’s abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships.ResultsAfter 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides.ConclusionsThese findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa.

Abortion incidence in Cambodia, 2005 and 2010

Although Cambodia now permits elective abortion, scarcity of research on this topic means that information on abortion incidence is limited to regional estimates. This estimation model combines national survey data from Demographic and Health Surveys (DHS) with national prospective data of abortion procedures from government health facilities, collected in 2005 and 2010, to calculate the national incidence of safe and unsafe abortion. According to DHS, the proportion of all induced abortions that took place in a health facility in the five years preceding each survey increased from almost 52% to 60%. Projecting from facility-based abortions to national estimates, the national abortion rate increased from 21 to 28 per 1000 women aged 15–44. The abortion ratio also increased from 19 to 28 per 100 live births. This research quantifies an increase in safely induced abortions in Cambodia and provides a deeper understanding of induced abortion trends in Cambodia.