62953 RepRODuCtIve HealtH at a GLANCe April 2011 CAMBODIA Country Context Cambodia: MDG 5 Status Despite a decade of robust economic growth, Cambodia MDG 5A indicators is still one of the poorest countries in Southeast Asia. The Maternal Mortality Ratio (maternal deaths per 100,000 live 290 country has made progress toward some of its Millennium births) UN estimatea Development Goals (MDGs) including poverty reduction, Births attended by skilled health personnel (percent) 43.8 expansion of primary education and closing the gender gap MDG 5B indicators in education literacy, and wage employment. Yet, twenty six percent of the population still subsists on less than US Contraceptive Prevalence Rate (percent) 40 $1.25 per day.1 Progress toward MDG 5 is lagging behind Adolescent Fertility Rate (births per 1,000 women ages 15–19) 47 despite improved rates of prenatal visits, increased use of Antenatal care with health personnel (percent) 69.3 trained midwives for delivery, and reduction in total fertil- Unmet need for family planning (percent) 25.1 ity.2 Limited access to health services including emergency obstetric care remains a barrier to further reduction of ma- The 2005 Cambodia DHS estimated maternal mortality ratio at 472 Source: Table compiled from multiple sources ternal mortality. Cambodia’s large share of youth population (34 percent of the country population is younger than 15 years old1 pro- vides a window of opportunity for high growth and poverty MDG target 5A: Reduce by three-quarters, between reduction—the demographic dividend. For this opportu- 1990 and 2015, the Maternal Mortality Ratio nity to result in accelerated growth, the government needs Cambodia has been making progress over the past two decades on to invest more in the human capital formation of its youth. maternal health but it is not on track to achieve its 2015 targets.5 Gender equality and women’s empowerment are impor- tant for improving reproductive health. Higher levels of Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target women’s autonomy, education, wages, and labor market 800 690 participation are associated with improved reproductive 700 640 health outcomes.3 In Cambodia, the literacy rate among fe- 600 470 500 males ages 15 and above is 69 percent.1 Education enroll- MDG 400 350 ment rates in primary are about the same for males and 300 290 Target females (around 50 percent) but fewer girls are enrolled in 200 170 secondary schools compared to boys with 82 percent ratio 100 of female to male secondary enrollment.1 0 1990 1995 2000 2005 2008 2015 Three-quarters of adult women participate in the labor Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. force that mostly involves work in agriculture.1 Gender in- equalities are reflected in the country’s human development ranking; Cambodia ranks 114 of 157 countries in the Gender- World Bank support for Health in Cambodia related Development Index.4 The Bank’s latest Country Assistance Strategy was for fiscal years 2005 to Greater human capital for women will not translate into 2008. greater reproductive choice if women lack access to repro- Current project: ductive health services. It is thus important to ensure that P102284 KH-Second Health Sector Support Program ($20.1m) health systems provide a basic package of reproductive • Strengthening Health Service Delivery health services, including family planning.3 • Improving Health Financing • Strengthening Human Resources • Strengthening Health System Stewardship Functions pipeline projects: None THE WORLD BANK previous Health project: P070542 KH-Health Sector Support Project n Key challenges Abortion became legal in Cambodia, in 2005 but women con- tinue to have unsafe abortion with several abortion-related com- High Fertility plications reported each year.9 Among the 8 percent of women Fertility has been declining over time but is still high among who reported having experienced induced abortion, 44 percent the poorest. Total fertility rate (TFR) has dropped between 2000 have had multiple induced abortions, a rise from the 29 per- and 2005, from an average of 4.0 births per woman to 3.4 births.6 cent reported in 2000.6 Lower TFR is associated with urban location, higher educa- Many women do not intend to use modern contraceptive tion, and wealth. TFR among poorest Cambodians is twice that of methods due to health concerns/fear of side effects (40 per- the wealthiest (Figure 2). A similar disparity is observed among cent).6 While a fifth indicated inability to get pregnant, reasons women with different levels of education: TFR is 2.6 among such as opposition to use and lack of knowledge were negligible. women with secondary education or higher compared to 4.3 Cost and access are lesser concerns, indicating further need to among women with no formal education. strengthen family planning services. Figure 2 n total fertility rate by wealth quintile poor pregnancy Outcomes 6 4.9 Majority of pregnant women receive antenatal care from 4 3.9 3.4 overall skilled health personnel. Sixty-nine percent of pregnant women 3.2 2.9 2.4 received antenatal care from skilled health personnel (doctor, 2 midwife, or nurse) a remarkable increase from just 38 percent in 2000.6 Further, 27 percent of them had the recommended four or 0 more antenatal visits. Poorest Second Middle Fourth Richest Source: DHS Final Report, Cambodia 2005. Forty four percent of women deliver with the assistance of skilled health personnel and wide disparities exist among Adolescent fertility rate is high (47 births per 1,000 births) income groups (Figure 4).6 Similarly, 70 percent of women in affecting not only young women and their children’s health but urban areas delivered with the assistance of skilled health per- also their long-term education and employment prospects. sonnel, only 39 percent of women in rural areas obtained such Births to women aged 15–19 years old have the highest risk of assistance. Of those women who did not give birth in a health infant and child mortality as well as a higher risk of morbidity facility, 37 percent never received a postnatal care.6 and mortality for the young mother.3,7 Figure 4 n Birth assisted by skilled health personnel (percentage) Two-fifths of married women are using contraception. Use of by wealth quintile contraception among married women was 40 percent in 2005, up 100 from 24 percent in 2000.6 Use of modern contraception methods 89.9 is more common among wealthier, and more educated women as 80 well as those living in urban areas (Figure 3). The pill is the most 60 62.0 commonly used method (13 percent), followed by injectables (8 43.8% overall 39.6 percent). Use of long-term methods. 40 29.0 20.7 20 Figure 3 n use of contraceptives among married women by wealth 0 quintile Poorest Second Middle Fourth Richest 60 Source: DHS Final Report, Cambodia 2005. 40 Overall (All methods) 21.7 40 12.6 Nearly three-quarters of women who indicated problems in 11.4 8.6 9.2 27.3 28.7 32.3 accessing health care cited concerns regarding inability to af- 20 25.1 22.1 ford the services. Concerns about unavailability of service pro- 0 viders or lack of drugs were raised by 50 percent of the women Poorest Second Middle Fourth Richest (Table 1).6 Source: DHS Final Report, Cambodia 2005. Modern Methods Traditional Methods Human resources for maternal health are limited with only Unmet need for contraception is high at 25 percent indicating 0.16 physicians per 1,000 population but nurses and midwives are that women may not be achieving their desired family size.6,8 slightly more common, at 0.85 per 1,000 population.1 table 1. Barriers in accessing health care (women aged 15–49) technical Notes Reason % Improving Reproductive Health (RH) outcomes, as outlined in the At least one problem accessing health care 88.5 RHAP, includes addressing high fertility, reducing unmet demand for Getting money needed for treatment 74.1 contraception, improving pregnancy outcomes, and reducing STIs. Concern no drugs available 51.4 The RHAP has identified 57 focus countries based on poor Concern no provider available 50.5 reproductive health outcomes, high maternal mortality, high fertility Not wanting to go alone 45 and weak health systems. Specifically, the RHAP identifies high priority countries as those where the MMR is higher than 220/100,000 Having to take transport 38.7 live births and TFR is greater than 3. These countries are also a sub- Distance to health facility 38.7 group of the Countdown to 2015 countries. Details of the RHAP are Concern no female provider available 36.9 available at www.worldbank.org/population. Getting permission to go for treatment 14.3 The Gender-related Development Index is a composite index Source: DHS final report, Cambodia 2005. developed by the UNDP that measures human development in the same dimensions as the HDI while adjusting for gender inequality. Its coverage is limited to 157 countries and areas for which the HDI rank The moderately high maternal mortality ratio at 293 maternal was recalculated. deaths per 100,000 live births indicates that access to and quality of emergency obstetric and neonatal care (EmONC) remains a challenge.5 StIs/HIv/AIDS prevalence is low The prevalence of HIV in Cambodia is 0.6 percent of the adult population aged 15–49.6 While HIV/AIDS’ awareness is high, Development partners Support for Reproductive Health knowledge of mother-to-child prevention methods is limited. in Cambodia While knowledge among women (aged 15–49 years) that HIV WHO: Health systems strengthening, safe can be transmitted by breastfeeding is high (87 percent), just 33 motherhood; percent knew that the likelihood of passing HIV from mother to uNFpA: Reproductive health and rights, access to child can be reduced by drugs.6 contraceptive, family planning training; There is a large knowledge-behavior gap regarding condom uNICeF: Child health, child protection, sexual use for HIV prevention. While most young women are aware exploitation. that using a condom in every intercourse prevents HIV, only 1 uSAID: HIV/AIDS; skilled birth attendance, MCH percent of them report having used condom at last intercourse voucher program. (Figure 5). This gap persists among older aged women likely due DFID: Maternal mortality reduction, health sector to the fact that the chance of using condoms as a form of contra- support; ception diminishes with marriage. AuSAID: Health sector support, emphasis on MCH service strengthening; Figure 5 n Knowledge behavior gap in HIv prevention among young women ADB: Health sector support; maternal and child health focus; 70% GtZ: quality improvement and increased access for 60% poor and rural populations with emphasis on 50% midwives; 40% 30% Marie Stopes: Family planning services, abortion and post- 20% abortion care, maternal health, HIV/STIs, 10% advocacy; 0% FHI: HIV/AIDS care and support with focus on sex 15–19 years 20–24 years workers and their clients Knowledge Condom use at last sex Source: DHS Final Report, Cambodia 2005 (author’s calculation). n Key Actions to Improve RH Outcomes Strengthen gender equality • Although abortion is legal, there needs to be an increase in the • The vulnerability of women and girls has been recognized in number of safe abortions; address the key issues that constrain the 2005 Domestic Violence Law; however, more emphasis access to safe abortion and post-abortion care including: short- needs to be directed towards gender issues and effective strate- age of trained staff, referral delays, and cost. gies to achieve gender equality; • Promote male involvement in reproductive health as a means Reducing maternal mortality to strengthening gender equality and to encourage women’s • Address the shortage of skilled birth attendants: invest in the health seeking behavior, especially in relation to reproductive training of midwives, develop innovative approaches that will health. increase the retention of midwives in remote areas, and sup- port incentive program to increase quality of care. Reducing high fertility • Promote the availability and access to emergency obstetric and • Increase family planning awareness by expanding the menu of newborn care (EmONC) services, especially in rural hard-to- family planning services available (also to include permanent reach areas, to reduce maternal mortality. and long lasting methods) and increasing utilization through • Establish a continuum of care to ensure women have access Community Based Distribution of family planning commodi- to both ANC and PNC by improving the referral system and ties, especially targeting rural and remote communities; strengthening coordination between public and private facilities. • Mobilize communities and increase women’s knowledge of contraceptive: promote IEC activities targeting both women Reducing StIs/HIv/AIDS and girls in their reproductive years to educate them of the po- tential health and side effects of contraception and to empower • Target most-at-risk populations to ensure they receive access them in making their own choices. to treatment and care, and the general population with more awareness raising and educational activities about HIV/AIDS, • Focus on adolescents to delay first pregnancy and design in- to avoid a resurgence of the epidemic. terventions that address their reproductive needs through the provision of culturally appropriate and user-friendly services • Support for the dissemination and use of the recently intro- in both urban and rural areas. duced female condom and promote its dual role of protecting against unwanted pregnancies as well as STIs, including HIV. References: 1. World Bank. 2010. World Development Indicators. Washington DC. 9. Fetters, T. et al. 2008. Abortion-related complications in Cambodia. 2. United Nations Development Programme. Cambodia MDGs. BJOG: An International Journal of Obstetrics and Gynecology. Updated October 18, 2010. http://www.un.org.kh/undp/mdgs/ 115(8); 957–68. . cambodian-mdgs. 10. Worldwide prevalence of anaemia 1993–2005: WHO global da- 3. World Bank, Engendering Development: Through Gender Equality tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, in Rights, Resources, and Voice. 2001. Ines Egli and Mary Cogswell.http://whqlibdoc.who.int/publica- 4. Gender-related development index. http://hdr.undp.org/en/media/ tions/2008/9789241596657_eng.pdf HDR_20072008_GDI.pdf. 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank 6. National Institute of Public Health, National Institute of Statistics [Cambodia] and ORC Macro. 2006. Cambodia Demographic and Correspondence Details Health Survey 2005. This profile was prepared by the World Bank (HDNHE, PRMGE, 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. and EASHH) and Management Science for Health (MSH) For more Geneva: WHO. http://www.who.int/making_pregnancy_safer/top- information contact, Samuel Mills, Tel: 202 473 9100, email: ics/adolescent_pregnancy/en/index.html. 8. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- smills@worldbank.org This report is available on the following ception. Human Development Network, World Bank. Available at website: www.worldbank.org/population. http://www.worldbank.org/hnppublications. CAMBODIA RepRODuCtIve HeALtH ACtION pLAN INDICAtORS Indicator Year Level Indicator Year Level Total fertility rate (births/woman ages 15–49) 2005 3.4 Population, total (million) 2008 14.6 Adolescent fertility rate (births/1,000 women ages 15–19) 2005 47 Population growth (annual %) 2008 1.6 Contraceptive prevalence (% of married women ages 15–49) 2005 40 Population ages 0–14 (% of total) 2008 34.1 Unmet need for contraceptives (%) 2005 25.1 Population ages 15–64 (% of total) 2008 62.5 Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 3.4 Median age at marriage (years) — — Age dependency ratio (% of working-age population) 2008 60 Mean ideal number of children for all women 2005 3.3 Urban population (% of total) 2008 21.6 Antenatal care with health /sonnel (%) 2005 69.3 Mean size of households 2005 5 Births attended by skilled health /sonnel (%) 2005 43.8 GNI/capita, Atlas method (current US$) 2008 640 Proportion of pregnant women with hemoglobin <110 g/L) 2008 66.4 GDP/capita (current US$) 2003 711 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 691 GDP growth (annual %) 2008 6.7 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 636 Population living below US$1.25/day 2003 25.8 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 470 Labor force participation rate, female (% of female population ages 15–64) 2008 75.6 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 347 Literacy rate, adult female (% of females ages 15 and above) 2004 68.6 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 293 Total enrollment, primary (% net) 2008 88.6 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 173 Ratio of female to male primary enrollment (%) 2008 93.6 Infant mortality rate (per 1,000 live births) 2008 66.4 Ratio of female to male secondary enrollment (%) 2007 81.6 Newborns protected against tetanus (%) 2008 87 Gender Development Index (GDI) 2008 114 DPT3 immunization coverage (% by age 1) 2005 75.5 Health expenditure, total (% of GDP) 2007 5.9 Pregnant women living with HIV who received antiretroviral drugs 2005 3.5 Health expenditure, public (% of GDP) 2007 1.7 (%) Prevalence of HIV (% of population ages 15–49) 2007 0.8 Health expenditure/capita (current US$) 2007 35.8 Female adults with HIV ( % of population ages 15+ with HIV) 2007 28.6 Physicians (per 1,000 population) 2000 0.16 Prevalence of HIV, female (% ages 15–24) 2007 0.3 Nurses and midwives (per 1,000 population) 2000 0.85 poorest-Richest poorest/Richest Indicator Survey Year poorest Second Middle Fourth Richest total Difference Ratio Total fertility rate DHS 2005 4.9 3.9 3.2 2.9 2.4 3.4 2.5 2.0 Current use of contraception (Modern method) DHS 2005 22.1 25.1 27.3 28.7 32.3 27.2 –10.2 0.7 Current use of contraception (Any method) DHS 2005 30.7 34.3 38.7 41.3 54 40 –23.3 0.6 Unmet need for family planning (Total) DHS 2005 31.4 29.2 26.2 22.3 16.8 25.1 14.6 1.9 Births attended by skilled health personnel DHS 2005 20.7 29 39.6 62 89.9 43.8 –69.2 0.2 (percent) National policies and Strategies that Have Influenced Reproductive Health National Strategy for Reproductive and Sexual Health in Cambodia (2006–2010): aims to ensure an effective and coordinated response to reproduc- tive and sexual health needs in the country; the strategy is based on 4 guiding principles: (a) human rights and empowerment, (b) gender equity, (c) multisectoral partnerships, linkages, and community involvement, and (d) evidence based programming. National population policy of Cambodia (2003) recognizes the central role of reproductive health services, empowerment of women through equal access to education and public office, and the link between poverty and rapid population growth. Abortion law (1997) – permissible upon request up to twelfth week and under special circumstances in the second trimester.