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Skip to 0 minutes and 13 secondsDR TUON SOVANNA: Hello. This is the Lancet Maternal Health Series-- the Cambodian case study. A rural doctor did a Caesarean-section on a woman with her first presentation. The woman went into shock after the operation but had no bleeding that the doctor could identify. What can be done at this point? Overall, in Cambodia, the maternal mortality rate is decreasing, while births in facilities are increasing. And those by skilled birth attendants are increasing. Of the maternal deaths that do occur, access to care and referral are contributing factors. Therefore, the efforts at improving this process will further strengthen the maternal chain of survival. Here are the links in the chain that have been strengthened. First, transportation.

Skip to 1 minute and 5 secondsAmbulance availability has improved dramatically in Cambodia since 2014. After a donation of 200 ambulances, the government now possesses over 350 functioning ambulances. This allows for a ratio of 1 ambulance per 40,000 citizens, exceeding the WHO recommendation. Communication strengthening initiatives are also helping to link patients and these ambulances more efficiently, which brings us to the next link-- communication. In order to improve communication between the sending hospital and the receiving hospital, we implemented a standardised referral slip, and all hospitals were provided with a phone and instructions to call the receiving facility. Third, financing. Financial barriers exist. But since 2014, the standard benefit package, a help fund for the poor, supports emergency referral.

Skip to 2 minutes and 9 secondsThis fee goes back to the hospital that operates the ambulance. Lastly, quality improvement. To prevent a break in the chain, quality has established a system through which continuous evaluation and feedback more commonly occur. The project has instituted standardised feedback forms for every case sent to a higher level of care, and regular team meetings where emergency cases are discussed and improvement opportunities identified. For example, Midwifery Coordination Alliance meetings, where leadership from referral hospitals, local government, and midwifes from health centres, come together to review referral cases and identify improvement opportunities.

Skip to 2 minutes and 59 secondsChallenges might include establishing an emergency coordination system, improving community access to transport, gaining sustainable support from the MOH (Ministry of Health), improve and ensure level of high leadership, and ensuring that the receiving centres are not only designated EmOC but are functionally able to provide this level of care. In summary, despite dramatic improvements in facility birth with a skilled birth attendant and decreasing maternal mortality rate, Cambodia has struggled with an inadequate referral system for obstetric and newborn complications. We are currently working to link geographically isolated areas into care networks. Recently, we did have a success story where a young mother was saved due to every link in the chain working perfectly.

Skip to 3 minutes and 51 secondsThe rural doctor called the referral hospital for the woman he had done a Caesarean-section on. When her haemoglobin dropped to 5, he recognised she was critical. His early communication allowed the OB (obstetrician) to prepare. The patient was transported right away.

Skip to 4 minutes and 8 secondsShe arrived at 11:30 at night, but everything was prepared ahead for her. She went straight to the operating theatre. She had an internal hematoma. The doctor was able to stop the bleeding. She required a total hysterectomy, but a new mother was saved.

Cambodia case study: Links to care

How do links to obstetric care work in practice, particularly in resource-limited settings?

In this step Dr Tuon Sovanna (University Research Co) presents a case study on how Cambodia sought to improve its emergency transport system by addressing transport, communication, financing, and quality improvement, and touches on the challenges that remain.

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This video is from the free online course:

The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine