Quality of care in maternal health : childbirth practices of public and private skilled birth attendants and a quality improvement system in Cambodia

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High-quality midwifery services, including access to skilled birth attendants (SBAs) and high quality emergency obstetric and neonatal care are essential for reducing maternal mortality worldwide. Yet there has been little emphasis in high-burden countries, such as Cambodia, on examining the actual practices of SBAs and women’s experiences with the care they receive. This thesis examines the practices of public and private SBAs during labour, birth and the immediate post-partum period, their working environments, women’s perspectives, and the quality improvement systems needed to maintain and support SBAs to deliver quality maternal and child care in Cambodia. A qualitative, naturalistic inquiry design was undertaken, using participant observation, in-depth interviews, focus group discussions and informal interviews. Data were audio-taped, transcribed, and analysed using a thematic approach. A purposive sampling of twenty public SBAs who attended 40 births collectively and five private SBAs who attended 10 births was observed. Interviews and focus group discussions with public SBAs and interviews with private SBAs were conducted after the observation. Thirty interviews were conducted with women who had recently given birth with public and private SBAs. Key stakeholders consisted of five medical doctors from the Cambodian Ministry of Health, the Provincial Health Department and an NGO who were selected for interview. The findings showed that childbirth practices of public and private SBAs were not consistent with evidence-based standards. Physical environment, remuneration and incentives, workplace culture, management practices, and professional development opportunities were identified as the main factors affecting SBAs’ practice. Women’s choice and use of health facilities were influenced by their perceptions of safety, staff attitudes, costs associated with the birth and support in labour and postnatal care. Stakeholder interviews identified facilitators and barriers to the implementation of a quality improvement system for maternity care in public health facilities. This thesis provides evidence of the current childbirth practices of SBAs and the healthcare-seeking behaviour of women in Cambodia. It illustrates the complex factors that influence SBAs’ practice, their working environments and the delivery of a quality improvement system. An empirically informed framework for coordinated action to improve maternal and newborn health care is proposed. This framework focuses on building the capacity of SBAs and provides decision-makers, practitioners, key health partners and researchers with a tool to guide policy and target investments to maximise the impact upon maternal health improvement in Cambodia and other similar countries.
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