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Background: In Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between 2017 and 2020 in a large maternity referral hospital in the country and identify their key determinants to inform future prevention efforts. Methods: This was a retrospective cross-sectional analysis with a nested case–control study of women giving birth at the National Maternal and Child Health Centre (NMCHC) in Phnom Penh, 2017–2020. We calculated percentages of singleton births at ≥ 22 weeks' gestation resulting in stillbirth and annual stillbirth rates by timing: intrapartum (fresh) or antepartum (macerated). Multivariable logistic regression was used to explore factors associated with stillbirth, where cases were all women who gave birth to a singleton stillborn baby in the 4-year period. One singleton live birth immediately following each case served as an unmatched control. Multiple imputation was used to handle missing data for gestational age. Results: Between 2017 and 2020, 3.2% of singleton births ended in stillbirth (938/29,742). The stillbirth rate increased from 24.8 per 1000 births in 2017 to 38.1 per 1000 births in 2020, largely due to an increase in intrapartum stillbirth rates which rose from 18.8 to 27.4 per 1000 births in the same period. The case–control study included 938 cases (stillbirth) and 938 controls (livebirths). Factors independently associated with stillbirth were maternal age ≥ 35 years compared to < 20 years (aOR: 1.82, 95%CI: 1.39, 2.38), extreme (aOR: 3.29, 95%CI: 2.37, 4.55) or moderate (aOR: 2.45, 95%CI: 1.74, 3.46) prematurity compared with full term, and small-for-gestational age (SGA) (aOR: 2.32, 1.71, 3.14) compared to average size-for-age. Breech/transverse births had nearly four times greater odds of stillbirth (aOR: 3.84, 95%CI: 2.78, 5.29), while caesarean section reduced the odds by half compared with vaginal birth (aOR: 0.50, 95%CI: 0.39, 0.64). A history of abnormal vaginal discharge increased odds of stillbirth (aOR: 1.42, 95%CI: 1.11, 1.81) as did a history of stillbirth (aOR: 3.08, 95%CI: 1.5, 6.5). Conclusions: Stillbirth prevention in this maternity referral hospital in Cambodia requires strengthening preterm birth detection and management of SGA, intrapartum care, monitoring women with stillbirth history, management of breech births, and further investigation of high-risk referral cases. Plain language summary: In Cambodia, there is very little information published on stillbirths to know precisely how many there are and to understand the underlying reasons they occur so they can be prevented in the future. Our study aimed to quantify the number of stillborn babies and identify some underlying risk factors from one of the largest maternity referral hospitals in Phnom Penh, Cambodia. We examined data from almost 30,000 health facility medical files of women who gave birth between 2017 and 2020 which included 938 stillbirths. We found that about 3.2% of births ended in a stillbirth and that this percentage increased between 2017 and 2020. Women who had preterm babies, or whose babies were small in weight for their gestational age, and babies that were born breech had a higher chance of being stillborn. Women who had abnormal vaginal discharge, which can indicate a possible infection, also had a higher odds of having a stillbirth. We also found that women who had a stillbirth previously had almost three times higher chance of having another stillborn baby. Having a caesarean section reduced the likelihood of having a stillborn baby by about half. These findings suggest that efforts are needed to better identify and manage women with preterm births and monitor fetal growth as well as ensure breech births are managed adequately. [ABSTRACT FROM AUTHOR]

A qualitative assessment was made of service provider and user perceptions of the quality of integrated reproductive health services established through a pilot intervention in Cambodia. The intervention aimed to promote pregnant women's HIV testing and general utilization of reproductive health facilities as well as improve the follow-up of HIV-positive women and exposed infants through strengthened referral and operational linkages amongst health facilities/services and community-based support interventions for PLHIV. The study was conducted in one operational district where the intervention was piloted and for comparative purposes in a district where integrated services had yet to be implemented. Service providers in the pilot district reported improved collaboration and coordination of services, more effective referral, and the positive impact of improved proximity of HIV testing through integrated local level facilities. Community-based support teams for PLHIV embraced their expanded role, were valued by families receiving their assistance, and were understood to have had an important role in referral, PMTCT follow-up and countering PLHIV stigmatization; findings which underscore the potential role of community support in integrated service provision. Challenges identified included stigmatization of PLHIV by health staff at district hospital level and a lack of confidence amongst non-specialized health staff when managing deliveries by HIV-positive women, partly due to fear of HIV transmission. [ABSTRACT FROM AUTHOR]

Objectives To document the pilot experience of provision of safe abortion/post-abortion services implemented in 2002 at the Mother Child Health clinic in Sihanoukville, Cambodia, and to profile clients and assess their uptake of post-abortion contraception. Methods The initial package of safe abortion/post-abortion clinics (SAPAC) services included counselling on family planning and prevention of sexually transmitted infections, pain management, Manual Vacuum Aspiration procedure and standard universal precautions at an affordable price (US$12.5). SAPAC services became operational in August 2002. The data of medical records from 1 August 2002 to 31 December 2005 (2224 clients) were analysed. Results The mean number of clients per month attending SAPAC services ranged from 26 in 2002 to 64 in 2005. Fifty-three per cent were housewives, 24% worked in sales or services, 8% in factories, 11% in bars or karaoke lounges and 3% were brothel-based sex workers. Ninety-three per cent of clients came for induced abortion and 7% sought post-abortion care. Pain management was used in 99% of cases. The overall rate of complications during intervention was 2.1% and dropped from 9.4% in 2002 to 1.3% in 2005. After SAPAC implementation, fewer women in Sihanoukville sought abortion services without any quality control and a safer technique was used. On average, 40% of patients took up contraception after the abortion. Conclusions Integrating comprehensive abortion-care services at a peripheral government health facility is feasible. There is a demand for such services provided at an affordable price in Sihanoukville, Cambodia. [ABSTRACT FROM AUTHOR]

In Cambodia, clinics established for the prevention and management of sexually transmitted infections (STIs) in women sex workers do not address other reproductive health services. The aim of this study was to assess the need for more comprehensive sexual and reproductive health services for women sex workers in Cambodia. In January 2000, relevant documents were reviewed, interviews with key informants carried out and group interviews with women sex workers conducted. Medical records from women sex workers were also reviewed and some data collected prospectively in one government STI clinic. Interviews with the women and data from the government clinic indicated that excluding condoms, a very low proportion of women sex workers were currently using a modern contraceptive method −5% of 38 women and 1.6% of 632 women, respectively. Induced abortion was widely used but was perceived to be risky and costly. Data from a mobile team intervention and the government clinic respectively showed that 25.5% (n=1744) and 21.9% (n=588) of women sex workers reported at least one previous induced abortion. These findings reveal the need for accessible contraception and safe abortion services among sex workers in Cambodia, and raise the issue of the reproductive rights and reproductive health needs of women sex workers in general. [Copyright &y& Elsevier]

In 2010, following its approval by the Ministry of Health, the medical abortion combination pack Medabon (containing mifepristone and misoprostol) was made available at pharmacies and in a restricted number of health facilities in Cambodia. The qualitative study presented in this paper was conducted in 2012 as a follow-up to longer-term ethnographical research related to reproductive health and fertility regulation between 2008 and 2012. Observations were carried out at several clinic and pharmacy sites and in-depth interviews were conducted with a purposive sample of 20 women who attended two MSI Cambodia centres and 10 women identified through social networks; six men (women’s male partners); eight health care providers at the two MSI centres and four pill sellers at private or informal pharmacies (who also provided health care services in private clinics). Although the level of training among the drug sellers and providers varied, their knowledge about medical abortion regimens, correct usage and common side effects was good. Overall, women were satisfied with the services provided. Medical abortion was not always a women-only process in this study as some male partners were also involved in the care process. The study illustrates positive steps forward being taken in making abortion safe and preventing and reducing unsafe abortion practices in Cambodia. [ABSTRACT FROM AUTHOR]

In 2010, following its approval by the Ministry of Health, the medical abortion combination pack Medabon (containing mifepristone and misoprostol) was made available at pharmacies and in a restricted number of health facilities in Cambodia. The qualitative study presented in this paper was conducted in 2012 as a follow-up to longer-term ethnographical research related to reproductive health and fertility regulation between 2008 and 2012. Observations were carried out at several clinic and pharmacy sites and in-depth interviews were conducted with a purposive sample of 20 women who attended two MSI Cambodia centres and 10 women identified through social networks; six men (women’s male partners); eight health care providers at the two MSI centres and four pill sellers at private or informal pharmacies (who also provided health care services in private clinics). Although the level of training among the drug sellers and providers varied, their knowledge about medical abortion regimens, correct usage and common side effects was good. Overall, women were satisfied with the services provided. Medical abortion was not always a women-only process in this study as some male partners were also involved in the care process. The study illustrates positive steps forward being taken in making abortion safe and preventing and reducing unsafe abortion practices in Cambodia. RésuméEn 2010, après son approbation par le Ministère de la Santé, le produit pour l’avortement médicamenteux Medabon, conditionnement qui associe la mifépristone et le misoprostol, a été commercialisé dans les pharmacies et dans un nombre restreint de centres de santé au Cambodge. L’étude qualitative présentée dans cet article s’est déroulée en 2012, comme prolongement d’une recherche ethnographique à plus long terme relative à la santé génésique et la régulation de la fécondité entre 2008 et 2012. Les observations ont été réalisées dans plusieurs dispensaires et pharmacies. Des entretiens approfondis ont été menés avec un échantillon raisonné de 20 femmes qui s’étaient rendues dans deux centres MSI Cambodge et dix femmes identifiées par les réseaux sociaux ; six hommes (des partenaires des femmes) ; huit prestataires de soins de santé dans les deux centres MSI et quatre vendeurs de comprimés dans des pharmacies privées ou informelles (qui assuraient également des soins de santé dans des dispensaires privés). Le niveau de formation des vendeurs de comprimés et des prestataires était divers, mais leur connaissance des schémas d’avortement médicamenteux, de leur utilisation correcte et des effets secondaires fréquents était bonne. Dans l’ensemble, les femmes étaient satisfaites des services fournis. L’avortement médicamenteux n’était pas toujours une « affaire de femmes » dans cette étude puisque certains partenaires masculins participaient également au processus. L’étude illustre les progrès accomplis pour rendre les avortements plus sûrs, tout en prévenant et réduisant les pratiques abortives à risque au Cambodge. ResumenEn el año 2010, después de ser aprobado por el Ministerio de Salud, el paquete combinación para el aborto con medicamentos Medabon (que contiene mifepristona y misoprostol) se hizo disponible en farmacias y en un número limitado de unidades de salud en Camboya. El estudio cualitativo presentado en este artículo fue realizado en 2012 como seguimiento a investigaciones etnográficas más extensas relacionadas con la salud reproductiva y la regulación de la fertilidad del 2008 al 2012. Se realizaron observaciones en varias clínicas y farmacias, así como entrevistas a profundidad con una muestra intencional de 20 mujeres que asistieron a dos centros de MSI Camboya y 10 mujeres identificadas por medio de redes sociales; seis hombres (parejas de mujeres); ocho profesionales de la salud en los dos centros de MSI y cuatro vendedores de píldoras en farmacias privadas o informales (que también prestaban servicios de salud en clínicas privadas). Aunque el nivel de capacitación entre los vendedores de medicamentos y profesionales de la salud varió, tenían buenos conocimientos acerca de los regímenes de aborto con medicamentos, uso correcto y efectos secundarios comunes. En general, las mujeres estaban satisfechas con los servicios que recibieron. En este estudio, el aborto con medicamentos no siempre fue un proceso solo para mujeres, ya que algunas parejas de sexo masculino también participaron en el proceso de brindar cuidados. El estudio ilustra los pasos positivos hacia adelante que se están realizando para lograr que el aborto sea más seguro y para prevenir y reducir las prácticas de aborto inseguro en Camboya. [ABSTRACT FROM PUBLISHER]

Objectives: We aimed to describe the challenges and outcomes of implementing a national syphilis follow-up system to improve syphilis management in maternal and child health (MCH) services in Cambodia., Design: Operational study; quantitative cohort data and cross sectional qualitative data., Setting: Public health facilities at national level and in four provinces with high syphilis prevalence in Cambodia., Participants: Pregnant women screened for syphilis; MCH health care providers and managers., Methods: We conducted an operational research using syphilis screening and treatment data collected from a national follow-up system (cohort data) and reported in the health management information system (HMIS) between 2019 and 2020. We also conducted indepth interviews with 16 pregnant women and focus group discussions with 37 healthcare providers and managers. Descriptive statistics and thematic content analysis were used., Outcome Measures: Syphilis testing and treatment results and perceptions regarding these services., Results: A total of 470 pregnant women who tested positive in rapid syphilis testing were recorded in the national syphilis follow-up system in 2019-2020. Of these, 71% (332 of 470) received a rapid plasma reagin (RPR) test and 95% (n=315) tested positive; 78% (246 of 315) received any syphilis treatment and only 28% (88 of 315) were treated adequately with benzathine penicillin G (BPG). Data from four provinces with high syphilis prevalence (more closely monitored) showed higher testing and treatment rates than at the national level. HMIS aggregated data reported a higher number of pregnant women screened and treated for syphilis than the follow-up system during the same period. Barriers to syphilis testing and treatment included late antenatal care, long distance to RPR testing and treatment, partners' lack of support to reach the health facility, BPG stockout and poor adherence to oral treatment in the absence of BPG. Providers and managers reported a lack of communication across services, insufficient skills to treat infants and absence of clear guidance regarding the revised follow-up system. Study findings contributed to changes in operating procedures nationwide to facilitate access to syphilis testing and adequate treatment and a systematic follow-up of pregnant women and exposed infants., Conclusions: Study results contributed to informing improvements to syphilis management in MCH services in Cambodia., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess contraceptive uptake and method choice among women living with HIV (WLHIV) attending an HIV care clinic serving most-at-risk women in Phnom Penh, Cambodia, before and after the implementation of family planning (FP) services., Methods: Semistructured questionnaires were administered to clients before (July, 2011) and after (July, 2012) FP service implementation with provision of contraceptive methods (pills, injectables, implants, and intrauterine device [IUD])., Results: Among 250 and 249 clients interviewed before and after implementation respectively, 24.5% of women reported selling sex for money during the last 6 months before and 35.3% after implementation. Awareness about contraceptive methods significantly increased among clients postimplementation. Among sexually active women, male condom remained the contraceptive method of choice with an overall condom use during the last 6 months at 91% postimplementation vs. 95.6% preimplementation (P = 0.11). Although the use of noncondom FP methods increased but not significantly (16.4% after vs. 12.6% before implementation, P = 0.8), the use of dual method (condom plus another method) remained low and did not significantly increase after implementation (14.8% after vs. 11.0% before, P = 0.28)., Conclusions: Our results show that FP practices of WLHIV attending an HIV care clinic for most-at-risk populations did not significantly change after integration on-site provision of a wide range of FP methods. Innovative strategies and further research are needed to better understand how to promote the use of noncondom FP methods and prevent unwanted pregnancies and abortions among most-at-risk women and WLHIV.

Introduction: In Cambodia, the Linked Response (LR) approach for strengthening linkages between HIV and reproductive health services, especially for the prevention of mother-to-child transmission of HIV (PMTCT), was scaled up in 2009. This article describes the LR scale-up and the concomitant evolution of key PMTCT indicators at the national level., Methods: A descriptive analysis of routine LR, PMTCT programme data, and national laboratory data from 2008 to 2012 was conducted., Results: LR data show that between 2008 and 2012, the number of LR/PMTCT sites increased from 67 to 956 (of 1004) public health facilities to cover 74 (of 77) operational districts. In LR operational districts, the number of pregnant women (PW) tested for HIV increased from 41,800 in 2009 to 269,935 [of whom 375 (0.14%) were newly tested positive for HIV] in 2012; the number of PW living with HIV and exposed infants receiving antiretrovirals increased from 49 and 44 in 2009 to 720 and 551 in 2012, respectively. Concomitantly, national PMTCT programme data showed that the percent of PW tested for HIV increased from 34.4% (117,832 of 342,929 estimated PW) in 2008 to 86.1% (324,996 of 377,340) in 2012. In 2012, 65.3% (862 of 1321) of estimated HIV-positive PW and 72.7% (960 of 1321) of exposed infants received antiretrovirals. By 6-8 weeks postpartum, 7.4% (8 of 108) and 1.5% (6 of 409) of DNA-polymerase chain reaction tested positive in 2008 and in 2012, respectively., Conclusions: The LR approach provided a model, which catalyzed increased access of PW to HIV testing and treatment, thereby contributing to the scale-up of PMTCT service provision and improved coverage in Cambodia.

Objectives: To describe the implementation and results of the linked response (LR) in Cambodia after 18 months of follow-up., Methods: The main objectives of the LR are to increase access to sexually transmitted infection/HIV prevention, testing, care, and treatment and to strengthen existing reproductive health services through increased linkages within and between public health facilities and community-based services. The LR was piloted in Cambodia in 2008, in 2 demonstration projects, covering 5 operational districts. Routine data were collected and analyzed before (2007), during (2008), and after (2009) the implementation of the LR., Results: Overall in the 5 operational districts, the proportion of pregnant women, tested for HIV increased from 6% (1261 of 21,376) in 2007 to 86% (18394 of 21,478) in 2009. Syphilis testing, introduced early 2009, reached similar (85%) coverage as HIV by the end of 2009. Between 2007 and 2009, reproductive indicators also increased: antenatal care coverage (at least 1 visit) from 80% to 100%, public health facility delivery rates from 26% to 46%, and contraceptive prevalence from 24% to 28%. Antiretroviral uptake was high among HIV-positive mothers and exposed infants, 84% and 95% respectively, and 3 of 36 (8%) infants tested so far for HIV were diagnosed positive. However, 6 maternal (HIV-positive women) and 7 child deaths (1 tested positive) occurred during the pregnancy or the 30-week postpartum follow-up period., Conclusions: Sexually transmitted infection/HIV indicators and follow-up dramatically improved after the LR was implemented. Efforts should be pursued to further improve quality of health care services.