Training, Employment and Activity Level of Cambodia Midwife Association (CMA) Members

Page 2 Training, Employment and Activity Level of Cambodia Midwife Association (CMA) Members RACHA Studies Number 5 July 1999

Page 3 Executive Summary RACHA conducted a survey of 165 midwives who are members of the Cambodian Midwives Association in Pursat, Kampot, and Siem Reap. Respondents were asked to report on their level of training, places of employment, and level of activity in attending deliveries. The key findings of the study are: Overall, 41 of midwives work in provincial hospitals, while 35 are employed in health centers; relatively few are employed in the District Referral Hospitals (8), the MCH Provincial Offices (15), and Other Provincial Offices (2). One hundred and five midwives - 64 - report working in the private sector, of which 103 attend home deliveries. However, only 40 of midwives in Kampot report private sector employment, compared to 74 in Pursat and Siem Reap. The very low salary of government midwives forces midwives to have an additional source(s) of employment from which they derive most of their income. However, government employment is important for access to training, gaining experience and confidence, meeting new clients for private practice, and enhancing the local community s positive perceptions of the midwife. The percentage of midwives engaging in private services is significantly greater for health center midwives (79) than provincial hospital midwives (55) and MCH Office midwives (50). Overall, 45 of midwives did not attend a delivery in the preceding month, while 59 attended one to five deliveries, and 12 attended more than five deliveries. However, 69 attended only 2 deliveries or less, suggesting that many CMA midwives are not very active. Key conclusions drawn from these results are: Working in a health center makes the services of midwives more accessible to local communities, meaning that a higher percentage of midwives assigned to health centers might be desirable. More frequent contact between midwives and clients might explain why health center midwives are more likely to have a private practice. Given the dual government/private employment of most midwives, training designed to improve government services directly contributes to upgrading the same services clients from midwives through their private practice. The low level of activity of many midwives in attending deliveries means that there is considerable need for efforts to increase the demand for services from midwives. Ensuring the Supply of, the Demand for, and Access to Reproductive and Child Health Services

Page 4 Background to the Survey RACHA works with the Cambodia Midwife Association (CMA) to strengthen its capacity to be an effective organization that provides leadership and support services to its members. To help CMA in this endeavor, RACHA and CMA distributed a brief questionnaire to CMA midwives from Kampot, Pursat, and Siem Reap. The questionnaire asked about their level of training (primary or secondary midwife), their place of work (public and private sector work sites), the number of deliveries they attended in the previous month, and when they last delivered a baby. A total of 165 midwives completed the questionnaire. While very simple, the questionnaire provides CMA with the first systematic overview of its members. The following tables present the results.! Training Level Table 1: Training Level and Place of Employment of CMA Midwives [1] Training Level and Place of Work Kampot Pursat Siem Reap Total 1. Training Level 100 100 100 100 a. Secondary Midwife 71 88 87 82 b. Primary Midwife 29 12 13 18 2. Place of Work [2] a. Government Facility 100 98 100 100 (1) Provincial Hospital 40 25 53 41 (2) District Referral Hospital 13 4 9 8 (3) MCH Provincial Office 25 6 13 15 (4) Other Provincial Office 6 2 2 2 (5) Health Center 27 61 24 35 b. [3] 40 73 74 64 (1) Clinic 6 4 0 3 (2) Home Births 38 71 74 62 c. Employed Exclusively in a Government Facility 60 27 26 3 d. Employed Exclusively in the 0 2 0 1 Number of midwives: N = 48 N = 49 N = 68 N = 165 [1] Percentages are based on number of midwives reported for the province. [2] Midwives can hold more than one government job and work in more than one location. Four midwives in Kampot reported holding two government jobs that are both counted for the place of employment, i.e., they are reported twice. [3] Three midwives work in private clinics and do home deliveries. One midwife is retired from government and only works in private practice. Table 1 shows that the majority of CMA s members have a more advanced level of training, 82 reported being secondary midwives. The same is true across all three provinces, with Pursat and Siem Reap having a somewhat higher percentage of secondary midwives than Kampot.! Place of Employment

Page 5 Table 1 includes the distribution of CMA midwives by place of employment. With the exception of one retired midwife in Pursat, all midwives reported holding government jobs. Overall, 41 work in the provincial hospital, while 35 are employed in a health center; relatively few are employed in the District Referral Hospitals (8), the MCH Provincial Offices (15), and Other Provincial Offices (2). However, there are significant differences between the provinces regarding place of employment. Compared to the other two provinces, Kampot has a somewhat higher percentage of midwives working in the MCH Provincial Office (25). In contrast, the percentage of midwives working in the provincial hospital is considerably lower in Pursat (25), with a much higher percentage (61) reporting health centers as their place of employment. In Siem Reap, the percentage employed in the provincial hospital (53) is highest, but the percentage working in health centers (24) is the lowest among the three provinces. To the extent that employment in a health center makes the services of midwives more accessible to local communities, a higher percentage of midwives assigned to health centers might be desirable. Working at a health center, as opposed to a higher level facility, such as the provincial hospital, might better distribute the services of midwives, bringing them closer to the target clientele. A very important finding of the survey is that two-thirds (64) of the CMA midwives also report working in the private sector. Of the 105 midwives working in the private sector, 103 perform home deliveries; very few work in private clinics. This reflects the fact that in rural communities, the home is the most common place where women give birth. However, Kampot differs significantly from Pursat and Siem Reap with respect to the private provision of services. Only 40 of midwives in Kampot report private sector employment, while almost three-quarters (73-74) in Pursat and Siem Reap work at non-government jobs. Subsequent interviews with midwives in Pursat Province reinforced the fact that most of them must have a private practice to support themselves. Midwives reported that their private practice extends to services far beyond traditional midwife functions. Most provide a full range of services, including home deliveries, treating illnesses of mothers and children, gynecological care, injections, birth spacing, and care for induced abortion cases. In effect, many midwives are serving as de facto country doctors in their private practices. The need to have government employment and a private practice reflects the very low pay of government midwives about $8 per month. Some health center staff in Pursat reported only being paid five out of 12 months in 1998 a total of $40 for the year. Clearly, no one can live on, let alone support a family on such a low salary even in the provinces. A very important question is why bother with government employment? What is the incentive to remain a government employee when the time spent doing such work could possibly be better used to earn more money elsewhere? From some initial study, it is clear that a government job serves additional purposes and beyond salary provides additional benefits for midwives. When we asked midwives this question in Pursat, the most common answer was that government employment offers the opportunity for further training. While such training is helpful for improving government Ensuring the Supply of, the Demand for, and Access to Reproductive and Child Health Services

Page 6 services, this training and the skills upgrading are directly transferable to and useful for the midwife s private practice. Government employment also functions as a meeting point, or market, that brings together future buyers of the midwife s private services expectant mothers - with the potential seller of services the midwife who will attend the home delivery. Government employment also serves as a gateway through which the midwife s family and friends gain easier access to government services, e.g., a midwife will accompany family members who need hospital services, assure they get treated quickly, and are served by the better staff on duty. Whatever the specific incentives are for an individual midwife, they are apparently strong enough for the majority of midwives to keep their government job, while engaging in private practice to earn a sufficient income. A simple table that shows the number of government midwives by place of employment and how many are working in private practice is instructive. Table 2 clearly shows from which government jobs midwives in private practice are coming. Table 2: Place of Employment by Government Employed Midwives ly Employed Midwives Percent Place of Government Total Total No. in the Employment No. of Midwives Clinic Home Births In 1. Provincial Hospital 67 1 36 37 55 2. District Hospital 14 2 9 11 79 3. MCH Provincial Office 24 1 11 12 50 4. Other Provincial Office 4 0 1 1 25 5. Health Center 58 1 45 46 79 The distribution of midwives attending home deliveries reflects the overall pattern of government employment, i.e., 149 of the respondents (91) are employed in three types of government jobs provincial hospitals (41), health centers (35), or MCH Provincial Offices (15). Focusing on these three major places of employment, Table 2 shows that the percentage of midwives engaging in private services is significantly greater for health center midwives (79) than provincial hospital midwives (55) and MCH Office midwives (50). This difference could reflect more frequent contact between midwives and their clients in health centers than in provincial hospitals. Midwives working in a health center are more likely to be viewed as part of the local community (many live near their health center), and perhaps more closely trusted, than a midwife from the provincial hospital (located in the provincial capital). This might result in health center midwives being asked to attend home deliveries more frequently in rural areas than those from provincial hospitals (who would tend to be serving clients in town). When government by private sector place of work is viewed by province, further differences are found, as shown by Table 3.

Page 7 Table 3: Place of Employment by Government Employed Midwives - by Province Kampot ly Employed Midwives Percent Place of Government Total Total No. in the Employment No. of Midwives Clinic Home Births In 1. Provincial Hospital 19 0 3 3 21 2. District Hospital 6 1 4 5 83 3. MCH Provincial Office 12 1 3 4 33 4. Other Provincial Office 3 1 0 1 33 5. Health Center 12 1 7 8 67 All Government Facilities 48 4 17 21 40 Note: Four midwives report two government jobs and are counted twice; the actual number is reported for all facilities 48. Two report private clinic and home birth work and are counted twice; the actual number is 19 and is used for the percent employed in the private sector. Pursat ly Employed Midwives Percent Place of Government Total Total No. in the Employment No. of Midwives Clinic Home Births In 1. Provincial Hospital 12 1 5 6 50 2. District Hospital 2 1 0 1 50 3. MCH Provincial Office 3 0 2 2 67 4. Other Provincial Office 1 0 0 0 0 5. Health Center 30 0 27 27 90 All Government Facilities 48 2 34 36 73 Note: One midwife is retired from government employment and works only in private practice; therefore, she is not included in the total for government facilities but is included in the private sector total. Place of Government Employment Total No. of Midwives Siem Reap ly Employed Midwives Percent in the Ensuring the Supply of, the Demand for, and Access to Reproductive and Child Health Services

Page 8 Clinic Home Births Total No. In 1. Provincial Hospital 36 0 28 28 78 2. District Hospital 6 0 5 5 83 3. MCH Provincial Office 9 0 6 6 67 4. Other Provincial Office 1 0 0 0 0 5. Health Center 16 0 11 11 69 All Government Facilities 68 0 50 50 74 Table 1 showed that a smaller percentage (40) of Kampot s midwives work outside of government, while a much greater percentage do so in Pursat and Siem Reap (73-74). Table 3 reinforces this point - it shows that a comparatively small percentage of midwives 21 employed at Kampot s provincial hospital work in the private sector. Similarly, only 33 of midwives working at the Provincial MCH Office report private sector employment. In contrast, 67 of midwives working in health centers in Kampot have private employment. In Pursat, the picture is very different. Half of the midwives working at the provincial hospital are also employed in the private sector; whereas 90 of those working in health centers have private sector employment. In Siem Reap, 78 of midwives employed at the provincial hospital are working in the private sector, while only 69 at health centers report private sector employment. These findings support the earlier conclusion that a greater percentage of midwives working at health centers provide private services compared to those working at provincial hospitals. While this is clearly the case in Kampot and Pursat, a slightly higher percentage of midwives working at the provincial hospital in Siem Reap have private employment compared to those assigned to health centers. What accounts for the variations between the provinces is unclear at this time.! Level of Activity The questionnaire included two questions to gauge the level of activity of CMA midwives. The respondents were asked to report: a) the number of deliveries they attended during the previous month, and b) the length time since their last delivery. Unfortunately, a translation problem invalidated the responses to the second question for Kampot and Siem Reap respondents; a corrected translation was given only to the Pursat midwives. Table 4 presents the results by province. Table 4: Level of Midwife Activity by Province

Page 9 Midwives with Following Numbers of Deliveries in the Previous Month Kampot Pursat Siem Reap Total a. None 29 41 59 45 b. 1-2 23 28 20 24 c. 3-5 40 31 12 25 d. 6-9 0 0 9 4 e. 10 or more 8 0 0 2 f. Percent one delivery or more 71 59 41 55 Length of Time Since Last Delivery [*] a. Less than one month - 41 - - b. More than one month but - - - less than 12 months 39 c. One year or more - 12 - - d. Never delivered a baby - 8 - - Number of Midwives 48 49 68 165 Due to a translation problem, data were collected from Pursat midwives only. Overall, 45 of midwives reported no deliveries in the preceding month, while 59 reported attending from one to five deliveries. Somewhat surprising, 12 reported attending more than five deliveries. However, 69 attended 2 deliveries or less, which suggests that a substantial number of CMA midwives are not very active. The results for the three provinces indicate that inactivity related to births is highest among Siem Reap midwives 59 report no deliveries in the past month, with only 32 reporting from one to five deliveries. Pursat follows the overall pattern of activity. However, midwives in Kampot report being appreciably busier with only 29 attending no deliveries in the past month, and 40 reporting from three to five deliveries. Kampot is also the province with the lowest percentage of midwives (40) reporting private sector employment. This may mean that the midwives in Kampot are attending a comparatively greater percentage of deliveries in government facilities than midwives in the other two provinces. The data for Pursat show that of the 20 midwives (41) who did not attend a delivery in the past month, only 4 reported never attending a birth. This means that 45 midwives in Pursat have attended at least one birth in their careers. While it is somewhat surprising to find that four midwives have never attended even one birth, subsequent study in Pursat found that some midwives are assigned other types of jobs, in hospitals and other government facilities, where they do not actually function as a midwife. To have no practical experience at delivering a baby might also be a reflection of age young midwives might indeed have no practical experience. If attendance of at least one birth within the past month is considered active, then 41 of Pursat s midwives are active by this criterion. But this is misleading; midwives report that their attendance of births is uneven, some months are busy, while the next might be very slow. Similarly, having attended at least one birth in the past year could mean one or 50, during the past 12 months. A better measure of activity, therefore, might be the total number of births attended in the past year, expressed as a monthly average. A consideration that will Ensuring the Supply of, the Demand for, and Access to Reproductive and Child Health Services

Page 10 be taken into account as RACHA continues to work with the MOH, CMA, and midwives, to develop a better understanding of reproductive and child health care.! Conclusions An important finding of this survey is the fact that so many midwives are in private practice. As mentioned earlier, this is an absolute necessity given the level of government salaries. This confirms what many already knew, but further study of midwife careers and employment patterns are revealing some very important facts that pertain to RACHA s possible future activities with midwives. Building on the results of this survey, a qualitative study conducted in Pursat found that midwives are, in effect, the country doctors for many rural communities. Their medical training, albeit limited, makes them a far preferable choice for health care than traditional sources (healers) and other untrained providers (drug sellers). How RACHA and the MOH responds to this situation in light of their RCH objectives and service-focused strategy is now being considered. As RACHA continues to promote safe motherhood to improve and protect the health of mothers and their children, it expects to expand its work with midwives, MOH and with CMA. Midwives might well become the key service providers in rural communities for quality reproductive and child health services. Different ways are being considered to assist and work with midwives to assume this role in line with expanding access to RCH services. Mentoring of young midwives with older midwives, partnerships with traditional birth attendants, and special support arrangements for midwife graduates of the Life Saving Skills program are possibilities. RACHA is also considering how it might redouble its efforts to 32 help CMA to become an even more effective representative of the interests of midwives. For example, CMA could be a conduit for IEC efforts that encourage women to use the services of midwives for ANC, their deliveries, and for post natal care. This survey is an initial effort to collect some basic data on CMA midwives. More recently, RACHA has developed a questionnaire designed to collect basic information about the government and private employment of midwives, work experience, services offered in private practice, recently attended training, future training needs, and career aspirations. Given RACHA s geographic focus, one possibility is to conduct interviews with all midwives perhaps as many as 300 - in RACHA-assisted areas to develop a central information source for the MOH and CMA. Such information would greatly facilitate monitoring existing skill levels, selecting candidates for training programs, and identifying where support arrangements are needed, to help make the services of midwives more accessible. This would also provide CMA with the first comprehensive database on its membership. With better information, RACHA and CMA will be able to develop more effective support programs for midwives to help them become the leaders of RCH services for rural women.