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

University of Technology, Sydney. Faculty of Health.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

Quality of maternity care practices of skilled birth attendants in Cambodia

Background: The World Health Organization's recommended package of interventions for the integrated management of pregnancy and childbirth provides guidance for the use of evidence-based interventions to ensure the best outcomes for mother and newborn. However, the extent to which skilled birth attendants (SBAs) follow evidence-based guidelines is not known. There are few studies into childbirth practices of SBAs in Cambodia. The aim of this study was to observe practices of SBAs during labour, birth and the immediate post-partum period and their consistency with evidence-based guidelines. Methods: A structured non-participant observation study was undertaken. Data were collected using an observational checklist of evidence-based practices adapted from the Cambodian clinical assessment tools for associate degree in midwifery. Maternity care settings in one provincial hospital, two district referral hospitals and two health centres in one province of Cambodia were purposively selected. Results: Twenty-five SBAs who attended 40 women during labour, birth and the postnatal period were observed. The results showed that the use of the partograph was low; birth companions were not permitted; cleanliness during birth was lacking; management of the third stage of labour was inappropriate; monitoring of mother and baby in the early postnatal period was lacking; the SBAs lacked skills in neonatal resuscitation; skin-to-skin contact with the newborn and early breastfeeding were rare; and intramuscular injection of vitamin K varied. Conclusion: The findings suggest that the current SBA practices during labour, birth and the immediate postpartum period in one province of Cambodia are not consistent with evidence-based guidelines. Service improvements that address evidence-based practices are likely to have an impact on clean and safe childbirth, thereby enhancing outcomes for Cambodia women. © 2012 The Authors International Journal of Evidence-Based Healthcare © 2012 The Joanna Briggs Institute

Reproductive ecology of wrinkle-lipped free-tailed bats Chaerephon plicatus (Buchannan, 1800) in Rrelation to Guano Production in Cambodia

Wildlife populations in Southeast Asia are subject to increasing pressure from climate change, habitat loss and human disturbance. Cave-roosting bats are particularly vulnerable to all three factors. Because of the ecological services they provide, it is important to assess specific vulnerabilities to inform their conservation management. We evaluated the reproductive phenology and body condition of Chaerephon plicatus for 14 months in 2015–2016 and quantified guano harvesting at the largest colony in Cambodia in 2011–2016. As in Thailand and Myanmar, two annual breeding cycles were recorded, characterized as continuous bimodal polyoestry, with parturition primarily occurring in April and October. Significant declines occurred in body condition between the late wet season and the late dry season, suggesting that bats experience increasing energetic stress as the dry season progresses. Annual guano harvests increased over the study period but could not be used as a proxy for monitoring population size due to the loss of unknown amounts during the wet season and unquantified movements of bats between C. plicatus colonies in the region. We recommend studies to determine the scale and drivers of such movements and creation of sustainable guano harvesting and population monitoring initiatives to ensure the conservation of C. plicatus colonies in Cambodia

Communication Education Curriculum For A Multicultural Learning Context

This study investigates the socio-academic experiences of international students in higher education through the review of existing research and conduct of original research. There is a need for interpersonal communication curriculum in higher education that addresses a multicultural learning context to meet the growing needs of an internationalized workforce (Qing, 2009). Curriculum that addresses a multicultural learning context should meet the needs of internationalization across the globe (2009). The growing number of international students learning in foreign contexts has increased by nearly 50% in the last 10 years. In order to meet the changing needs in higher education, this study aims to develop a curriculum to meet the needs of the student in a multicultural learning context. The first phase of the research takes a close look at existing research by exploring concepts that affect the social and academic success of international students like: Maslow’s (1954) hierarchy of basic needs, Cornell West’s philosophy of ethics (Griffin, 1999), the goals of communication education (Vangelisti, 1999), cultural intelligence (Botton et al., 2013), culture shock (Lee, 2011), learning shock (Lee, 2011), and power distance (Qing, 2009). The second phase of the research gathers original research from a purposive sample of community college students that represent the international student and domestic student perspectives as well as qualitative interviews of the campus’ faculty to get the instructors’ perspective. Quantitative research was conducted on the students using a series of self-evaluations on a purposive sample of 26 students. For this project’s purposes, only one of the three evaluations that were conducted during the original research phase is explored in this study. The students’ and instructors’ participation was voluntary

Effects of a short-term overfeeding with fructose or glucose in healthy young males

Consumption of simple carbohydrates has markedly increased over the past decades, and may be involved in the increased prevalence in metabolic diseases. Whether an increased intake of fructose is specifically related to a dysregulation of glucose and lipid metabolism remains controversial. We therefore compared the effects of hypercaloric diets enriched with fructose (HFrD) or glucose (HGlcD) in healthy men. Eleven subjects were studied in a randomised order after 7d of the following diets: (1) weight maintenance, control diet; (2) HFrD (3·5g fructose/kg fat-free mass (ffm) per d, +35% energy intake); (3) HGlcD (3·5g glucose/kg ffm per d, +35% energy intake). Fasting hepatic glucose output (HGO) was measured with 6,6-2H2-glucose. Intrahepatocellular lipids (IHCL) and intramyocellular lipids (IMCL) were measured by 1H magnetic resonance spectroscopy. Both fructose and glucose increased fasting VLDL-TAG (HFrD: +59%, P<0·05; HGlcD: +31%, P=0·11) and IHCL (HFrD: +52%, P<0·05; HGlcD: +58%, P=0·06). HGO increased after both diets (HFrD: +5%, P<0·05; HGlcD: +5%, P=0·05). No change was observed in fasting glycaemia, insulin and alanine aminotransferase concentrations. IMCL increased significantly only after the HGlcD (HFrD: +24%, NS; HGlcD: +59%, P<0·05). IHCL and VLDL-TAG were not different between hypercaloric HFrD and HGlcD, but were increased compared to values observed with a weight maintenance diet. However, glucose led to a higher increase in IMCL than fructos

Fuel metabolism during exercise in euglycaemia and hyperglycaemia in patients with type 1 diabetes mellitus—a prospective single-blinded randomised crossover trial

Aims/hypothesis: We assessed systemic and local muscle fuel metabolism during aerobic exercise in patients with type 1 diabetes at euglycaemia and hyperglycaemia with identical insulin levels. Methods: This was a single-blinded randomised crossover study at a university diabetes unit in Switzerland. We studied seven physically active men with type 1 diabetes (mean ± SEM age 33.5 ± 2.4years, diabetes duration 20.1 ± 3.6years, HbA1c 6.7 ± 0.2% and peak oxygen uptake [ $$\mathop {\text{V}}\limits^{\text{.}} {\text{O}}_{2{\text{peak}}}$$ ] 50.3 ± 4.5ml min−1 kg−1). Men were studied twice while cycling for 120min at 55 to 60% of $$\mathop {\text{V}}\limits^{\text{.}} {\text{O}}_{{\text{2peak}}}$$ , with a blood glucose level randomly set either at 5 or 11mmol/l and identical insulinaemia. The participants were blinded to the glycaemic level; allocation concealment was by opaque, sealed envelopes. Magnetic resonance spectroscopy was used to quantify intramyocellular glycogen and lipids before and after exercise. Indirect calorimetry and measurement of stable isotopes and counter-regulatory hormones complemented the assessment of local and systemic fuel metabolism. Results: The contribution of lipid oxidation to overall energy metabolism was higher in euglycaemia than in hyperglycaemia (49.4 ± 4.8 vs 30.6 ± 4.2%; p < 0.05). Carbohydrate oxidation accounted for 48.2 ± 4.7 and 66.6 ± 4.2% of total energy expenditure in euglycaemia and hyperglycaemia, respectively (p < 0.05). The level of intramyocellular glycogen before exercise was higher in hyperglycaemia than in euglycaemia (3.4 ± 0.3 vs 2.7 ± 0.2 arbitrary units [AU]; p < 0.05). Absolute glycogen consumption tended to be higher in hyperglycaemia than in euglycaemia (1.3 ± 0.3 vs 0.9 ± 0.1 AU). Cortisol and growth hormone increased more strongly in euglycaemia than in hyperglycaemia (levels at the end of exercise 634 ± 52 vs 501 ± 32nmol/l and 15.5 ± 4.5 vs 7.4 ± 2.0ng/ml, respectively; p < 0.05). Conclusions/interpretation: Substrate oxidation in type 1 diabetic patients performing aerobic exercise in euglycaemia is similar to that in healthy individuals revealing a shift towards lipid oxidation during exercise. In hyperglycaemia fuel metabolism in these patients is dominated by carbohydrate oxidation. Intramyocellular glycogen was not spared in hyperglycaemia. Trial registration: ClinicalTrials.Gov NCT00325559 Funding: This study was supported by unrestricted grants from the Oetliker-Stiftung für Physiologie, from the Swiss Diabetes Foundation, from NovoNordisk, Switzerland, and from the Swiss National Science Foundatio

Can positive inquiry strengthen obstetric referral systems in Cambodia?

Maternal death remains high in low resource settings. Current literature on obstetric referral that sets out to tackle maternal death tends to focus on problematization. We took an alternative approach and rather asked what works in contemporary obstetric referral in a low income setting to find out if positive inquiry could generate original insights on referral that could be transformative. We documented and analysed instances of successful referral in a rural province of Cambodia that took place within the last year. Thirty women, their families, healthcare staff and community volunteers were purposively sampled for in‐depth interviews, conducted using an appreciative inquiry lens. We found that referral at its best is an active partnership between families, community and clinicians that co‐constructs care for labouring women during referral and delivery. Given the short time frame of the project we cannot conclude if this new understanding was transformative. However, we can show that acknowledging positive resources within contemporary referral systems enables health system stakeholders to widen their understanding of the kinds of resources that are available to them to direct and implement constructive change for maternal health

after Paris peace areement in 1991

Thesis(Master) --KDI School:Master of Public Policy,2013masterpublishedSorphorn Ith