BATI COMMUNE, SVAY RIENG PROVINCE, CAMBODIA — Prak Soda and Suon Sakhen, high school sweethearts, married seven years ago. Lifelong residents of Svay Rieng province, one of Cambodia’s poorest, they were expecting an uneventful delivery of their second child earlier this month.
Prak Soda had taken a few days off work at a nearby garment factory to rest up and prepare.
But 27-year-old Prak Soda, a woman who knew how to add fun and laughter to a party, died from severe bleeding shortly after delivering her baby boy with a midwife’s assistance.
Her death sparked a national conversation.
Suon Sakhen, also a garment worker, said his wife appeared to be in good health immediately after giving birth.
“My wife was OK. She asked the baby after delivering: ‘Can you cry?’” he told VOA Khmer in a recent interview at his home.
But Prak Soda kept bleeding, bleeding so severe Suon Sakhen said he argued with the midwife until she dispatched the new mother to the provincial hospital.
Prak Soda died from the loss of blood en route to the hospital.
“Inside the ambulance, the medical person told me that my wife died, but I couldn’t believe it. So I asked the driver to continue driving until we reached the provincial hospital,” Sakhen said. “They confirmed that my wife died.”
The next day, Feb. 5, he filed a complaint with district police alleging negligence by the midwife. VOA Khmer obtained a copy of the filing, which detailed how tragedy struck.
Prak Soda’s death highlights how women risk death with each birth in developing nations such as Cambodia even though pregnancy is a normal phase of life for women of childbearing age.
Approximately 830 women die from preventable causes related to pregnancy and childbirth each day, according to the World Health Organization (WHO), which reports that 99 percent of all maternal deaths occur in developing countries.
Reducing maternal deaths, defined as any death that occurs during pregnancy, childbirth or within two months after a birth or terminating a pregnancy, is a UN goal.
Postnatal care is critical. According to a 2003 report by the Population Research Bureau, “of the women worldwide who die of pregnancy-related causes, about a quarter die during pregnancy, about 15 percent at delivery, and 61 percent after delivery.”
Under the Sustainable Development Goals set by the United Nations, world leaders pledged to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. Between 1990 and 2015, maternal mortality worldwide dropped by about 44 percent, according to the World Health Organization. Maternal mortality is higher among women living in rural areas and among poorer communities.
The maternal mortality rate in Cambodia has decreased since 2005, from 472 deaths per 100,000 births in 2005 to 161 deaths per 100,000 births in 2015, according to official data.
Earlier goal achieved
Cambodia achieved the United Nations’ Millennium Development Goal to cut maternal deaths by at least 75 percent by 2015, having decreased its ratio by 84 percent between 1990 and 2015.
Because many women die during childbirth because of the dearth of trained personnel, the government trained midwives and sent them to rural areas with high infant and maternal mortality rates. To discourage unattended home births, the government paid midwives $10 for a live birth at a hospital and $15 for one at a health center.
“Ten years ago, we had from 15 to 18 deaths per year,” said Ker Rotha, who heads the health department in Prak Soda’s Svay Rieng province.
Today, Cambodia’s improved local health centers provide basic delivery services, but any sign of complications is supposed to result in a quick transfer to the provincial referral hospital.
Chan Theary, executive director of the NGO Reproductive and Child Health Alliance (RACHA), said the new protocols had significantly reduced maternal mortality, but more work is needed, including providing more extensive training to midwives. RACHA focuses on improving reproductive, maternal, newborn and child health.
These advances seemingly failed Prak Soda, the first woman to die in childbirth in several years in Svay Rieng province.
News of her death triggered online discussions of unsafe childbirth in Cambodia. Mam Bunheng, the minister of health, and Or Vandin, the health ministry spokeswoman, could not be reached for comment.
‘So much blood’
Feb. 4 was the first day of the Lunar New Year. While not an official holiday — Cambodians celebrate the new year, Choul Chhnam Thmey, in April — life often slows down a little in the big cities and larger provincial towns.
Prak Soda arrived at the local health center Mesor Thngork in Chantrea district about 5 a.m., according to the complaint. Suon Sakhen accompanied Prak Soda as did her sisters and mother-in-law, a traditional midwife.
Prak Soda’s sister, Prak Sinuon, 37, told VOA she called the midwife who had delivered Prak Soda’s first baby, a girl who is now 5 years old. The woman came to the center, checked Prak Soda’s health and found nothing amiss, according to Prak Sinoun.
The baby arrived around 2:30 p.m., attended by one midwife rather than the usual two, according to the complaint.
After delivering the baby, the midwife, Ouk Chamrong, asked all family members to leave the room so that she could dispose of the placenta.
The victim’s mother-in-law, Pov Sakhorn, 62, a traditional midwife, remained behind.
“She and I were inside the room. I was watching her,” said Pov Sakhorn. “I was wondering why there was so much blood coming out.”
Sent to hospital too late
Listening through a window, Suon Sakhen said he could hear his wife complaining of a pain in her stomach.
“I asked the midwife, Ouk Chamrong, to send my wife to Svay Rieng provincial hospital, but the midwife said the bleeding and her overall condition was normal,” read the complaint.
Thirty minutes passed. Prak Soda continued to bleed. Only after Suon Sakhen argued with the midwife did she call an ambulance, according to the complaint.
Prak Soda, a garment factory worker for 10 years, died en route to the hospital, about 40 kilometers from the local health center where she gave birth.
The wife who had helped her husband on their rice farm “had 10 days off ahead of her birth,” said Suon Sakhen. “My wife’s health was fine. She went to the health center for checks and to take medicine every month.”
Only one midwife
Central to Suon Sakhen’s complaint is the presence of only one midwife, rather than the usual two, during the birth, and the delay in sending his wife to the hospital. In the filing, he claimed health center officials, including the head of the center, Has Sophun, and his wife, Mu Narou, are responsible for his wife’s death. He has requested compensation of about $10,000.
Has Sophun runs a private clinic in his home treating children and the elderly. In an interview with VOA Khmer, Mu Narou said that while she was not on call the day Prak Soda died, she went in to examine her.
Suon Sakhen said Mu Narou and Has Sophun examined Prak Soda once her condition was deteriorating.
Mao Sopheary, another trained midwife and the deputy head of the health center, said it was her turn to oversee births at the time of Prak Soda’s death, but she had requested leave for the Chinese New Year.
“I told my boss that if we have patients who are in labor and we can’t treat them, we could send patients [elsewhere],” she said. “So I don’t know why they accepted [Prak Soda].”
When asked about why there was only one medical attendant present during the delivery, Has Sophun told VOA Khmer, “Normally, there are two midwives delivering the baby. But at that time, there was only one, but when there was a problem, more people came to help.”
He referred questions to his superiors at the provincial health department.
‘A weak uterus’
Svay Rieng provincial health director Ker Rotha said it was a mistake that there was only one midwife present during the delivery.
“Normally, there are two midwives helping, but because of Chinese New Year, some didn’t come,” he said, adding that the responsible staff would face “administrative punishment.”
He defended midwife Ouk Chamrong, saying, “She has worked for six years and she has skills in helping mothers deliver babies safely.”
Ouk Chamrong could not be reached for comment.
Ker Rotha said, “We finally hypothesized that too much bleeding caused the death. The victim’s uterus was weak and could not curb the blood flow.”
He added that if Prak Soda had reached the provincial hospital faster, she may have been saved.
After Prak Soda’s death, many commune residents have become wary of giving birth at the local health center.
“I will send [pregnant women] to Svay Rieng provincial hospital. If there is any problem, they will be helped on time,” said Chab Srey, 60, a villager in Bati commune.
“The health center is nearby and it is good, but if there is any urgent problem, we can’t [get to the hospital fast enough],” she added. “I am scared when there is such a problem.”
Prak Soda’s mother said that she wanted justice for her daughter and accused the midwife of negligence.
“They killed my daughter. Who will feed her children?” said Puth Saban. “As normal people, [we] had to have faith in the midwife.”