We're safe and happy already: traditional birth attendants and safe motherhood in a Cambodian rural commune

Deposited with permission of the author © 2002 Dr. Elizabeth HobanThe central concern of this study is the social, cultural and political position of traditional birth attendants (TBA), known as yiey maap (grandmother midwives) in Chup Commune (pseudonym). In particular, this study explores strategies yiey maap use to negotiate or bypass Western model health services in an attempt to maintain their personal integrity and cultural capital as birth attendants, and to ensure the physical, emotional, economic and cultural safety of the woman they care for. This thesis explores traditional maternity knowledges and practices using ethnographic methods to investigate the central issues, concerns and barriers confronting rural woman as they make choices to adapt, resist or negotiate Western maternity care. It is vital to consider historical, political, cultural and economic factors that influence women's decisions in order to understand how and why women hold onto or surrender their traditional childbirth knowledges and practices, including the preservation of yiey maap, their favoured birth attendant. Safe Motherhood initiatives were introduced into resource-poor countries by the World Health Organization in 1987 with the goal of reducing maternal mortality rates. They were based on the premise that pregnancy, childbirth and postpartum care were safer when provided by skilled birth attendants in a modern health facility. TBAs were not considered skilled birth attendants by Safe Motherhood partner agencies, as training and utilizing TBAs in Safe Motherhood initiatives did not have a measurable impact on maternal mortality rates. Instead, TBAs' roles have been recast, and TBAs are expected to be health promoters and educators, referral agents and information gatherers. I argue that Khmer women do not engage with the modern health system because it is unfamiliar and expensive, and health personnel provide poor quality care. Instead, in times of obstetric emergencies, women attempt to negotiate their own and their family's safety through personal autonomy and agency. I conclude by proposing alternative approaches and strategies, including the increased utilisation of yiey maap in Cambodian Safe Motherhood programs. A central question is whether the Ministry of Health, supported by bilateral and multilateral agencies, should train and utilize yiey maap or midwives in maternity care. I argue that both are of equal importance. Until yiey maap are valued for their contribution to, and enjoy equitable inclusion in midwifery care, initiatives that involve yiey maap as program "extras", who undertake peripheral tasks, will not reduce maternal mortality rates