Thursday, April 7, 2016

It takes a village: Eliminating maternal and neonatal tetanus in Cambodia’s northeast

By Ponlok Leng

Chrum Chai, village health volunteer, visits a pregnant woman‘s house
©UNICEF Cambodia/2015/Leng

Chrum Aei is eight months pregnant with her second child. She lives in Pou Chrey Chang, a village populated by ethnic Phnong people in the remote, northeastern province of Mondulkiri. Here, there are still centuries-old rituals being practiced in everyday life. But some of them—like those used for pregnant women and newborns in place of proper health care—can be very harmful. Coupled with inadequate antenatal care, such practices make Mondulkiri one of three provinces in Cambodia where pregnant women and newborns are at the highest risk of contracting tetanus.

Tetanus is a painful disease that can kill mothers and their newborn babies. Tetanus occurs when bacteria enter the body through a break in the skin. The bacteria produce a poison that attacks the central nervous system.
After the birth of her first child, Chrum Aei followed the Phnong practice of placing a wasp’s nest on her infant’s umbilical cord stump to speed healing. She didn’t realize this placed her child at risk of infection. Inappropriate cord care practices are commonplace among the Phnong, who number about 35,000 in Cambodia, or half of Mondulkiri’s population. A 2014 rapid assessment conducted by a team representing the National Immunization Program, Mondulkiri Provincial Health Department and UNICEF showed that of 15 women interviewed in Chrum Aei’s village, eight (53 per cent) reported that they had put unclean substances such as wasp’s nest, ashes, cow dung and rust on umbilical cord stumps.

 Village health volunteers use images like this to educate expecting mothers about the danger of traditional cord care 
©UNICEF Cambodia/2015/Leng

But this pregnancy, Chrum Aei will not be turning to traditional practices. Following a house visit by a village health volunteer trained with UNICEF support, she now understands she could harm her baby. She now understands the risks of tetanus.  Tetanus can be fatal for newborns because their respiratory muscles can become paralyzed, causing difficulty in breathing and inability to breastfeed.  

“With my first child, I followed the older people’s advice about how to take care of the cord. But now I know that doing that was harmful. It can cause infection,” Chrum Aei says. “The village health volunteer taught me not to put anything on the newborn umbilical cord. I am aware of pregnancy care, the need for tetanus vaccination, clean delivery and clean cord care of my newborn.”

Chrum Chai is the village health volunteer whose work will have a life-long impact for Chrum Aei’s child. She has been trained on these issues during a series of ongoing behaviour change communication forums organized by provincial health department and health centre staff with UNICEF support.

Behaviour change communication forum in Puchrey Health Centre, Mondulkiri Province
©UNICEF Cambodia/2015/Leng

Such forums, which are designed to encourage healthy practices among women and families by promoting clean cord care and proper antenatal care in high-risk areas like Pou Chrey Chang, are taking place quarterly. They target local stakeholders that play a role in women’s and children’s health, such as traditional birth attendants, midwives and local officials.

These communication activities form an integral part of UNICEF Cambodia’s work in hard-to-reach, tetanus-risk areas like Mondulkiri. In cooperation with provincial health departments and operational districts, UNICEF is supporting the running of the sessions, while also conducting outreach services with health centre midwives, who provide antenatal care services and tetanus vaccinations for pregnant women and women of reproductive age.

Chrum Chai, who is ethnic Phnong, has been a village health volunteer since 2012. She was trained on community care for mothers and newborns by a UNICEF-supported midwife, who passed on to her the knowledge of antenatal and postpartum care, including tetanus vaccination.
“I have gained knowledge about clean cord care to prevent neonatal tetanus by participating in the behaviour change communication forums. I have since been educating pregnant and postpartum women in my village,” she says. “I can already see the changes in family cord care practices.”

Tetanus spores are extremely resistant and can remain in the environment for a long period of time. Although, the eradication of tetanus is not possible, in 2015 the World Health Organisation confirmed that Cambodia has eliminated maternal and neonatal tetanus. Elimination means that less than one case of neonatal tetanus per 1,000 live births is reported in all districts of the country. Immunization, hygienic birth practices and proper post-natal care are vital to preventing the disease and maintaining elimination status.  

Chrum Chai is one of 149 volunteers in Cambodia’s three high-risk districts that are helping fight tetanus using essential expertise from the communication activities. Together, they are working hard to promote clean cord care, one village at a time.

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