Sociodemographic inequalities in utilizing maternal healthcare services in Cambodia

Background Cambodia is a Southeast Asian country and has one the highest rates of maternal and child mortality with inadequate use of maternal healthcare services in the region. The present study aimed to analyse the progress made in terms of using maternal healthcare services since 2000. Methods Two rounds of Demographic and Health Surveys (DHS 2000 and DHS 2014) were used in the study. Sample population consisted 11,961 women aged between 15-49 years. The outcome measures were: Timing of rst ANC attendance, adequacy of ANC attendance, place of delivery and postnatal checkup. WHO guidelines were used to set the cut-off/dene these measures. Results Findings indicated that the overall prevalence of making the rst ANC visit in the rst trimester was 64.19% [95%CI=62.22,66.11], and that of having at least four ANC visits was 43.80% [95%CI=41.89,45.73]. Prevalence of health facility delivery was 48.76% [46.62,50.90] and that of postnatal checkup was 71.14% [95%CI=69.21,73.01]. Between 2000 and 2014, the percentage of timely and adequate use of ANC increased by respectively 61.8% and 65.3%, while that of health facility delivery and postnatal care increased by respectively 74.5% and 43.9%. Important demographic, socioeconomic and geographic disparities were observed in the utilization of ANC, health facility delivery and postnatal care services. Urban residency, having better educational status, white collar job, access to electronic media showed positive association, whereas higher parity (having >2 children) and unwanted pregnancy showed negative association with the use of maternal healthcare services. Having at least four ANC visits was associated with signicantly increased higher odds of using health facility delivery and postnatal care.


Background
Cambodia is low-lying country in the Southeast Asian region, and has a population of over 16 million (as of 2019). Since obtaining independence in 1953, the country has made signi cant improvements in terms of reducing the percentage of absolute poverty, malnutrition, and improving the key public health indicators such as maternal and child mortality rates. Between 2000 and 2014, Cambodia managed to cut the rate of neonatal mortality by 46% [1] in parallel with an equally impressive gain in reducing maternal mortality (488 in 2000 to 160 in 2017) [2]. Despite these major advancements, the country still ranks among the least developed countries (LDCs) and faces critical challenges for meeting the millennium and sustainable development goals.
In recent years, healthcare system in Cambodia has implemented nationwide initiatives to promote reproductive, maternal, newborn and child health (RMNCH). A continuum of essential medical services such as antenatal care, skilled childbirth, and postnatal care services has been put in place in order to provide lifesaving medical services for pregnant women and their newborn. ANC services include a wide range of interventions designed to minimize obstetric complications and ensure a healthy pregnancy outcome. These services generally include anthropometric tests, blood and urine analysis, nutritional and psychological counselling, vaccination, dietary supplementation, informing the mother regarding the danger signs, mental and nancial preparedness for childbirth, and importance of using skilled birthing services [3][4][5][6][7]. A study involving 69 lowmiddle countries found that even a single ANC visit could reduce the probability of neonatal and infant mortality respectively 1.04% points and 1.07% points [3]. In addition to routine ANC, WHO also emphasizes on choosing professional childbirth services and postnatal checkup which are crucial for providing emergency obstetric services and avoiding the risks of prolonged labour, stillbirth, obstetric and postpartum hemorrhage [8][9][10][11][12]. These services are highly cost-effective and their proper utilization is regarded as a central strategy to reducing maternal and child mortality in all low-middle-income countries like Cambodia.
WHO recommends attending at least four antenatal visits (which was later revised to eight) during the course of the pregnancy with the rst visit taking place no later than the twelve weeks from conception. Nonetheless, making these services universally available and ensuring their optimum use in an equitable manner is an extremely challenging task, especially for resource-poor countries where medical infrastructure and skilled professionals are often shockingly scarce. In Cambodia, geographic remoteness, high out-of-pocket costs of care, absence of skilled care provider and medium for health communication pose signi cant challenges for improving the use of antenatal care services particularly among the disadvantaged communities [13]. Addressing the barriers is crucial for promoting public health and meeting the national and international development goals targeted to reducing maternal and child mortality e.g. Millennium (MDGs) and Sustainable Development Goals (SDGs).
ANC service in Cambodia are mainly provided through the primacy care facilities, however, midwives and community health workers also play vital roles especially in the remote areas with limited access to service [13,14]. Large demographic and regional gaps remain in the provision and utilisation of these services as the healthcare system suffers from infrastructural and manpower crises. Understanding the population sub-groups who are being deprived from these services is an important step to scaling up the existing maternal health programs and making new evidence-based policies. In this regard, the present study attempts to provide an assessment of the progress made in terms of maternal healthcare services since 2000. We used two rounds of Demographic and Health Surveys (DHS 2000 and DHS 2014) that collected data on various demographic, socioeconomic and healthcare related indicators among women of childbearing age (15-49 years). DHS data for Cambodia were studied previously to identify the inequalities in the use of ANC and childbirth services. However, there is no single study covering all the components of pre-(timing and frequency of ANC) and postpartum services (childbirth and postnatal care). International Development (USAID). This is a nationally-representative project that surveys adult men, women (15-49 years) and children under ve years of age. The survey is cross-sectional in nature and collects data using a standard questionnaire which comprises questions covering demographic, socioeconomic, knowledge of reproductive health, and healthcare use related topics. Detailed description of these surveys was published elsewhere: National Institute of Statistics, Directorate General for Health, and ICF International, 2015.

Data analysis
Data analysis consisted of descriptive statistics, chi-squared bivariate tests and multivariate analyses using Stata version 14. Firstly, descriptive statistics were used to calculate the prevalence of maternal healthcare utilisation between 2000 and 2014. This was followed by binary regression analysis (logit link) to measure the adjusted association between the outcome and independent variables. For each of the four outcome variables, three sets of regression models were run: overall sample, urban and rural. The urban-rural strati cation was done given the growing recognition of the regional difference in healthcare seeking and importance in designing intervention measures. Results of regression models were presented as odds ratios and 95% con dence intervals. Statistical signi cance was assumed at p < 0.05.

Results
Table 1 (in appendix) summarises the prevalence of utilization of the four types of services. Sample population consisted of 11,961 women aged 15-49 years. Descriptive results indicated that a greater proportion of the women who used these services were generally aged between 25 to 34 years, rural residents, had primary level education, from higher wealth index households, male-headed households, employed in blue collar jobs, made healthcare decisions by themselves, had access to electronic media, reported last child as wanted, and had 1-2 children.
Sociodemographic inequalities in timely and adequate use of ANC services were presented in Increased odds ratios were also observed among women who had secondary/higher education, and the same was true when the husband had secondary/higher education as well. Wealth status didn't show any signi cant association with early initiation of ANC, however, women in the middle [Odds ratio=1.30, 95%CI=1.05,1.62] and richer [Odds ratio=1.49, 95%CI=1.18,1.88] wealth quintiles were more likely to have adequate ANC visits. Women who were employed in white collar profession had signi cantly higher odds of timely and adequate use of ANC.
Having access to electronic media was associated higher odds of making adequate ANC visits [Odds ratio=1.45, 95%CI=1.22,1.73]. Having unwanted child and higher parity (>2 children) showed a negative association with both timely and adequate use of ANC services.

Discussions
The objective of this study was to assess the situation of maternal healthcare service utilization in Cambodia.
Previous studies have highlighted that services such as timing and frequency of using antenatal care, place of delivery, and postnatal checkup are vital components of maternal healthcare services, promoting which lies at the center of attaining maternal and child health related Sustainable Development Goals. From the descriptive analysis we found that little less than two-third of the women made their rst ANC visit in the rst trimester, while more than two-fth attended four or more ANC visits. Despite the low ANC attendance, we observed a relatively higher percentage of health facility delivery, with more than half of the deliveries taking place at respondent's home. The prevalence of postnatal checkup was even higher which stood at 71.14%. Although a large percentage of women are still not being able to access these life-saving healthcare services, there has been a considerable improvement in the percentage of women who used these services since 2000. Comparing the latest statistics with those from 2000 suggests that the percentage of timely and adequate use of ANC increased by respectively 61.8% and 65.3%, while that of health facility delivery and postnatal care increased by respectively 74.5% and 43.9%. The positive trend marks a major healthcare success for a low-income country like Cambodia, and provides a good example for other countries that are still lagging behind the international targets. Continued efforts will be required to further promote this success with the goal of reaching universal coverage of maternal healthcare services in Cambodia.
Further analyses were performed to identify the sociodemographic factors that are associated with the use of these services. Higher age, urban residence, better educational status, household wealth quintile (with some exceptions), employment status, access to electronic media, relatively lower parity and not having unwanted pregnancy were found to have a protective effect on the use of the healthcare services. The patterns behind these associations are in line with previous studies, and re ect the role of socioeconomic status which acts as an enabling factor for accessing healthcare, and overall health and well-being of individuals [17-19, 25, 26]. The positive role of educational status on the use of the services of the husband was particularly interesting. The absence of correlation between household wealth status with timely initiation of ANC and PNC checkup was a potentially contradictory one, although wealth status did show a signi cant association with having adequate ANC visits and using health facility delivery. Household nancial well-being is a strong predictor of maintaining a healthy pregnancy and accessing essential medical care to ensure a successful termination of pregnancy, and health of the mother and her newborn [27][28][29][30]. The ndings indicate that women in relatively poorer households are less likely to use healthcare services compared with those living in better nancial situation. In low-income countries like Cambodia, out-of-pocket expenditure can pose serious constraints to availing lifesaving medical services [5,31,32]. Removing user fees can therefore prove bene cial to promoting the use of healthcare services and contribute to lower rates of maternal and child mortality.
Having access to electronic media showed a positive association with using adequate ANC and PNC services. Health communication through electronic media is an increasingly popular strategy to improve health knowledge and self-e cacy, which eventually contribute to more effective use of healthcare services and better population health [5,[33][34][35][36]. Regarding parity, women who had more than > 2 children were less likely to use healthcare services compared with those who had 1-2 children. The exact explanation behind this association can vary depending on individual circumstances, however, it is likely that women who experienced several pregnancies consider themselves being aware of pregnancy related health risks, and thus made healthcare visits less frequently [20,37,38]. Another explanation might be that the higher costs associated with having higher number of children may prevent women from seeking care. Women who reported their last pregnancy as unintended were signi cantly less likely to access care. Unintended pregnancy is a complex issue and has been shown to have negative health outcomes for both mother and children in previous studies [16,[39][40][41].
Healthcare strategies that can help prevent unintended pregnancies include better provision of family planning products and counselling, especially among newly married couples. Effective use of family planning services can also increase reproductive health awareness, and thereby promote the care-seeking behaviour. Lastly, we found that women who attended four or more ANC visits were more likely to deliver at a health facility and take PNC checkup. In primary care settings, ANC services can greatly increase women's exposure to health counselling and discussion with care providers, which enable them to make better healthcare decisions. From this view, improving ANC attendance can result in higher percentage of health facility delivery and PNC checkup, two key strategies for preventing maternal and child mortalities [42][43][44].
This study has several strengths and limitations to report. This study used large nationally-representative data from Cambodia Demographic and Health Survey, which is a nationally-representative survey that collects data on various domains including demographic, socioeconomic, healthcare related variables and adult men and women. The latest data were collected in 2014, and therefore may not represent the recent situation. Although the data are little old, they provide a comparative picture of the trend in maternal healthcare utlisation during the 2000-2014 period. As mentioned earlier, this was a secondary study which limited the choice of the variables or sample characteristics. For this reason, some critical variables such as cultural and infrastructure related factors were not included in the analysis. There were also no data to assess the quality of the services which are important determinants of healthcare seeking behaviour. Lastly, the surveys were cross-sectional and hence the associations are not guaranteed to establish any causal relationship. Despite these limitations, the present study provides important insights regarding the prevalence and predictors of using reproductive services which can have practical implications for reproductive health programs in the country. Further research is necessary to explore the quality of the reproductive health services in addition to merely increasing the access, to ensure sustained success in terms of maternal and child health outcomes.

Conclusions
In this study we assessed recent progress in maternal healthcare use as well as their predictors in Cambodia.
Findings indicate that little less than two-third of the women made their rst ANC visit in the rst trimester, more than two-fth attended four or more ANC visits, more than half of the deliveries took place at respondent's home, and less three quarter had PNC checkup.
Year by year analysis revealed a signi cant improvement in the use the maternal healthcare services. Nonetheless, considerable disparities still exist in the utilisation of these services. Based on the ndings, its suggestible that investing on women's socioeconomic status, access to electronic media, and interventions targeting to reducing higher parity and unintended pregnancies may contribute to better use of maternal health services in Cambodia.

Ethics approval
The survey was approved by the DHS review committee.

Consent for publication
All participants gave informed consent prior to taking part in the interview.  Figure 1 shows that between 2000 and 2014, the percentage of timely and adequate use of ANC increased by respectively 61.8% and 65.3%, while that of health facility delivery and postnatal care increased by respectively 74.5% and 43.9%.