Research for stronger health systems during and after crisis

Access to obstetric care and referral in rural Cambodia

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Photo: © Nicolas Axelrod/Ruom for UNFPA

This page presents a complete summary of ReBUILD's Responsive Fund project, Obstetric Referral in the Cambodian Health System - What Works?

This research project was conducted by ReBUILD Affiliate partners - Nuffield Centre for International Health & Development, University of Leeds and Cambodian Development Resource Institute. The project ran from September 2013 – December 2015.

Overview - Why Cambodia?

Between 1970 and 1997, the Kingdom of Cambodia experienced ongoing conflict and violence - a coup removing the then head of state in 1970; the years of the notorious Khmer Rouge mass genocide between 1975 to 1979; subsequent Vietnamese backed takeover between 1979 to 1988, and later factional fighting between two political parties that resulted in a coup d'état[1] by Hun Sen in 1997. In 2015, Prime Minister Hun Sen continued to lead the country, which Transparency International ranked one of the most corrupt in the world[2].

In the health sector, public healthcare staff focused their time on their private practice to improve their income; ‘under the table’ payments to healthcare providers to obtain care, and obtain a higher quality of care, along with numerous unnecessary medical procedures so that staff may charge higher informal fees have been widely reported. However, the economy is growing and the country has decreased maternal death in childbirth and reduced under five child mortality[3].

Why Referral?

Notwithstanding these successes, high maternal mortality continued to be reported in rural areas. UNICEF reported high home births for rural women, often alone (see Figure 1, using 2000/2005 data) who were 4 times as likely to have complications in childbirth compared to women living in urban centres. Rural traditional medical providers, private clinics, urban healthcare or facilities in Thailand, Laos or Vietnam were often preferred over local rural public healthcare facilities, when family resources allowed. Healthcare fees, including informal payments meant the very poor didn’t use available services. UNICEF argued that a major reason for underuse was:

weak communication and referral among various levels of (the health system), including inadequate linkages between communities and health facilities[4].

This project came about because the Ministry of Health was concerned that a high maternal death rate in Cambodia continued because rural women underused public healthcare facilities and that weak referral was part of the cause.






Why Appreciative Inquiry?

Profiles of Cambodia emphasised certain key aspects of Cambodian life over others – a legacy of conflict, corruption and high poverty. It has become normal for the international development industry to describe Cambodia, and other low income countries, as having “problems”, which they are unable to overcome themselves rather “need” solutions in the shape of development policies, programmes and expatriate workers[5]. In this project, we took a different approach. Instead of asking what “problems” exist in obstetric referral within the public health system in rural Cambodia, we asked what is currently working and what local assets exist that enabled safe and positive delivery journeys for rural women now that could be used to improve referral and develop a more women centred maternal health strategy in the future.  

We based our methodology on Appreciative Inquiry - a positive way to manage change. It focuses on what is working well now, analysing why, and doing more of it. Critically, it assumes that change can be brought about by using existing assets rather than seeking external help, that is, assumes no new resources are available. This is important in the cash constrained Cambodian health system. We were aware that Appreciative Inquiry had been critiqued as unscientific. For that reason, we included a rigorous quality assurance stream throughout. In addition, we were interested to know the immediate impact of using a novel form of positive inquiry and a final evaluation was also built in.



The project aims were to:

  • Investigate access and referral to public obstetric care for rural women

  • Identify existing positive resources within Operational District care for women giving birth to support future health system reform

  • Adapt and assess whether strengths-based analytical tools can generate robust research evidence

  • Enhance Cambodian capacity to undertake qualitative research and use results in policy making.



Information about the Cambodian health system was scattered and little predated the entry of the United Nations to the country in 1992. Before fieldwork, we undertook a literature review to understand the current state of knowledge about availability and access to obstetric healthcare services in the country and the study province.

Appreciative Inquiry is a structured interviewing process that invites local participants to identify what works now, how things could work better in the future and how participants will contribute to achieving that future vision. We adapted Appreciative Inquiry to our unique research needs, focusing on describing current high points; describing future dreams; identifying responsibility for change.

As the team was new to Appreciative Inquiry, training in the method was undertaken shortly before a pilot of the questionnaire. The questionnaire was based on the concept of a delivery journey (from home, through the health system, and back home again) and our adaptation of Appreciative Inquiry. The pilot was used to learn how to conduct an Appreciative Inquiry interview and how the questions and process could be improved.

The project featured in Research Methods teaching for the Nuffield Centre for International Health & Development undergraduate and postgraduate students and Leeds Institute for Health Sciences postgraduate students from 2013-15.

An overview presentation up to and including the pilot that was used in teaching can be found here.

For the main fieldwork, the questionnaire was revised, and specific questionnaires used for women, for relatives or neighbours, and for other stakeholders. In addition, picture mapping was used to help participants recall aspects of delivery journeys. The pilot also highlighted that both information sheet and consent form needed to be revised. We developed text based and a unique picture based consent form, as we were aware that some participants had only completed some years of primary school.

We conducted 30 interviews (see Table 1), covering both normal and emergency births taking place within the public health system in one rural province of Cambodia. After preliminary analysis, interim results were fed-back to research participants in a validation workshop.

We developed our quality assurance framework by combining agreed characteristics of high quality qualitative research with the unique characteristics of Appreciative Inquiry. We conducted reflective individual and group interviews throughout our fieldwork and analysis and fed results back into our research process for continual quality improvement.

Our internal evaluation against the project objectives was conducted at the end of the project in November 2015. The framework we used can be found here.


We used a framework approach, based on AI and the concept of a delivery journey to thematically analyse data from our main fieldwork interviews and validation workshop. Interview transcripts were read three times and sections coded by slotting the information into our framework. A report setting out our findings in great detail was created and will be made available on this website when publishing is completed. Our research highlights are set out below. Our analyses have been published as a policy brief, a blog, a teaching case study and in academic journals.

Research highlights

Our findings against research objectives in brief are:

Objective 1: Investigate access and referral to public obstetric care for rural women

  • Based on the literature review, feedback at stakeholder workshops, and interview results, we saw that

    • Publicly provided obstetric care is available, is accessed and shows instances of high quality care in one rural province in Cambodia.

    • Recent data shows disparities between rural areas in access and uptake of publicly provided maternity care

  • Implication. Not all rural are the same – and it’s not enough to analyse inequity using a blunt urban-rural divide. It follows that not every rural area requires the same strategy for improving quality of care. There is potential for decentralisation of the health system to enable local stakeholders to use existing positive resources to improve care – this should be an area of future research.


Objective 2: Identify existing positive resources within Operational District care for women giving birth to support future health system reform

  • Based on interview results, we identified the following:

    • Community and referral hospital facilities exist and function to provide normal and emergency care

    • Women and their families are aware of these facilities and that birthing women can be referred if difficulties with the birth are encountered

    • Some clinical staff in our study followed a philosophy of care encompassing physical, social, emotional and spiritual aspects of care for women giving birth

    • There is proactive referral from the community to Health Centres and onwards through the health system

    • Effective teamwork between clinical staff exists within and between obstetric care facilities at different levels of the health system

    • Strong support is provided to birthing women by husbands, brothers, mothers and other family

    • There is community wide collaboration at time of birth and for a period after

    • There was instances of proactive, confident and transparent hospital leadership

  • Implication. Future health system reform should configure the health system into a partnership between clinical facilities/staff and family and community. Practical ways to do so include, enabling a greater family role inside clinical facilities (e.g. family in birthing rooms, family centred facility design), nurturing a changed relationship between clinicians, patients and community in which clinicians are challenged to be less paternalistic and patients and communities less passive (also entailing changed modes of communication), and redesign training for clinical staff that enables them to articulate and thereafter build on existing philosophies of care.


Objective 3: Adapt and assess whether strengths-based analytical tools can generate robust research evidence

  • Based on documents gathered for our quality assurance process,

    • We can evidence a process of learning about AI, creating and refining an interview guide based on this approach, using these in fieldwork and building an analytical framework using AI parameters. We can also evidence ongoing reflection on fieldwork and analysis and how ‘lessons learnt’ were fed-back into research process.

    • Using strength based analysis imposes a discipline on researchers to change their accustomed approach in research (from either negative bias or balanced) and could be difficult to use initially.

    • Valid evidence can be produced with such tools within a robust research process and by ensuring that skilled and reflective researchers are using them

  • Implication. Strength based tools are no different to other kinds of research tools in that validity arises from adapting a tool that is appropriate to a particular research question, which is used within a quality assured research process, by researchers who may require additional training and support to use them in a skilled manner.


Objective 4: Enhance Cambodian capacity to undertake qualitative research and use results in policy making.

  • Based on information gathered for our internal evaluation, we observed that

    • Individual researcher capacity to develop and use strengths based analysis was developed

    • Policy makers reacted positively to the research findings but we were unable to evidence changes in their capacity to use strengths based research in policy making.

  • Implication. Changing individual researcher capacity is faster than policy making capacity. Capacity projects need longer timelines to evidence impact and change.


[1] Human Rights Watch

[2] Transparency International

[3] World Bank

[4] UNICEF (2011). Maternal, Newborn and Child Health and Nutrition. Retrieved from

[5] McNally, S. (2002). HIV in Contemporary Vietnam: An Anthropology of Development. Unpublished PhD Thesis. (Ph.D dissertation), Australian National University, Canberra.

Further information:

For a further overview of the project, see briefing paper 'Building on our Assets - What works in Cambodia's obstetric referral system?'