Insights from a Midwifery Delegation Trip to Cambodia

By Allyson Crain, DNP, CNM, WHNP-BC & Cathy Collins-Fulea DNP, CNM, FACNM, FAAN 

In October 2023, a delegation of 10 ACNM midwife members from across the country, traveled to Cambodia with the Citizens Ambassador Program. Our purpose was to exchange ideas, knowledge and experiences with Cambodian midwives related to regulation, clinical practice, education and challenges adhering to the International Confederation of Midwives (ICM) Global Standards. Also to explore barriers to midwifery promotion in both countries. Approximately 50% of our time was spent interacting with education faculty, hospital representatives and local midwives. The rest of the time was spent exploring the local culture.

Historically, birth in Cambodia was assisted by Traditional Birth Attendants (TBA) in the home. Prince Norodom Sihanouk’s administration tried to modernize healthcare but by 1962 there were only 140 trained midwives (3 year education) in the country with most births still occurring in the home with TBA who were given a 6 month training course. During the Khmer Rouge period (1975-79) most healthcare schools and hospitals were closed and many intellectuals and professionals were killed. In the aftermath of the Khmer Rouge regime, the country faced the challenge of rebuilding its healthcare system from near collapse. With only a handful of doctors surviving the conflict, Cambodia had to train a new generation of healthcare professionals. The resurgence involved international support and a concerted effort to gradually establish medical schools that now offer education in both French and English. It wasn't until 2002 that the government increased it’s efforts to increase the supply of midwives. Initially training was 1 year post 3-year nursing training. In 2012 a 4-year direct entry Bachelor’s of Midwifery program was established.
We started out at the University of Puthisastra in Phnom Penh, where we sat down with the Head of Nursing and Midwifery, and a few other educators. The dialogue highlighted the evolution from traditional birth attendants to formalized nursing and midwifery education, reflecting a pivot towards enhancing maternal and newborn health outcomes. We talked about advancements within midwifery education in Cambodia, as well as the complexity and diversity in educational and clinical practices, with ongoing considerations for introducing a Masters of Midwifery program to further expand the profession.

Conversations contrasting and comparing American and Cambodian midwifery education underscored a shared commitment to training skilled practitioners, despite the differences in healthcare infrastructure and cultural contexts between our two countries.

Our visit to Preah Ang Duong Hospital, a governmental healthcare facility, offered a glimpse into the integration of midwives in a hospital setting. The observed clinical practices, such as a low use of epidurals among patients, reflected the unique blend of cultural norms and medical infrastructure influencing care approaches. The midwives worked in partnership with the physicians to ensure high quality care.

The next stop was Angkor Hospital for Children in Siem Reap, founded by Kenro Isu (a Japanese photographer who saw a need for care of children). Our discussions with healthcare professionals here shed light on the challenges of pediatric care in a resource-limited setting, from managing premature births to combating antibiotic resistance. The narrative of the Deputy Hospital Director included information about the resurgence of medical education post civil conflict of the 1970’s. Lastly, our visit to the Neak Tep Hospital, a private institution, illustrated an alternative model of healthcare delivery. Here, midwives expressed a desire for autonomy and an environment that respects the mother's choice, from birth positions to postpartum care.

The dialogue with Cambodian healthcare professionals from all interactions highlighted a critical theme – the need for ongoing education and cross-cultural exchange to enhance midwifery practices. The discussions also underscored the pervasive issue of resource disparity and the importance of contextually adapted practices to improve maternal and newborn health outcomes.

This delegation trip was not only an exploration and collaboration, but also a reminder of the universality of our mission as midwives and healthcare practitioners. The resilience, dedication, and compassion of midwifery in Cambodia reflects a clear call for continued collaboration, knowledge exchange, and mutual support across borders.

As we reflect on our experiences and integrate these insights, we are reminded that midwifery transcends geographical and cultural boundaries, by uniting us in our common goal of caring for women throughout the lifespan.