Background

Postnatal care is recognized as an important aspect of improving neonatal and maternal survival [1, 2], but is often overlooked in provision of health services [3]. The period after birth is the most vulnerable one for both mothers and their newborns. Gaps in postnatal care have been identified as an important barrier to improving the continuum of care for improving maternal and newborn health [4]. In Cambodia, maternal mortality has decreased markedly [5], but gaps in equity persist and quality of care remains an important priority [4, 6, 7].

In Cambodia, approximately 75% of women attend maternity care services provided by a skilled attendant [8]. Most seek care through public health facilities, which is provided by primary or secondary midwives during the antenatal period, delivery, and postnatally, requiring modest user fees set by the local operational health district, or provided free for those deemed unable to pay [5, 8, 9]. A robust culture of traditional medicine (only available through the private sector) also greatly influences care during the perinatal period. As is the case in many countries, supplies and medicines needed for perinatal care from public health facilities must be paid out of pocket, along with transportation, food, and accommodation [10]. During antenatal visits, women have blood pressure measured, are counseled on various health topics including general advice on a healthy diet, breastfeeding, and signs of complications requiring care seeking [11].

Given the importance of local understandings of health and illness in the perinatal period, several qualitative studies have focused on Cambodian mothers’ care behaviors in relation to traditional medicine before and after childbirth [12–16]. Traditional medicine is considered an important component of health care for Cambodian consumers, with estimates from the Ministry of Health (MOH) of 40–50% of the population reportedly using traditional medicine on a regular basis [17]. Recently the use of traditional medicine in Cambodia has come under scrutiny for its impact on out of pocket expenditures, which can lead to impoverishment among lower income populations where the practice of using traditional medicine is very common [18].

Traditional maternal medicine in Cambodia is influenced by Khmer etiology and by the relationship of hot and cold states to health. A woman is considered to be in a hot state during pregnancy, loses heat through the birthing process, and is considered in a dangerously cold state afterwards. The latter condition is associated with vulnerability throughout the postpartum period referred to locally as sor sai kchey which conveys the meaning that “the body is weak”. The individual words sor sai can be translated to “vessels” or “small tubes that allow flow” and the word kchey may been translated as “weak” or “green/not yet mature”. If heat is not returned during the post-partum period, illnesses or more severe symptoms may extend from this state of bodily weakness into future illness over the lifetime, referred to as toa (sometimes spelled tos), which directly influence post-partum care practices and behaviors [4–5]. Traditional postpartum care is thus focused on restoring “heat” through various means including foods considered to generate heat, tonic beverages containing herbs and/or alcohol, placing warm stones on the abdomen, and other physical means of heating of the body [13, 19]. Heating of a postpartum mother in previous times typically consisted of ang pleung or “roasting”. This entailed a newly delivered woman resting on a raised wooden bed over charcoal embers where heating would take place for three to seven days, and the mother would not leave the heated area during the process. Heating the body is thought to help chha-an sor sai which may be translated as to “mature/harden” or “cook” the “vessels”. This is commonly understood as the means to prevent post-birth illness, help women recover from childbirth, and restore internal hot/cold balance [12, 13, 20, 21].

A modern, biomedical approach that has become common in the last decade for heat balance is the use of medical injections in the postnatal period to warm the body and promote recovery. However, a gap exists in the literature on these as used for post-partum care, and health consequences as a result of their use. Injections for varied health ailments are usually delivered privately, paid for out of pocket by families, and typically include vitamins, antibiotics, and/or pain medication given in a patient’s home [22]. These injections appear to be typically provided privately by midwives in the homes of women during the post-partum period. Due to the physical sensations associated with post-natal injections, these have been called “heat injections” [13], and have been reported in popular media since as early as 2004 as a replacement for ang pleung [23, 24]. However, medical injections generally are often unnecessary, expensive, and raise the risk of blood-borne infections resulting from administration in unregulated settings with potentially unsterile equipment or improper injection practices. Cambodia has one of the highest rates of overall medical injection usage worldwide, where more than one in three individuals reported receiving a medical injection in the previous 12 months, with 65% of those medical injections taking place in the home [25]. However, the study did not identify the specific uses of those medical injections, so the proportion of those which were post-natal is unclear.

There is a paucity of biomedical literature on the use of medical injections for post-partum care, an apparently widespread health practice in Cambodia and for the diaspora [26], thus the current study sought to explore this topic through ethnographic research to understand mothers’ experiences and provide information that may be used to continue improving care that addresses maternal morbidity and mortality. Safety of injection practices has been noted as an important issue for preventing blood-borne illnesses, particulary in lower income countries [27]. As Cambodia continues to experiences rapid economic and social development, this data may inform approaches to improving quality of care, and allow for understanding of the integration of locally acceptable health interventions with biomedical practice.

Methods

An ethnographic approach was utilized to document and describe routine postnatal care behaviors in the natural setting of communities and homes where families go about day to day activities. Qualitative data collection took place in Takeo, Cambodia from June—August 2016 and included information drawn from 15 in-depth interviews conducted with female participants who had a child under 6 months old and unstructured, opportunistic observation in and around homes as allowed by participants. Maximum variation in participant characteristics guided the purposive sampling approach [28] to include participants in more and less rural areas, and with varying socioeconomic status and educational attainment, and the number of interviews was determined by availability and comfort of interview participants in discussing post-natal care [29]. All interviews were conducted by two of the study authors (AB an experienced qualitative research, RD a junior researcher), alongside Cambodian research colleagues (CV and DK in acknowledgements section) who provided input and translation. All researchers participated in preparation and training for the data collection process, and supervisory critical input was provided by the senior author (CV), a Cambodian physician specialized in reproductive health. Interviews were conducted in homes of participants in Khmer language with translation to English. Interviewees had previously participated in a newborn health intervention [30] with infants up to one week old, which did not specifically address postnatal care of the mother, and those with an infant less than 6 months of age were invited separately to participate in the study using study-specific informed consent procedures and with detailed information provided on the qualitative study aims and procedures. After agreeing and providing written informed consent, the participants engaged in interviews lasting no more than 45 minutes. Potential participants were introduced to the researchers through local community-based staff including village health workers and study coordinators. Discussion guides used for data collection were developed and pre-tested in the study area and translated to and from English for proofing. Interviews were audio recorded at time of interview and field notes were written during review of audio recordings and after interview. All transcripts and notes from ethnographic observation were uploaded to NVivo software in English for the analysis process. Approximately 40 hours of unstructured observation also contributed to field notes and memos included in the analysis. The COREQ guidelines served as a reference for conducting and reporting this research [31].

Written informed consent was provided by all participants, who were provided with information on the study purpose and how data would be used. Precautions were taken to ensure privacy so that interviews took place in a private location, and pseudonyms were used for all participants. The study protocol was approved by the National Ethics Committee Health Research of the Cambodia Ministry of Health and by the Institutional Review Board of Tulane University. The larger trial in relation to which this research was conducted is registered with ClinicalTrials.gov, number NCT02271737. All study data was kept under secured and password protected conditions and only the study authors had access to the data, which is maintained by the National Institute of Public Health in Cambodia.

Qualitative data was synthesized via thematic content analysis [32]. This method utilized content analysis to understand participant’s perspectives. Data analysis steps consisted of: (1) familiarization with transcripts and fieldnotes; (2) iterative development of a coding framework; (3) coding all transcripts; (4) discussion of preliminary themes; and (5) synthesis and interpretation of findings. NVivo software was utilized to facilitate systematic and rigorous exploration of the data. Ethnographic observations around maternal care practices in the home, where interviews also took place, provided contextual information in which to ground the interview data. Photographs were taken during observation of objects and materials used for postpartum care (e.g. herbs, stones, food considered to bring heat to the body), which provided reference material for analysis. These photos were also entered to NVivo and coded to appropriate nodes. Once the preliminary analysis was complete, the research team reflected on how implementation and outcomes reflected textual data collected by the research team, and member checking through one author’s network (CV) in Cambodia facilitated trustworthiness. Major and minor themes related to postnatal care practices were explored to understand behaviors and beliefs.

Results

Participant characteristics are summarized below in Table 1. Of the fifteen women interviewed, most were between the ages of 25 to 30. Most women had 5–10 years of education. Twelve women interviewed reported at least one type of occupation. All women reported being Buddhist and having relatives living nearby. Three women reported having an ID Poor card (a designation indicating free or subsidized access to health services due to socioeconomic status), while the majority (n = 12) did not. Although eleven women reported not using a form of contraceptives, two were currently using contraceptives, while two additional women reported planning to use contraceptives in the future.

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Table 1. Characteristics of participants–Mothers (n = 15).

https://doi.org/10.1371/journal.pone.0228529.t001

Analysis resulted in exploration of the following themes: valuing of care through different lenses, transitioning forms of postnatal care, and diverse sources of advice on postnatal care.

Participants described the value of postpartum care through the lenses of traditional knowledge of the pregnancy and postpartum period, and as also a mechanism to prevent future ill-health. Sub-themes included post-partum vulnerability, common post-natal illnesses or health conditions, and preventive practices.

Discussion

This ethnographic research sought to query and describe traditional and modern postnatal care practices as understood and practiced by women who have recently given birth, since these have continued to evolve over time. This was accomplished through in-depth interviews and unstructured observation with mothers who had given birth in the last 6 months. Themes from the data analysis related to transitioning forms of postnatal care, valuing of care through different lenses, and diverse sources of advice on postnatal care were identified, along with a focus on medical injections.

The findings of this research confirmed those from previous studies regarding the use of traditional methods of care for Cambodian women in the perinatal period [9, 11, 13–14]. Uniquely, our study identified injections as an important, and indeed customary, component of the postnatal care regimen described by participants, which had previously only been mentioned in passing by one peer-reviewed study citing data collected in 1995 without reference to injections for heat [33], and one student report of an interview study from 2008 [13]. The study by White mentioned injections without any specific detail, as one among many practices that women in Cambodia used primarily to ensure that “bad blood” from pregnancy was expelled in the post-partum period [33], while the work by Montesanti described “heat injections” [13].

A broader, recent review of traditional beliefs and practices during the perinatal period in Asian countries identified many similar themes to those noted here, including hot/cold balance, dietary modifications, and the importance of protecting future health by enacting preventive practices during pregnancy and the postpartum period, however, other than for a brief mention of the study noted above, which does not provide detail on the topic, the recent comprehensive review notably did not identify injections to promote heat in the body as a reported in the literature from any other source [21]. Generally among studies from the region, preventive care during the post-partum period is expected to protect later health, and practices for keeping the body warm feature prominently, along with dietary modifications, and rest [34, 35]. In a study from neighboring country Myanmar, the authors report many post-partum practices similar to those identified in this study, including a focus on warming the body through internal or external means such as diet and application of “warming” substances such as turmeric, respectively [36]. Another study from Myanmar identified inducing perspiration through steam or other means among postpartum practices performed by women, similar to the practice identified here [37]. Sharma described traditional perinatal care practices in Nepal, which differed somewhat from those reported in this study barring rest and seclusion, and noted that “local people’s beliefs and practices offer both opportunities and barriers to health service providers…” concluding that “maternity care providers need to be aware of local values, beliefs and traditions to anticipate and meet the needs of women, gain their trust and work with them” [38].

Similarly, this study also provides insight into what kind of post-partum health care community members want to receive, often described as the demand-side of the health services. A study by Dingle et al. noted that although equity gaps were improving in use of reproductive and maternal health services in Cambodia, postnatal care was one of the least utilized health services, and additionally noted a slight increase in inequity from 2000 to 2010 [7]. Previous qualitative work has described barriers to postpartum care seeking care including: a need to stay in the house for healing, a need to tend to household duties, or not having the autonomy to make decisions about care seeking [13], but it is unknown whether or how injections might hinder care. White noted that “midwives often serve a cultural brokers interpreting the culture of professional midwifery with its biomedical beliefs to women whose cultural beliefs about pregnancy and birth may be significantly different” [39]. This role may be critical in ensuring appropriate and high-quality care, and future research in Cambodia should address the extent of the practice of injections for post-partum care, the specific manner in which these are provided, the medications used, and how these may impact individual women’s health.

Based on review of the literature, this is the first study providing detailed description of the use of injections for postnatal health care in Cambodia and the cultural etiologies underlying the practice, which appears to be very common based on media reports and available information [20, 21]. In light of a 2015 HIV outbreak that occurred in rural Cambodia due to unsafe injection practices by a private health provider, affecting 242 individuals including mothers and children, this issue is particularly relevant [40]. While it is not reported whether post-partum injections for heat were part of the private provider’s practice in question, the case demonstrates the level of risk and potential for harm reduction by investigating this topic. Given the possible health dangers associated with unnecessary medical injections in Cambodia, a recent intervention sought to develop an educational tool to improve population level understanding of injections as a medical treatment [15]. The authors noted that knowledge about injection safety was increased following intervention, and that such improvement in knowledge would be a helpful strategy to scale up. The data presented here may be used to implement a similar strategy through understanding the importance of traditional and cultural explanations around postnatal injections.

What has been learned from the study may be used by others to improve perinatal care at both individual and population level. The key results of this research, namely that women in this setting and similar Southeast Asian settings prefer to adhere to traditional customs regarding maintaining warmth in the body during the post-partum period and rely on traditional postnatal practices for ensuring future health, can be used to inform recommendations.

A key recommendation is that health care providers and population health programs align postnatal care recommendations with culturally important beliefs. For example, the postnatal care recommendation that iron and folic acid supplementation should be provided for at least 3 months after delivery could be aligned with the message that care in the postpartum period impacts future health [41]. Another recommendation is that the guideline for home visits to assess postpartum health [42] be aligned with cultural preferences for staying warm and remaining in the home postpartum.

An additional recommendation is that where post-partum injections for heat are desired, other less potentially harmful practices are suggested through social behavior change messaging and health care workers. For example, suggesting intake of warm water in conjunction with recommended iron and folic acid supplements may address the desire to keep the body warm and still follow essential care practices. In this way, it may be possible to adhere to traditionally important practices while maintaining recommended postnatal care guidance.

Finally, given that traditional postpartum practices are passed on through older family members, it is recommended that maternal health counselling throughout the continuum of care include not only the mother, but also close family relatives involved in supporting mother and newborn, such as grandmothers and aunts. [21] Counseling and education on maternal care practices and educational programs should be inclusive of not only women but also husbands, parents, and in-laws. This may include discussion of traditional practices, such as warming the body, and how these could impact health.

Strengths of this study include the questions answered regarding what postpartum practices are used and why, the specificity of focus provided from in-depth interviews and ethnographic context, and insights gained. Our data add new information to the peer-reviewed literature on postnatal care in Cambodia concerning use of medical injections, which come with attendant potential health consequences. As a widespread practice, this would be important to the overall landscape of maternal and neonatal health in the country. However, the study has limitations given the ethnographic nature, thus this information is not intended to be widely generalizable. The results of the study may be utilized as a background for future quantitative studies and interventions to improve maternal and newborn health.

In order to continue the trend toward improving accessibility and quality of postnatal care in the country for sustained improvement in maternal and newborn health outcomes [43], health care workers and policy makers must take into account how traditional understandings of health inform current care practices. In future, it will be important to utilize the understanding provided by this research on sociocultural dimensions of postpartum health and illness to address both demand and supply side issues in the provision of postnatal health services.

Acknowledgments

We would like to acknowledge Prof. Chhea Chhorvan, Director of National Institute of Public Health, Prof. Tung Rathay, Director of National Maternal and Child Health Center, and Dr. Nuth Sinat, Director of Pronvical Health Department, Cambodia for their guidance and administrative support. We are grateful to Ms. Dyna Khuon of the University of Health Sciences, Phnom Penh and UCLA, for her crucial support during fieldwork.