title: Delivery as Trauma: A Prospective Time-Cohort Study of Maternal and Perinatal Mortality in Rural Cambodia.
abstract: OBJECTIVE
  The majority of maternal and perinatal deaths are preventable, but still women and newborns die due to insufficient Basic Life Support in low-resource communities. Drawing on experiences from successful wartime trauma systems, a three-tier chain-of-survival model was introduced as a means to reduce rural maternal and perinatal mortality.
  
  
  METHODS
  A study area of 266 villages in landmine-infested Northwestern Cambodia were selected based on remoteness and poverty. The five-year intervention from 2005 through 2009 was carried out as a prospective study. The years of formation in 2005 and 2006 were used as a baseline cohort for comparisons with later annual cohorts. Non-professional and professional birth attendants at village level, rural health centers (HCs), and three hospitals were merged with an operational prehospital trauma system. Staff at all levels were trained in life support and emergency obstetrics. Findings The maternal mortality rate was reduced from a baseline level of 0.73% to 0.12% in the year 2009 (95% CI Diff, 0.27-0.98; P<.01). The main reduction was observed in deliveries at village level assisted by traditional birth attendants (TBAs). There was a significant reduction in perinatal mortality rate by year from a baseline level at 3.5% to 1.0% in the year 2009 (95% CI Diff, 0.02-0.03; P<.01). Adjusting maternal and perinatal mortality rates for risk factors, the changes by time cohort remained a significant explanatory variable in the regression model.
  
  
  CONCLUSIONS
  The results correspond to experiences from modern prehospital trauma systems: Basic Life Support reduces maternal and perinatal death if provided early. Trained TBAs are effective if well-integrated in maternal health programs. Houy C , Ha SO , Steinholt M , Skjerve E , Husum H . Delivery as trauma: a prospective time-cohort study of maternal and perinatal mortality in rural Cambodia. Prehosp Disaster Med. 2017;32(2):180-186.
authors.affiliation: 1Trauma Care Foundation Cambodia,Battambang,Cambodia.
authors.forename: Chandy
authors.initials: C
authors.lastname: Houy
authors.affiliation: 1Trauma Care Foundation Cambodia,Battambang,Cambodia.
authors.forename: Sam Ol
authors.initials: SO
authors.lastname: Ha
authors.affiliation: 2Tromso Mine Victim Resource Centre,University Hospital Northern Norway,Department of Community Medicine,University of Tromso,Tromso,Norway.
authors.forename: Margit
authors.initials: M
authors.lastname: Steinholt
authors.affiliation: 3Department of Food Safety and Infection Biology,Norwegian University of Life Sciences,Oslo,Norway.
authors.forename: Eystein
authors.initials: E
authors.lastname: Skjerve
authors.affiliation: 4Department of Community Medicine,University of Tromso,Tromso,Norway.
authors.forename: Hans
authors.initials: H
authors.lastname: Husum
mesh_terms: D000293:Adolescent; D000328:Adult; D002160:Cambodia; D015331:Cohort Studies; D036861:Delivery, Obstetric; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends; D007231:Infant, Newborn; D008297:Male; D008428:Maternal Mortality / Q000639:trends; D008507:Medically Underserved Area; D017063:Outcome Assessment, Health Care; D018743:Perinatal Care; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality* / Q000517:prevention & control; D011446:Prospective Studies; D012424:Rural Population; D055815:Young Adult
keywords:  DSL Delivery Life Support;  HC health center;  MMR maternal mortality ratio;  ROC Receiver Operating Characteristics;  TBA traditional birth attendant;  VHV village health volunteer; Cambodia; maternal mortality; prehospital; traditional birth attendant; trauma system