Advanced Medical Science – International Health (01518) “No need to spend time on them, they are useless” The specific needs, perceptions and vulnerabilities of and surrounding pregnant women who use drugs in Phnom Penh, Cambodia. Haylee Rae Walsh (314929) Supervised by Dr Nick Thomson May 2011 WALSH 314929 Abstract This study took place in Phnom Penh, Cambodia and explored the specific needs and perceptions and subsequently the vulnerabilities that pregnant women who use drugs experience in their day-to-day life. Women who use drugs make up 6.5% of all people who use drugs in Cambodia, and NGO Friends-International identified an increase in the number of pregnant women accessing their various programs and services. The study involved 18 participant interviews with women who use(d) drugs during their pregnancy and 21 interviews with key informants from various organisations in Cambodia, conducted in January and February 2011. Oral consent was obtained to preserve the identities of participants and KIs. Thematic analysis of transcripts identified that women who use drugs during pregnancy have needs associated with survival on the street, harm reduction, and reintegration into their community. In addition to these general needs, pregnant women who use drugs also have specific needs concerning their health and that of their unborn child. Stigma in the community and discrimination towards pregnant women who use drugs was also identified. Contributing factors to the vulnerability of women who use drugs during pregnancy were fear of or actual arrest, influence of partner and the status of women in Cambodian society according to the “Chbap Srey”. 2 WALSH 314929 Acknowledgements I would like to thank the following people who made my project possible and made the journey more pleasant for me: Staff at the Nossal Institute, especially: - Nick Thomson, for seeing me through and bringing the best out of me - Greg Denham, for getting my project off the ground - Tim Moore, for helping with my project even when he had his own student to supervise - Joni Law, for sticking around to make sure our year went smoothly Staff at Friends-International, especially: - Pauline Marteil, for facilitating so much of my field work - David Harding, for providing me with invaluable insight about my research topic - Rothanak and the team on the table next to me in the office, for briefing my interpreter and helping with the translation of my question guides - Everyone who made me feel welcome and helped me out in any way Staff at other NGOs - Pin Sokhom, for organising many interviews with key informants and participants - Staff at Mith Samlanh, Kalyan Mith, SMO and Korsang, for helping me to arrange interviews with participants - Siheang, at Kaliyan Mith, for being my interpreter when Lang was unavailable - For anyone, including the various MS outreach team members, who carried me around on the back of their motorbike, or explained things to me in their 3 WALSH 314929 best English, or helped with my orientation to the drug situation in Phnom Penh My interpreter, Sok Lang, for her perseverance and ability to come in and help at short notice My key informants, for being willing to share their experiences and shed some light on this topic Liang Supheap, Kate‟s field supervisor, for finding us a place to live in Phnom Penh during data collection My fellow AMS students, Kate, Hye Jin, Michael, Jason, Sammy, Joshua, Hope and Winus, for an amazing year, especially Kate, for putting up with me for the whole time overseas. Without your help, this project would never have happened. Thank you. I am grateful to my boyfriend, friends and family for their love and support over this year, and to God for giving me the strength and motivation to continue working at this project as best I could until the very end. I would like to dedicate this report to my participants, the nineteen lovely women who took time out of their busy lives to speak to me, a total stranger, and share with me some very deep and heart-wrenching stories of the hardships, challenges and struggles they have endured in their lives. Thank you! 4 WALSH 314929 Table of Contents Abstract ...................................................................................................................... 2 Acknowledgements .................................................................................................... 3 List of Figures ............................................................................................................. 7 List of Tables .............................................................................................................. 7 List of Appendices ...................................................................................................... 7 Abbreviations and Acronyms ...................................................................................... 7 Definition of Terms ..................................................................................................... 8 INTRODUCTION ........................................................................................................ 9 Rationale .................................................................................................................... 9 Aims and objectives ................................................................................................... 9 CHAPTER 1: BACKGROUND ................................................................................. 10 1.1 Cambodia (context and history) .................................................................. 10 1.2 Maternal Health in Cambodia ...................................................................... 10 1.2.1 Barriers to access ................................................................................. 11 1.3 Global impact of drugs ................................................................................ 11 1.3.1 Illicit drug use in Cambodia ................................................................... 11 1.3.2 People who use illicit drugs .................................................................. 12 1.3.3 Women who use illicit drugs ................................................................. 13 1.3.4 Pregnant women who use illicit drugs................................................... 14 1.4 Support services for people who use illicit drugs ......................................... 14 CHAPTER 2: METHODS ......................................................................................... 16 2.1 Study Design ............................................................................................... 16 2.2 Inclusion Criteria and Recruitment .............................................................. 16 2.2.1 In-depth interviews ............................................................................... 16 2.2.2 Key Informant Interviews ...................................................................... 17 2.3 Data Collection Process .............................................................................. 17 2.3.1 Data Collection Tools............................................................................ 17 2.3.1.1 Question Guides ............................................................................ 18 2.3.1.2 Plain Language Statement ............................................................. 18 2.3.1.3 Consent Forms .............................................................................. 18 2.3.1.4 Interviews ....................................................................................... 19 5 WALSH 314929 2.4 Data Analysis .............................................................................................. 21 2.5 Ethics .......................................................................................................... 21 CHAPTER 3: FINDINGS .......................................................................................... 22 3.1 Demographic ............................................................................................... 22 3.1.1 Pregnancy and contraceptive knowledge ............................................. 23 3.1.2 Drug use ............................................................................................... 24 3.2 Emergent themes ........................................................................................ 25 3.2.1 Needs ................................................................................................... 25 3.2.1.1 Food ............................................................................................... 25 3.2.1.2 Accommodation ............................................................................. 26 3.2.1.3 Delivery services/ check-ups .......................................................... 27 3.2.1.4 Services after delivery .................................................................... 29 3.2.2 Knowledge/ Perceptions ....................................................................... 30 3.2.2.1 Of hospital / check-ups ................................................................... 30 3.2.2.2 Of the effects on the baby‟s health ................................................. 32 3.2.2.3 Information sharing between pregnant women who use drugs ...... 34 3.2.3 Opinions of others ................................................................................ 35 3.2.3.1 Opinions of the community ............................................................. 35 3.2.3.2 Opinions of health care