Over the past two decades, Cambodia has witnessed profound transformations in its healthcare landscape, particularly in the domain of childbirth care. A recent comprehensive study, spanning from 2000 to 2021, illuminates a startling and persistent disparity in the utilization of cesarean section deliveries between public and private healthcare facilities throughout the country. This delineation not only underscores variations in healthcare access and quality but also raises pressing questions regarding the implications for maternal and neonatal outcomes, healthcare equity, and policy efficacy in low- and middle-income countries.
Cambodia’s healthcare system, historically burdened by limited resources, infrastructural challenges, and workforce shortages, embarked on a substantial evolution since the turn of the century. With increasing economic growth and international aid, the nation prioritized maternal health, evident in the steady reduction of maternal and infant mortality rates. Despite these improvements, the mode of delivery during childbirth has emerged as a critical, and somewhat controversial, indicator of care quality and accessibility. Notably, cesarean sections (C-sections), often lifesaving in complicated births, have become a subject of intense scrutiny regarding their uneven distribution across different healthcare providers.
The study conducted by Zhang, Khuon, Saphonn, and colleagues methodically gathered and analyzed data across a 21-year timeline, offering a rare longitudinal perspective on childbirth practices in Cambodia. The investigators critically examined national health surveys, facility records, and demographic data to map the trends and disparities in cesarean section rates between the public sector—comprising government hospitals and clinics—and the burgeoning private healthcare sector. The findings reveal a multifaceted scenario shaped by socio-economic factors, healthcare financing, institutional protocols, and cultural expectations.
One of the most pronounced observations from the research is the markedly higher rate of cesarean deliveries in private facilities compared to their public counterparts. Whereas cesarean rates in public hospitals reflected a gradual increase aligned with global clinical recommendations, private hospitals exhibited an accelerated and substantially elevated frequency of surgical births. This divergence prompts inquiries into the underlying drivers—whether medically justified by patient needs or influenced by financial incentives, provider preferences, or patient demand dynamics.
Clinical decision-making around cesarean sections is inherently complex, balancing risks and benefits amidst varying resource availability. In Cambodia’s public hospitals, constraints such as limited operating room capacity, shortages of skilled obstetricians, and emphasis on cost containment often result in conservative obstetric management. Conversely, private hospitals may have greater technological capabilities, staffing, and financial motivation to perform cesarean deliveries, sometimes beyond strict medical necessity. This phenomenon is not unique to Cambodia but echoes global patterns where privatization in healthcare correlates with higher intervention rates.
Delving deeper, the disparity raises concerns about equity and quality in maternal healthcare. Cesarean section, when medically indicated, can prevent maternal and neonatal morbidity and mortality. However, unnecessary cesareans can introduce surgical risks, longer recovery times, and increased healthcare costs. The skewed distribution of cesarean rates suggests that some women might be underutilizing this critical intervention due to infrastructural or systemic barriers in public facilities, while others in private settings might be subjected to unwarranted surgeries for non-medical reasons. This dual challenge complicates public health efforts aimed at optimizing maternal outcomes.
The socio-economic gradients in Cambodia further complicate the discourse. Women from wealthier households and urban areas are disproportionately represented in private hospitals and, by extension, in higher cesarean section rates. In contrast, rural and lower-income populations predominantly rely on public health services, where access to cesarean delivery might be limited or delayed. This disparity not only reflects healthcare access inequities but also highlights broader social determinants of health influencing childbirth experiences.
Moreover, the cultural perception and expectations around cesarean sections have evolved in Cambodia, influenced by education, media, and peer narratives. In some circles, cesarean delivery is erroneously regarded as a modern or preferred mode of childbirth, further propelling elective procedures in private settings. This cultural dimension amplifies the challenges of bridging gaps between evidence-based obstetric care and patient preferences, necessitating tailored health education and counseling interventions.
On a systemic level, the governance and regulation of healthcare providers emerge as pivotal factors. Cambodia’s rapid expansion of private healthcare, often outpacing regulatory frameworks, possibly facilitates variable adherence to clinical guidelines. The study suggests the need for robust policy measures to standardize cesarean section indications, enhance monitoring mechanisms, and foster accountability within both public and private sectors to curb medically unjustified surgeries while improving access where necessary.
Technological advancements and improvements in obstetric training also underpin the changing childbirth care landscape. Over the two decades, Cambodia invested heavily in upgrading healthcare infrastructure and workforce skills, including emergency obstetric care capabilities. However, these enhancements have not uniformly translated into equitable cesarean section access, reflecting gaps in distribution and utilization that compound the urban-rural divide.
The implications of these findings are profound for policymakers, healthcare providers, and international health organizations committed to maternal and child health. Ensuring optimal cesarean section rates—neither too low to jeopardize lifesaving care nor excessively high to engender unnecessary risks and costs—remains a delicate balancing act. Cambodia’s experience elucidates the challenges faced by countries navigating rapid healthcare transitions amid socio-economic development.
To address these multifaceted issues, integrated strategies are essential. Strengthening public healthcare infrastructure, expanding skilled birth attendance, and ensuring timely access to emergency obstetric care can mitigate underutilization of cesareans where needed. Concurrently, enhancing regulatory oversight, promoting adherence to clinical protocols, and fostering patient-provider shared decision-making can curb over-medicalization in private facilities.
Furthermore, community engagement and targeted health communication campaigns can recalibrate cultural perceptions around childbirth modes, empowering women with balanced information to make informed choices. Collaboration with private sector stakeholders to align incentives and standards also holds promise in harmonizing care quality and equity.
This extensive study, by contextualizing two decades of childbirth care evolution in Cambodia, provides critical empirical evidence to inform such endeavors. Its methodological rigor and comprehensive scope offer a template for similar assessments in other low- and middle-income countries grappling with healthcare disparities amid rapid modernization.
Beyond Cambodia, these insights resonate amidst global efforts to achieve the United Nations Sustainable Development Goal 3, which aims to ensure healthy lives and promote well-being for all at all ages. Maternal health improvement is central to this agenda, and understanding the nuanced interplay between healthcare sector dynamics and childbirth interventions is indispensable.
In conclusion, the Cambodian case underscores that advances in maternal health are not merely a function of increased healthcare provision but hinge critically on equitable, appropriate, and patient-centered care modalities. The disparity in cesarean section utilization between public and private facilities encapsulates broader challenges and opportunities in transforming healthcare systems to serve all populations effectively.
As countries continue to navigate the path toward universal health coverage, Cambodia’s experience serves as both a cautionary tale and a beacon, emphasizing the necessity to balance technological progress with ethical stewardship, patient education, and health equity. Only through such comprehensive approaches can we hope to realize childbirth care that is safe, respectful, and accessible to every woman, regardless of socioeconomic status or geographic location.
Subject of Research:
Disparities in cesarean section utilization between public and private childbirth care facilities in Cambodia from 2000 to 2021.
Article Title:
Two Decades of Change in Childbirth Care in Cambodia (2000–2021): Disparities in Ceasarean Section Utilization Between Public and Private Facilities.
Article References:
Zhang, Y., Khuon, D., Saphonn, V. et al. Two Decades of Change in Childbirth Care in Cambodia (2000–2021): Disparities in Cesarean Section Utilization Between Public and Private Facilities. Glob Health Res Policy 10, 32 (2025). https://doi.org/10.1186/s41256-025-00429-7
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