Beyond Effectiveness--The Adversities of Implementing a Fortification Program. A Case Study on the Quality of Iron Fortification of Fish and Soy Sauce in Cambodia

Fortification of fish and soy sauces is a cost-effective strategy to deliver and increase iron intake in the Cambodian diet, as both are widely consumed by the entire population. In order to qualify as fortified sauces recognized by international regulations, iron content must be between 230 and 460 mg/L, whilst nitrogen and salt should contain no less than 10 g/L and 200 g/L respectively. This survey aims to analyze the progress of the fortification program. Through a better understanding of its obstacles and successes, the paper will then consider approaches to strengthen the program. Two hundred and fifty two samples were collected from 186 plants and 66 markets in various provinces. They were then analyzed for iron, nitrogen and salt content. The study demonstrates that 74% of fortified fish and soy sauces comply with Cambodian regulations on iron content. 87% and 53.6% of the collected samples do not have adequate level of nitrogen and salt content, respectively. The paper will discuss additional efforts that need to be implemented to ensure the sustainability of the project, including the need to: (i) comply with International Codex; (ii) adopt mandatory legislation; and (iii) ensure enforcement.

Fish sauce, soy sauce, and vegetable oil fortification in Cambodia: where do we stand to date?

BACKGROUND

The prevalence of micronutrient deficiencies in Cambodia is among the highest in Southeast Asia. Fortification of staple foods and condiments is considered to be one of the most cost-effective strategies for addressing micronutrient deficiencies at the population level. The Government of Cambodia has recognized the importance of food fortification as one strategy for improving the nutrition security of its population.

OBJECTIVE

This paper describes efforts under way in Cambodia for the fortification of fish sauce, soy sauce, and vegetable oil.

METHODS

Data were compiled from a stability test of Cambodian fish sauces fortified with sodium iron ethylenediaminetetraacetate (NaFeEDTA); analysis of fortified vegetable oils in the Cambodian market; a Knowledge, Attitudes, and Practices (KAP) study of fortified products; and food fortification program monitoring documents.

RESULTS

At different levels of fortification of fish sauce with NaFeEDTA, sedimentation and precipitation were observed. This was taken into consideration in the government-issued standards for the fortification of fish sauce. All major brands of vegetable oil found in markets at the village and provincial levels are imported, and most are nonfortified.

CONCLUSIONS

Fish sauce, soy sauce, and vegetable oil are widely consumed throughout Cambodia and are readily available in provincial and village markets. Together with an effective regulatory monitoring system, the government can guarantee that these commodities, whether locally produced or imported, are adequately fortified. A communications campaign would be worthwhile, once fortified commodities are available, as the KAP study found that Cambodians had a positive perception of fortified sauces.

Abortion-related complications in Cambodia

INTRODUCTION

Although termination of pregnancy (termination) has been legal in the Kingdom of Cambodia since 1997, a number of barriers to safe termination services persist and many women continue to induce their own terminations or seek unsafe services that result in complications requiring 'post-abortion' care.

OBJECTIVE

To describe the complications of miscarriage and failed terminations and document the magnitude of the resulting morbidity in the Cambodian public sector.

DESIGN

Cross-sectional descriptive study.

SETTING

Public sector hospitals and health centres.

SAMPLE

Stratified multistage sampling design included all hospitals (n = 71), 14% of eligible high-level health centres (n = 58) and 22% of eligible low-level health centres (n = 57).

METHODS

Data collectors used a standardised questionnaire to record information on diagnosis, reproductive history and treatment from 629 women seeking care for termination or miscarriage-related complications in study facilities over a 3-week period.

MAIN OUTCOME MEASURES

Annual estimate of cases, clinical symptoms, severity distribution of morbidity, ratio of complications to live births and incidence of abortion complications for Cambodian public health facilities.

RESULTS

In 2005, an estimated 31,579 women with complications of miscarriage or terminations were treated in Cambodian government facilities; 80% of these women sought care at a health centre. Forty percent of all women seeking care for complications either reported or showed strong clinical evidence of prior attempted terminations. Nearly 17% of these women were in the second trimester of pregnancy and 42% of them presented with high severity complications. The annual incidence of termination and miscarriage complications (abortion complications) was 867 per 100,000 women of reproductive age. The projected ratio of complications was 93 per 1000 live births.

CONCLUSIONS

To reduce maternal morbidity in Cambodia, women must be encouraged to seek safe termination services or seek postabortion care without delay. Additionally, providers need further training, and facilities greater commitment, to provide safe terminations and care for complications of unsafe terminations and miscarriage.