Performance of Village Midwives as Maternal and Child Health Care Providers in Selected Districts in Indonesia

Background:

Indonesia's maternal mortality ratio, currently estimated at 307 deaths per 100,000 live births, remains one of the highest among ASEAN nations. Between four and a half and five million women give birth in Indonesia each year. Approximately 20,000 of these women die as a result of pregnancy and childbirth. An additional 410,000 to 620,000 women each year will have pregnancy or labor complications, which will result in subsequent illness or disability. While the child mortality rates are better, an increasing proportion of that mortality occurs in the neonatal period. Both maternal and neonatal mortality can in part be attributed to the large proportion of births in Indonesia not attended by a skilled provider (34%) and the fact that 59% of births still occur at home.

The government's Safe Motherhood Program began in 1991 and concentrated on educating some 54,000 community-based midwives. The focus shifted in 1995 to improving the performance of these village midwives, strengthening quality of care, and increasing maternal and neonatal health services throughout the country. Since 1997, the MOH has emphasized an integrated reproductive health framework of services, including safe motherhood. In 2001, the MOH adopted the World Health Organization's (WHO) Making Pregnancy Safer approach as its national framework. This approach calls for attendance by a skilled provider as a key component of reducing maternal and newborn morbidity and mortality. Per the 2003 Demographic and Health Survey, although 90% of all pregnant women attend at least one antenatal visit, the number of births attended by skilled providers is only about 66% nationally.

For births that are attended, midwives are the single largest provider of care. Private sector midwives, as well as village-based midwives, who have a semi-private status (i.e., they charge fees to clients, but their presence in the village is also subsidized by the government),attend 55% of all births in Indonesia . Their role in reducing maternal mortality is widely recognized as being of critical importance and as the most economically viable for people of limited financial means. The professional development of midwives is focused specifically on maternal and reproductive health care, and their fee structure is accessible to most Indonesians.

Increasing the quality of midwifery care in Indonesia can directly impact maternal and infant mortality. Midwives are absolutely crucial to improving reproductive health services at the grassroots level, given that they are found in almost every village in the country. They are trusted within their communities and are knowledgeable about the local health issues that affect families.

In partnership with the Indonesian Midwives Association (IBI) and with support from ExxonMobil, JHPIEGO developed and conducted a survey in 2006-2007 to assess the current status and performance of VMWs and to specifically collect information on their main role as an MCH service provider.

Methodology:

 Design of study

The design of this study was a survey which was deemed to be the most useful method for learning about the current performance of VMWs.

 Location of study

The study locations were determined in discussions between IBI and JHPIEGO, in consultation with ExxonMobil. The study areas were:

• Blora District (Central Java) in four subdistricts: Cepu, Sambong, Jiken and Kedung Tuban

• Bojonegoro District (East Java) in four subdistricts: Ngasem, Kalitidu, Dander and Kapas

• Aceh Besar District (Aceh) in three subdistricts: Darul Imara, Ingin Jaya and Lhoong

• Aceh Utara District (Aceh) in four subdistricts: Muara Batu, Syamtalira Aron, Matangkuli and Paya Bakon

 Selection of sample

At least ten percent of the total number of VMWs in Blora, Bojonegoro and Aceh Utara were selected for this study, as well as all VMWs in Aceh Besar that are involved in JHPIEGO's programs in that district. With the assumption that within a district the problems/challenges encountered by a VMW would be similar, some cluster areas were purposely selected, in discussion with IBI. It was initially planned that a random selection of VMWs would be made in each subdistrict; however, given limited numbers of VMWs, the total number of VMWs for the subdistrict was included. In some districts additional subdistricts had to be included in order to meet the representative sample of 10%.

The numbers of respondents in each district needed were as follows:

• 30 VMWs in Bojonegoro District

• 20 VMWs in Blora District

• 60 VMWs in Aceh Utara District

• 19 VMWs in Aceh Besar District

• 12 groups of women, husbands or community leaders

• 14 puskesmas observations

• Time of data collection

Data collection was conducted over a three week time period during December 2006 to January 2007.

 Method of data collection

Data was collected through:

• interviews with VMWs

• observation of polindes facilities

• review of equipment used by VMWs

• review of reports and records

• observation of puskesmas

• focus group discussions (FGDs) with 3 groups: women who had delivered in the last three years, husbands and community leaders

Results/Outcome:

Key findings from the survey of 129 VMWs are as follows:

1. The VMW plays an essential role in maternal and child health (MCH) care and she has many responsibilities, including clinical services as well as community mobilization

2. The VMW generally has a good partnership with the traditional birth attendants (TBAs) in her community.

3. The D3 preservice midwifery program schools are not in compliance with the standardized curriculum.

4. The communities are generally supportive of the VMW and recognize her role.

5. Even though most of the VMWs stated that they can manage the current workload, there are concerns that they might be overloaded and less effective if given additional responsibilities.

6. Mobilization of the community tends to fall on the shoulders of the VMW, with some limited support from community volunteers.

7. VMWs are generally not using the puskesmas (primary health care centers) for referral because of this facility's lack of ability to manage complications.

8. VMWs generally have insufficient equipment and facilities for quality basic delivery care.

9. Supervision of the VMWs by puskesmas staff is infrequent.

Recommendations for continued improvement of VMW performance:

1. Broader/more structured efforts to promote the VMW and educate communities about the need to access her services for safer pregnancies and deliveries. This could be done through introduction of the Ministry of Health's Desa SIAGA (Alert Village) model, which is broad health care, promotes the VMW and advocates for development of a referral system, or through other modified versions of Desa SIAGA. Another option is to support IBI at the provincial level to develop and implement a public relations campaign to promote the VMW.

2. Building the capacity of the VMWs to deliver quality services. This could be addressed by conducting additional Normal Delivery Care (APN) trainings and other updates, and following up VMWs post-training to ensure the skills acquired are well-integrated into their service delivery. The Government of Indonesia and IBI recommend that all midwives in Indonesia complete the APN inservice training. The results of the knowledge questionnaire clearly indicate that VMWs would benefit from APN training. Other initiatives to be considered include establishing a simple quality assurance system for continued support, performance improvement and monitoring; implementing a radio vignettes program to educate VMWs and fostering discussion between and among VMWs and their communities; establishing and equipping of additional polindes so that VMWs have adequate facilities to provide safe delivery services. Data from other studies show that caseloads increase when quality is improved. This is an area for IBI to explore further given its role in setting and monitoring standards for quality.

3. Strengthen the capacity of the puskesmas as a primary referral center for managing basic emergencies. International experience indicates that community health centers hold the most potential for promptly responding to emergency complications. Life threatening complications such as postpartum hemorrhage and eclampsia require immediate care, which should be provided at the puskesmas. Capacity development of this facility would involve: training of facility staff, on-site follow-up and guidance by district-level staff following training (to ensure new skills are fully integrated into service delivery) and provision of the necessary equipment and supplies, including magnesium sulphate for the prevention and management of eclampsia. The post-training follow-up is particularly critical to ensure that puskesmas staff are competent and confident in providing emergency care.

4. Continue to promote the VMW's partnership with TBAs in her community