Evidence Summit on Reducing Maternal and NeonatalMortality in Indonesia

2016-2017

DRAFT OFRECOMMENDATION

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As of March 31, 2017

Alternative Policies Current Proposed Changes

ANC Midwife, 4 times, 10 T (Doctor + Midwife), 8 times (WHO suggestion +mother’s nutrition + monitor fetal development)

Pregnant woman with comorbid disease: ANC alwaysunder doctor supervision

Labor &Delivery

Home, Private midwife,Maternal house/hospital,Puskesmas, Pustu,Poskesdes/Polindes

PONED-certified Puskesmas, PONED-certifiedmaternal house (Competent personnel, open 24/7, etc),Every district have PONED-certified Puskesmas

Anywhere Maximum 30 minutes from PONEK HOSPITAL

Referral Referral still not optimal On-line referral network (Ex: Sijari Emas)

Personnel Training Training and rotation internship in PONEK Hospital

PublicHospital

Not all have PONEK ability ALL district public hospital should have PONEKability

Coverage JKN, Jampersal, BOK JKN, Jampersal,BOK: for all pregnant women 2

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Health Facility providing ANCInstitution Primary Care Center/FKTP (Fasilitas Kesehatan Tingkat Pertama):

• Puskesmas (complete with doctor + midwife + nurse)• Clinic (complete with doctor + midwife + nurse)

Personnel Doctor, Midwife, Nurse

Facility Outpatient

Strategic solution All Primary Care Center should have doctor + midwife + nurse

Regulation • First ANC should under doctor supervision• KN by nurse/midwife, if problem detected, refer to doctor• Increase ANC frequency to 8 times• If comorbid disease present: next ANC selanjutnya should under

doctor supervision• If comorbid disease affecting fetal growth, communicate with FKTP

PONED/FKTL PONEK• ANC outside certified Primary Care Center, will not be covered by

insurance (by JKN rules).

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Health Facility providing Labor andDelivery Service

Institution PONED-certified Primary Care Center

Time of service 24 hours/day, 7 days/week

Personnel Minimum 2 teams of PONED-trained doctor + midwife + nurse

Facility Delivery room and inpatient ward

Location “Reachable” from PONEK hospital (< 30 minutes travel time)

Strategic Solution• All inpatient Puskesmas turned into PONED Puskesmas, priority inlocation which “reachable” from PONEK Hospital

• Private midwives facilitated to join PONED-certified maternityhouse.

Regulation • All maternal and neonatal service covered by the government• JKN regulation based on this policy• Delivery in non-PONED facility will not be covered by insurance• Following the regulation will get several advantages: Free birth

certificate, free family planning, etc.

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Referral Health FacilityInstitution FKTL (Fasilitas Kesehatan Tingkat Lanjut) with PONEK ability:

• Hospital with PONEK ability• Maternity Hospital with PONEK ability

Time of service 24 hours/day, 7 days/week

Personnel Trained OBGYN specialist, Pediatrician, Anesthesia, Doctor, midwife,nurse

Facility Operating Room and inpatient ward, including Blood Bank

Supporting 24 hour electricity (with generator), clean water guaranteed, goodinternet connection

Strategic Solution• All district public hospitals should have PONEK ability• Maternity Hospitals facilitated to have PONEK ability

Regulation • Reward & punishment system towards the institution performance• Develop referral network that can monitor its patient whereabouts

and the response anytime.Suggestion for referral system improvement:

• Referral system improvement is ongoing• BPJS regulation should follow the referral standard

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Health Facility Map: FKTP – FKTP PONED – PONEK HOSPITAL

PONEKHospital

FKTP FKTPPONE

D

FKTPPONE

D

FKTPPONE

D

FKTPPONE

D

FKTP

FKTP

FKTP

FKTPRTK

Bulin

RTK

Good clinical and non-clinical communication system is neededin primary and referral Health facility.

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Movement For Better Care

PolindesMidwifepractice

FKTP / ClinicNon-PONED

FKTP / MaternalhousePONED-certified

Hospital / MaternalHospital withPONEK ability

Personnel Midwife Midwife

Team:Doctor,Midwife,Nurse

Team:PONED trainedDoctor, Midwife,Nurse

Team:PONEK-trainedSpecialist: OBGYN,pediatric, anesthesiadoctor, midwfe, Nurse

Present ANC ANC ANC ANC ANC

Suggested ANC ANC ANC

Present Linakes Linakes Linakes Linakes Linakes

Suggested Linakes Linakes

Works individually Works in team

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Preliminary Conclusion1. 75% of maternal death happened in labor and 48-hours

postpartum;2. 58% of neonatal death happened in 48 hours after birth3. Study suggest 70% death are preventable4. Quality improvement in maternal and neonatal care is needed:● Quality Continuum of care available 24/7● ANC and Labor & Delivery Service move from single to team-

based provider (with minimally involve a physician).● Delivery in PONED-certified primary care center● Pregnant and in-labor woman with complication should be

referred to PONEK Hospital.

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Preliminary Conclusion

1. Comprehensive and supporting change of regulation(including JKN) need to take place.

2. Literature exploration by hand-searching is still needed to

strengthen the evidence.

3. Support in literature contribution, good-practice/lessonslearned evidence are needed from all stakeholder.

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