Maternal and Early Neonatal Health Care System StrengtheningStrengthening

M A T E R N A L H E A L T H A S S E S S M E N T S T U D Y A N D W E S T J A V A P I L O T SW E S T J A V A P I L O T S

Background and Study Resultsg y

Main Question: Is the MDG-5 Target Achievable?

390 400

500

Liv

e B

irth

334 307

228

300

er 1

00

.00

0

102100

200

nal

Dea

th p

e

Target MDG 5 by 2015

-

1990-1994 1993-1997 1998-2002 2003-2007 2015Mat

ern

YearYear

Data source : IDHS, 1991-2007

How did we do the study?

Secondary Data Analysis y y:IDHS, SUSENAS, IHHS, and IMMPACT

Verbal Autopsy Reports (235 reports from 3 districts in West Java)

Interviews with Experts

Input from Indonesia Experts from Academia and Professional Institutes

Gl b l Li R iGlobal Literature Review

Field Work

Investment in antenatal care alone can not reduce the maternal mortality

Name Age Preg.History

ANC Cause of death ProviderFirstHistory First

Nj 19 G1P0A0 5 Eclampsia TBAMu 29 G3P2A0 4 post partum bleeding TBATa 23 G8P6A1 5 prolonged labor TBANh 35 G3P1A1 4 Eclampsia TBANh 35 G3P1A1 4 Eclampsia TBANr 21 G2P1A0 2 Infection TBAEr 1 35 G5P4A0 4 post partum bleeding TBAMe 20 G1P0A0 3 undiagnosed TBAEy 30 G3P2A0 6 post partum bleeding TBAEy 30 G3P2A0 6 post partum bleeding TBAOy 30 G4P3A0 3 obstructed labor TBALn 25 G2P1A0 6 post partum bleeding TBANs 22 G1P0A0 10 post partum bleeding TBAEr 2 35 G5P4A0 4 post partum bleeding TBAEr 2 35 G5P4A0 4 post partum bleeding TBAIr 20 G2P1A0 3 post partum bleeding TBAUm 40 G7P6A0 3 post partum bleeding TBAHer 33 G4 P2A1 3 post partum bleeding TBAS 40 G10P9A0 8 post partum bleeding TBAS 40 G10P9A0 8 post partum bleeding TBAMul 31 G2P1A0 2 post partum bleeding TBA

Data source : Verbal Autopsy 3 districts in West Java, 2009

Quality of antenatal care varies widely

Antenatal care component (IDHS 2007)

70

80

90

100DI Aceh

North Sumatera West Sumatera

Riau

Jambi Maluku

North Maluku

Papua West Papua

Antenatal care component (IDHS, 2007)

10

20

30

40

50

60 South Sumatera

Bengkulu

Lampung

Bangka Belitung South Sulawesi

Southeast Sulawesi

Gorontalo

West Sulawesi

0Bangka Belitung

Riau Islands

DKI Jakarta

West Java East Kalimantan

North Sulawesi

Central Sulawesi

South Sulawesi

Central Java

DI Yogyakarta

East Java Banten

Bali West Nusa Tenggara East Nusa Tenggara

West Kalimantan

Central Kalimantan

South Kalimantan

ANCInform sign of complicationg pTT >=2 timesIron consumption

Demand for TBAs remains high; large variation between i l l i f SBA f d li iincome levels in use of SBA for deliveries

100

60

80

de

liv

ery

40

60

AN

C/p

rof

d

0

20

Poorest Poorer Middle Richer Richest

% A

Poorest Poorer Middle Richer Richest

ANC/Prof del ANC/No prof del No care (No ANC/No prof del) No ANC/Prof del

Data source : IMMPACT 2006, Based on IDHS 2003

At province level there is little correlation between midwife availability and SBA while availability of a TBA is strongly correlated

DIY DKIDKIDIY

100

al

SBA VS Ratio midwife, 2007

120

al

SBA VS Ratio TBA, 2007

WJ

CJ

EJ

WJ

CJ

EJ

6080

heal

th p

rofe

sion

a

DKI DIY

EJCJ

DKI

CJ

DIY

EJ8010

0he

alth

pro

fesi

ona

40%

Del

iver

y by

h

WJWJ

60%

Del

iver

y by

h

20

20 40 60 80 100Ratio midwife per 100000 pop

40

200 400 600Ratio TBA per 100000 pop

Source : SBA (IDHS, 2007), Ratio midwife (Indonesia health profile, 2007), Ratio TBA (PODES, 2008)

Referrals fall short when complications arise; “A”, 27 years old with elementary school education, first pregnancy, 3 times to do ANC with

id if (l t h k > hi h bl d d id if f d t h it l

Massage by TBA Stomach ache at 

midwife (last check-> high blood pressure and midwife referred to hospital

7 May 2009Massage by TBA

night, swelling throughout the body (Oedem Anasarka)

8 May 2009Morning

Visited midwife, midwife was not there

Wait for6 hours

Morning was not there

8 May 200916.00

2nd visit to the same midwife and she

wait 8 hours

1st hospital rejected (Not CEONC)Reason : full

16.00 midwife, and she directly referred

2nd hospital rejected (Not CEONC)Reason : Full

9 May 200900.05 AM

Accepted in 3th hospital• Caesar->baby death

• Mother coma

10 May 200920.00 PM

11 May 200905.00 AM

source: Verbal autopsy, 2009

Results

SBA not enoughg

Quality lacking

Demand high for TBAg

Referral problems

The Pathway to Safe Motherhood

Maternal ? Maternal Survive/ Death Delivery by MW

• 85% normal•15%

?

Use of SBA

complication, mostly unpredictable

Q lit f C

COST

Quality of Care- Complication prevention- Emergency identification- First Aid

Accessible Hospital

•Quality of Care

Timely Referral

Hospital

Source: Endang Achadi

Logical Framework(intervention model for 18 months)

Access• Financing

(intervention model for 18 months)

• Financing• Transportation

PUSKESMAS+Private Clinic

CONTINUUM OF CARE

Increasing the DEMAND

ClinicHOSPITAL (pub;priv)

MOTHER AND BABY SURVIVEDAND WELL

Pregnant women & Comm.

CO UU O C

Quality of Obstetric Care• Quality assurance in health facilities• Accreditationcc ed tat o• Referral network• Recording and reporting system

Elements of the Model

1. Promoting facility-based delivery in certified birth delivery facilities2 Implementing policies to ensure access of the poor to facility based delivery2. Implementing policies to ensure access of the poor to facility based delivery3. Operating an adequate referral network of birth delivery facilities and referral

hospitals (public and private facilities)4. Implementing policies to ensure adequate quality of care at the hospitals

particularly for the management of normal deliveries prevention and particularly for the management of normal deliveries, prevention and management of post partum hemorrhage and management of Caesarean Section

5. Designing and implementing a promotion strategy to increase demand for facility based delivery including exploring the TBA-midwife partnership facility based delivery including exploring the TBA midwife partnership approach

6. Implementing a functioning surveillance system (community and institutional based) for maternal and neonatal deaths

7 Establishing an accreditation system to standardize the quality of birth 7. Establishing an accreditation system to standardize the quality of birth delivery facilities

• Point 1 6 collaboration with PUSKA UI• Point 1-6 collaboration with PUSKA UI• Point 7 collaboration with PMPK UGM

Pilot area

Worldbank support for technical assistant aspect, implementation will be financed by local government Local government allow to choose certain approach Local government allow to choose certain approach based on their capability to implement the modelArea study (2 sub-district per district)y ( p )

Bandung District (All propose model): Urban : Banjaran Nambo; Rural : Pangalengan

Bogor District (All propose model):Bogor District (All propose model):Urban : Cileungsi; Rural : Sukamakmur

Cianjur District (model reporting and recording system):All b di t i tAll sub-districts

Process : phase 1

Several workshops and series of meetings with all stakeholder include B d DPRD d l f i l i i h b Bappeda, DPRD, and also professional organizations have been conducted to discuss on model development.

2 Workshops for each district has been conducted with different purpose :

The aimed of 1st Workshop was to have same perception and understanding on the current maternal health situation and also to get agreement from local government to work together to reduce MMR based on the model agreed

The aimed of 2nd workshop was to discuss more on technical aspect for each agreed component of the model

A series of meetings with stakeholder has been conducted also specific meeting such as :meeting such as :

Focus meeting with Bappeda

Focus meeting with DPRD commission D

Focus meeting with private sectorg p

Agreement

Facility-based Delivery: Definition :Definition :

24/7 days

2 midwifes per shift Challenge : Providing 2 midwifes per shift will not be easy to achieved

Location less than 2 hours from nearest referral hosp

Able to manage : a.Normal delivery care ; b. Vacuum extraction or forceps ; c. Management of mild complications; and d. First aid for complications

Activities :

Health office should provide relevant trainings for health providers, primary care should be able to manage complication cases

Finding : Not all midwives had trainings on delivery attendance, and complication management and skills to g g y , p gutilize equipments - Increase budget for training and advocacy with Bappeda also Pemda and approved --Congrats

Challenge: Low utilization will result in skill-loss

Facilities need to improve equipments and emergency medication.

Finding : there is no special room for labour and delivery and post partum care ; Inadequate equipment to Finding : there is no special room for labour and delivery and post partum care ; Inadequate equipment to manage complication ; Lack of water supply during the dry season Budget requirement for improving equipment has been approved--- Congrats

At facility midwives should be on standby (not on call), additional midwives for three shifts,

Finding : Midwives preferred to work with other midwives when attending deliveries and managing complications Add the number of midwives or involve village or private midwives in the shifts clear role complications Add the number of midwives or involve village or private midwives in the shifts, clear role and responsibility for village midwives in the village and PKM.--- ON PROCESS

Challenge: Fee for service at facility is lower than in Polindes or private practice

Agreement (cont)

“Midwife-TBA Partnership”: It is necessary to have the legal basis for midwife TBA partnership clear role and responsibility for It is necessary to have the legal basis for midwife-TBA partnership, clear role and responsibility for TBAs in the community (as midwife’s partner, marketing agent for facility-based delivery) need to be established,

Discussed with Sub-district office, “Polres”, “Kodim”, in pilot area to have legal basis on TBA partnership through local sub-district regulation ON PROCESS

Incentive system for TBAs if they send patients to the midwife will need to be developed. Bandung can provide this incentive for TBA because it is allow by the local regulation but NOT in Bogor APPROVED Congrats

Bandung developed 5 years plan for this incentive with assumption after 5 years demand of delivery by TBA will Bandung developed 5 years plan for this incentive with assumption after 5 years demand of delivery by TBA will reduce GOOD PLAN

Challenge : Incentive for referring pregnant women to midwife is lower than TBA earning from assisting labor

Supervision of this partnership need to be worked-out by health office, local government and related sectors and also community for sustainability.

Launching of TBA partnership program will involve local government until village level ON PROCESS

Agreement (cont)

Adequate Referral Network: establish quality referral network between one referral hospital and several referring health establish quality referral network between one referral hospital and several referring health facilities and other referral hospitals.

Develop communication between health facility (PONED, Hospital public/private) through system - ON PROCESS

Supports for this model to work are special ambulance for referral, ready 24 hours / 7 days pp p y / yincluding the driver and also accompanied by competent health provider.

Bandung can provide budget for ambulance’s driver to be ready 24 hours/7 days Congrats

Bogor plan to use reimbursement mechanism to cover transport cost based on “actual cost” approved by head of health center using BOK money.

Agreement (cont)

“Adequate Quality of Hospital Care” for Normal Delivery Management, Prevention and Management of Postpartum Hemorrhage and Cesarean Section Management in Management of Postpartum Hemorrhage, and Cesarean Section Management in compliance to standards:

Service standards and SOP on management of normal deliveries, postpartum hemorrhage and especially Cesarean Section, and management of other obstetric conditions and complications in general. general.

Assurance of adequate obstetric services 24 hours a day 7 days a week and availability of standard facilities and infrastructure.

Plan for monitoring and evaluation scheme for service quality improvement activities in the hospitals.p

Improvement of management capacity (planning, budgeting, monitoring, and evaluation activities) and other relevant skills to support improvement of service quality in the hospitals ON PROCESS

Cibinong hospital agreed to have a more regular AMP activity, budget allocated Congrats

Challenge: Other hospital feels that the model add burden to their work, rather than benefiting ON PROCESS PROCESS

Agreement (cont)

Proposed Facility and Community-Based Data Collection Systems for Maternal and Neonatal Deaths: Neonatal Deaths:

RAPID and ACTIVE as facility based systems will produce information of all maternal and neonatal deaths with direct or indirect causes of death.

At the community level SKIN and MADE IN/MADE FOR will provide information on maternal and neonatal mortality. and neonatal mortality.

The proposed model is only accepted in Cianjur district Congrats

Bandung and Bogor has difficulty to accept the model because budget for any activity related to information system is unavailable due to Bappeda instruction

Agreement (cont)

Assuring poor community’s access to a birth facility: Prevailing regulations should be reviewed to look at possibilities of incentives and providers’ Prevailing regulations should be reviewed to look at possibilities of incentives and providers payment.

Other funding sources such as transportation cost from community funds (Tabulin), CSR contribution or Village Allocation Fund can be included in the scheme.

New development: JAMPERSAL scheme is launched starting in April 2011. Challenge: awaiting for operational New development: JAMPERSAL scheme is launched starting in April 2011. Challenge: awaiting for operational and technical guideline for using JAMPERSAL