Contraceptive Practice in Indonesia: Did the Village Midwife Program Make a Difference?

Forty years after Indonesia's Family Planning Program was created, the country continues to struggle to meet the reproductive health needs of some of its hardest-to-reach populations. Over the last decade, contraceptive prevalence has stagnated and unmet need for contraceptives has risen. One Government initiative that provides reproductive health services is the Village Midwife Program, which was designed to address gaps in access to reproductive healthcare for rural women and has been in place since1989. The midwives are poised to expand safe motherhood promotion among the poor and hard-to-reach populations, improve accessibility and utilization of family planning services, and enhance the mix of contraceptives available to target populations (World Bank, 1991). Although provision of family planning services is one of the midwives' core responsibilities, no research has explored the dynamic between the Village Midwife Program and contraceptive practice. Using data from the Indonesia Family Life Survey from 1993 to 2007, this dissertation evaluates the linkages between village midwife availability, contraceptive prevalence and method choice using a fixed effects logit methodology to control for selective placement of midwives. Also evaluated is the midwives' effect on the Government's targeted priority populations. The study's findings indicate that although village midwives did not affect contraceptive prevalence, for women using modern contraceptives, the village midwives influenced women's method choice. Specifically, the midwives increased the probability of injectable contraceptive use by 10.5% in 2007 while decreasing the probability of oral contraceptive use by 5.5% in 2000 and 5.2% in 2007 and of contraceptive implants by 4.8% in 2007. Although the Government hoped that village midwives would channel women into longer-lasting methods such as intrauterine devices and implants, the women's switching behavior indicates that the program succeeded in providing additional outlets for a preferred method type. Given the halt in contraceptive prevalence rate and rising unmet need in Indonesia, the Government should consider new approaches to promote longer-lasting methods focusing on demand-side issues such as information, education and communication campaigns and targeted approaches for women with unmet need

Measuring Maternal Mortality: Three Case Studies Using Verbal Autopsy with Different Platforms

Accurate measurement of maternal mortality is needed to develop a greater understanding of the scale of the problem, to increase effectiveness of program planning and targeting, and to track progress. In the absence of good quality vital statistics, interim methods are used to measure maternal mortality. The purpose of this study is to document experience with three community-based interim methods that measure maternal mortality using verbal autopsy

Measuring Maternal Mortality: Three Case Studies Using Verbal Autopsy with Different Platforms

Accurate measurement of maternal mortality is needed to develop a greater understanding of the scale of the problem, to increase effectiveness of program planning and targeting, and to track progress. In the absence of good quality vital statistics, interim methods are used to measure maternal mortality. The purpose of this study is to document experience with three community-based interim methods that measure maternal mortality using verbal autopsy

The increasing trend in preterm birth in public hospitals in northern Argentina

Objective: To identify factors associated with the increasing incidence of preterm birth in northern Argentina. Methods: In an observational study, data were reviewed from a prospective, population-based registry of pregnancy outcomes in six cities in 2009-2012. The primary outcome was preterm birth (at 20-37 weeks). Bivariate tests and generalized estimating equations were used within a conceptual hierarchical framework to estimate the cluster-corrected annual trend in odds of preterm birth. Results: The study reviewed data from 11 433 live births. There were 484 (4.2%) preterm births. The incidence of preterm births increased by 38% between 2009 and 2012, from 37.5 to 51.7 per 1000 live births. Unadjusted risk factors for preterm birth included young or advanced maternal age, normal body mass index, nulliparity, no prenatal care, no vitamins or supplements during pregnancy, multiple gestation, and maternal hypertension or prepartum hemorrhage. The prevalence of many risk factors increased over the study period, but variations in these factors explained less than 1% of the increasing trend in preterm birth. Conclusion: The incidence of preterm births insix small cities in northern Argentina increased greatly between 2009 and 2012. This trend was unexplained by the risk factors measured. Other factors should be assessed in future studies.Fil: Weaver, Emily H.. University of North Carolina School at Chapel Hill; Estados UnidosFil: Gibbons, Luz. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Belizan, Jose. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Althabe, Fernando. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentin

Effect of Village Midwife Program on Contraceptive Prevalence and Method Choice in Indonesia

Indonesia established its Village Midwife Program in 1989 to combat high rates of maternal mortality. The program’s goals were to address gaps in access to reproductive health care for rural women, increase access to and use of family planning services, and broaden the mix of available contraceptive methods. In this study, we use longitudinal data from the Indonesia Family Life Survey to examine the program’s effect on contraceptive practice. We find that the program did not affect overall contraceptive prevalence but did affect method choice. Over time, for women using contraceptives, midwives were associated with increased odds of injectable contraceptive use and decreased odds of oral contraceptive and implant use. Although the Indonesian government had hoped that the Village Midwife Program would channel women into using longer-lasting methods, the women’s “switching behavior” indicates that the program succeeded in providing additional outlets for and promoting the use of injectable contraceptives

Bves and NDRG4 regulate directional epicardial cell migration through autocrine extracellular matrix deposition

Directional cell movement is universally required for tissue morphogenesis. Although it is known that cell/matrix interactions are essential for directional movement in heart development, the mechanisms governing these interactions require elucidation. Here we demonstrate that a novel protein/protein interaction between blood vessel epicardial substance (Bves) and N-myc downstream regulated gene 4 (NDRG4) is critical for regulation of epicardial cell directional movement, as disruption of this interaction randomizes migratory patterns. Our studies show that Bves/NDRG4 interaction is required for trafficking of internalized fibronectin through the “autocrine extracellular matrix (ECM) deposition” fibronectin recycling pathway. Of importance, we demonstrate that Bves/NDRG4-mediated fibronectin recycling is indeed essential for epicardial cell directional movement, thus linking these two cell processes. Finally, total internal reflectance fluorescence microscopy shows that Bves/NDRG4 interaction is required for fusion of recycling endosomes with the basal cell surface, providing a molecular mechanism of motility substrate delivery that regulates cell directional movement. This is the first evidence of a molecular function for Bves and NDRG4 proteins within broader subcellular trafficking paradigms. These data identify novel regulators of a critical vesicle-docking step required for autocrine ECM deposition and explain how Bves facilitates cell-microenvironment interactions in the regulation of epicardial cell–directed movement

Integrin-mediated traction force enhances paxillin molecular associations and adhesion dynamics that increase the invasiveness of tumor cells into a three-dimensional extracellular matrix.

Metastasis requires tumor cells to navigate through a stiff stroma and squeeze through confined microenvironments. Whether tumors exploit unique biophysical properties to metastasize remains unclear. Data show that invading mammary tumor cells, when cultured in a stiffened three-dimensional extracellular matrix that recapitulates the primary tumor stroma, adopt a basal-like phenotype. Metastatic tumor cells and basal-like tumor cells exert higher integrin-mediated traction forces at the bulk and molecular levels, consistent with a motor-clutch model in which motors and clutches are both increased. Basal-like nonmalignant mammary epithelial cells also display an altered integrin adhesion molecular organization at the nanoscale and recruit a suite of paxillin-associated proteins implicated in invasion and metastasis. Phosphorylation of paxillin by Src family kinases, which regulates adhesion turnover, is similarly enhanced in the metastatic and basal-like tumor cells, fostered by a stiff matrix, and critical for tumor cell invasion in our assays. Bioinformatics reveals an unappreciated relationship between Src kinases, paxillin, and survival of breast cancer patients. Thus adoption of the basal-like adhesion phenotype may favor the recruitment of molecules that facilitate tumor metastasis to integrin-based adhesions. Analysis of the physical properties of tumor cells and integrin adhesion composition in biopsies may be predictive of patient outcome

4-Phenylbutyric acid treatment rescues trafficking and processing of a mutant surfactant protein C

Mutations in the SFTPC gene, encoding surfactant protein–C (SP-C), are associated with interstitial lung disease (ILD). Knowledge of the intracellular fate of mutant SP-C is essential in the design of therapies to correct trafficking/processing of the proprotein, and to prevent the formation of cytotoxic aggregates. We assessed the potential of a chemical chaperone to correct the trafficking and processing of three disease-associated mutant SP-C proteins. HEK293 cells were stably transfected with wild-type (SP-C(WT)) or mutant (SP-C(L188Q), SP-C(Δexon4), or SP-C(I73T)) SP-C, and cell lines with a similar expression of SP-C mRNA were identified. The effects of the chemical chaperone 4-phenylbutyric acid (PBA) and lysosomotropic drugs on intracellular trafficking to the endolysosomal pathway and the subsequent conversion of SP-C proprotein to mature peptide were assessed. Despite comparable SP-C mRNA expression, proprotein concentrations varied greatly: SP-C(I73T) was more abundant than SP-C(WT) and was localized to the cell surface, whereas SP-C(Δexon4) was barely detectable. In contrast, SP-C(L188Q) and SP-C(WT) proprotein concentrations were comparable, and a small amount of SP-C(L188Q) was localized to the endolysosomal pathway. PBA treatment restored the trafficking and processing of SP-C(L188Q) to SP-C(WT) concentrations, but did not correct the mistrafficking of SP-C(I73T) or rescue SP-C(Δexon4). PBA treatment also promoted the aggregation of SP-C proproteins, including SP-C(L188Q). This study provides proof of the principle that a chemical chaperone can correct the mistrafficking and processing of a disease-associated mutant SP-C proprotein

Care-seeking and health insurance among pregnancy-related deaths: A population-based study in Jember District, East Java Province, Indonesia

Background Despite the increased access to facility-based delivery in Indonesia, the country’s maternal mortality remains unacceptably high. Reducing maternal mortality requires a good understanding of the care-seeking pathways for maternal complications, especially with the government moving toward universal health coverage. This study examined care-seeking practices and health insurance in instances of pregnancy-related deaths in Jember District, East Java, Indonesia. Methods This was a community-based cross-sectional study to identify all pregnancy-related deaths in the district from January 2017 to December 2018. Follow-up verbal and social autopsy interviews were conducted to collect information on care-seeking behavior, health insurance, causes of death, and other factors. Findings Among 103 pregnancy-related deaths, 40% occurred after 24 hours postpartum, 36% during delivery or within the first 24 hours postpartum, and 24% occurred while pregnant. The leading causes of deaths were hemorrhage (38.8%), pregnancy-induced hypertension (20.4%), and sepsis (16.5%). Most deaths occurred in health facilities (81.6%), primarily hospitals (74.8%). Nearly all the deceased sought care from a formal health provider during their fatal illness (93.2%). Seeking any care from an informal provider during the fatal illness was more likely among women who died after 24 hours postpartum (41.0%, OR 7.4, 95% CI 1.9, 28.5, p = 0.049) or during pregnancy (29.2%, OR 4.4, 95% CI 1.0, 19.2, p = 0.003) than among those who died during delivery or within 24 hours postpartum (8.6%). There was no difference in care-seeking patterns between insured and uninsured groups. Conclusions The fact that women sought care and reached health facilities regardless of their insurance status provides opportunities to prevent deaths by ensuring that every woman receives timely and quality care. Accordingly, the increasing demand should be met with balanced readiness of both primary care and hospitals to provide quality care, supported by an effective referral system

Neonatal mortality in two districts in Indonesia: Findings from Neonatal Verbal and Social Autopsy (VASA)

Background The Government of Indonesia is determined to follow global commitments to reduce the neonatal mortality rate. Yet, there is a paucity of information on contributing factors and causes of neonatal deaths, particularly at the sub-national level. This study describes care-seeking during neonates’ fatal illnesses and their causes of death. Methods We conducted a cross-sectional community-based study to identify all neonatal deaths in Serang and Jember Districts, Indonesia. Follow-up interviews were conducted with the families of deceased neonates using an adapted verbal and social autopsy instrument. Cause of death was determined using the InSilicoVA algorithm. Results The main causes of death of 259 neonates were prematurity (44%) and intrapartum-related events (IPRE)-mainly birth asphyxia (39%). About 83% and 74% of the 259 neonates were born and died at a health facility, respectively; 79% died within the first week after birth. Of 70 neonates whose fatal illness began at home, 59 (84%) sought care during the fatal illness. Forty-eight of those 59 neonates went to a formal care provider; 36 of those 48 neonates (75%) were moderately or severely ill when the family decided to seek care. One hundred fifteen of 189 neonates (61%) whose fatal illnesses began at health facilities were born at a hospital. Among those 115, only 24 (21%) left the hospital alive–of whom 16 (67%) were referred by the hospital. Conclusions The high proportion of deaths due to prematurity and IPRE suggests the need for improved management of small and asphyxiated newborns. The moderate to severe condition of neonates at the time when care was sought from home highlights the importance of early illness recognition and appropriate management for sick neonates. Among deceased neonates whose fatal illness began at their delivery hospital, the high proportion of referrals may indicate issues with hospital capability, capacity, and/or cost