IMMPACT

Population Reference Bureau

Aberdeen University Research

Background In 1989, the government of Indonesia launched the Midwife in the Village programme. Its purpose was to reduce maternal death by assigning a resident midwife to each village in the country. By definition, she would live in the village and be part of the community she served. By 1996, 54,000 midwives had been trained and deployed and virtually all villages had their own assigned midwife. Skilled attendance at delivery rose in rural areas. But it is unclear whether the substantial resources invested resulted in fewer maternal deaths. In 2005, Immpact, a global research initiative, examined the effect of the programme on the health and survival of mothers in two districts in Java. Immpact sought to answer two questions: Did posting midwives in villages improve maternal health and survival and if so, how? To answer these questions, Immpact examined the overall coverage, configuration, and quality of midwifery care; when and which services women and families used; and the nature of the barriers that prevented women and families from seeking care. FindingsUrban areas have adequate midwifery coverage,  but rural areas do not.In urban areas, almost all neighborhoods have their own assigned providers. But in remote areas midwives may have to manage care in up to five villages. Since many midwives prefer to live in urban areas, overall, only 29 percent of villages have a resident midwife. This means more than two-thirds of rural villages do without a resident midwife.Having a resident midwife in a village increases skilled attendance at delivery, but coverage remains low. In villages with no midwives, on average only about 20 percent of women deliver with a skilled attendant. Even in villages with more than 6 midwives per 10,000 inhabitants, only 60 percent of women use a skilled attendant. While overall use of skilled attendants at birth is low, Immpact data suggest that the presence of at least one resident midwife is associated with increased use of a skilled attendant at delivery and that having three or more midwives in a village is associated with half the risk of maternal death compared with villages with no resident midwife. Village midwives reduce maternal deaths by identifying complications, making timely referrals, and facilitating access to hospitals. Midwives help avert maternal deaths by facilitating timely access to emergency obstetric care, which is essential IndonesiaResident midwives help avert maternal deaths when financial barriers are removed.February 2007POPULATION REFERENCE BUREAUUse of Skilled Attendant at Delivery by Wealth QuintileSource: Immpact.PoorestquintileMiddlequintile4thquintile2ndquintileRichestquintilePercent of deliveries with skilled attendant020406080100to save women’s lives. The professional status of the midwives helped persuade families of the need for referral. To allay the concerns of the family about paying for delivery services, trained midwives also made good use of community and professional contacts to help organize fee-exemption documents and transportation. Midwives accompanied women to the hospital and used profes-sional contacts to gain rapid entry to the wards.Results from a small-scale qualitative study suggest that trained midwives’ clinical capacity to provide emer-gency obstetric care is limited. Data suggest that trained midwives made correct diagnoses, recognized danger signs, and made referral decisions rapidly and appro-priately during an emergency. However, their clinical management of emergencies was substandard—their practice was not based on existing standards of care and was hindered by inadequate knowledge and skills. Women in villages with a resident midwife still face barriers to care. These barriers can be socio-cultural, financial, or educa-tional. Immpact data suggest that 67 percent of women deliver at home with a traditional birth attendant (TBA) and a trained midwife is called only in the event of a compli-cation. In Immpact research areas, 33 percent of women overall deliver with a trained midwife, 62 percent in urban areas and 23 percent in villages. Such choices are due to cost, tradition, and long-standing family links with TBAs. The cost of a normal delivery in the community attended by a TBA is about US$7, while a delivery attended by a midwife is about US$23. The Indonesian health insurance programme for the poor may help lower the financial barrier to hospital delivery by exempting families from the direct cost of delivery. But the programme is imper-fectly implemented and some fees not covered by the programmes, such as medication, blood, and transpor-tation, still pose a burden to families and may impede access to care. Richer families tend to benefit from health services more than poorer families. Immpact found a large rich-poor gap in the use of a skilled attendant (see figure). While 76 percent of the richest fifth of society gave birth with a trained midwife or doctor, only 9 percent of the poorest did so. The large majority of women (71 percent) who gave birth with a skilled attendant belonged to the top 40 percent of the wealth distribution. Access to caesarean delivery showed similar inequalities: Less than 1 percent of the poor delivered by caesarean, compared to 4 percent of the rich. Immpact data suggest that about 40 percent of public resources for maternal health are directed to the richest 20 percent of the population, while only 10 percent reach the poorest fifth of society. Recommendations• Provide incentives for midwives to work and live in remote villages. Immpact research suggests that midwives can help avert maternal deaths. Rural areas lack adequate coverage by midwives, in part, because midwives prefer to live in more urban areas. Incentives, such as increased payments for services, may entice more midwives to live and work in underserved areas. • Improve access and affordability of maternal care services for the poor. New initiatives are needed to ensure that the poor derive more benefit from maternal health services. One method could be to help poorer families access the national fee exemption programme to help manage costs asso-ciated with delivery care. Future financing policies may also need to target resources to areas with higher levels of poverty. For more information on Immpact, please visit www.immpact-international.org.

Indonesia : resident midwives help avert maternal deaths when financial barriers are removed

https://aura.abdn.ac.uk/bitstream/2164/215/1/Indonesia.pdf

Indonesia : resident midwives help avert maternal deaths when financial barriers are removed

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