Challenges of reducing maternal and neonatal mortality in Indonesia: Ways forward

Abstract

Every death counts. The death of a mother or newborn is not just a tragedy for the family but also an indicator of an egregious failure of the health system, especially because many of these tragic deaths are preventable. In lowand middleincome countries, most maternal deaths—deaths that occur during pregnancy, childbirth, and the 42 days of the postpartum period—are preventable.1 In addition, complications during labor and childbirth are responsible for about a quarter of all newborn deaths—deaths that occur within the first 28 days of life.1 However, optimal maternity care could prevent most maternal and newborn deaths.2 Childbirth with skilled attendance is promoted as the key strategy for reducing maternal mortality in lowand middleincome countries. Although skilled birth attendance has reached 83% in Indonesia, the maternal mortality ratio (MMR) is still one of the highest in Southeast Asia: 305 deaths occur for every 100 000 live births,3 compared with 110 for the region.4 The majority of these deaths (70.5%) occur in health facilities, which should be prepared to handle obstetric emergencies.5 We know “what works” to prevent newborn and maternal deaths, and proven, effective, and costeffective interventions are available.1,6 However, implementation is challenging, even for a country like Indonesia, where impressive economic growth has occurred in recent years.7 That said, economic growth does not automatically translate into low rates of maternal and newborn deaths. To help reduce these rates, the United States Agency for International Development launched the Expanding Maternal and Neonatal Survival (EMAS) program in support of the Indonesian Ministry of Health s efforts to improve the quality of emergency obstetric and newborn care through a series of interventions at health facilities. The program, which was implemented by Jhpiego and country partners, instituted a number of strategies to systematically document program activities and collect data on changes in health indicators. The wealth of data collected during the program provided an opportunity to examine not only the performance of the program, but also many aspects of the quality of the health system in program districts. This Supplement compiles a number of papers that present relevant programmatic findings and lessons learned from the EMAS program. The scientific community and medical journals often demand randomized controlled trials as the gold standard design for the unbiased evaluation of an intervention program. But, undertaking such a trial is logistically challenging and ethically questionable in many study contexts. Programs frequently target poor performance areas or are implemented in places where the health problems are most pronounced so that tangible program benefits can reach the most vulnerable populations as soon as possible. Due to the selective nature of program areas, it is often not feasible to conduct a randomized controlled trial for health intervention programs. Unfortunately, important lessons learned from those programs often do not appear in highimpact journals, and therefore fail to contribute to evidencebased practice literature. More programbased evidence is needed so that countries can reproduce, adapt, and scale up successful programs at the national level and avoid failures or missteps of unsuccessful interventions.8 The papers in this Supplement address this important need. To provide an overview of the EMAS program, Hyre et al.9 describe the context and rationales that went into program planning and design, and the specific intervention activities that were implemented to achieve programmatic goals. The description of the program within the country context will help other areas and countries replicate and adopt the intervention contents and components.