Eko Setyo Pambudi

Professional assistance during birth and maternal mortality in two Indonesian districts

OBJECTIVE To examine determinants of maternal mortality and assess the effect of programmes aimed at increasing the number of births attended by health professionals in two districts in West Java, Indonesia. METHODS We used informant networks to characterize all maternal deaths, and a capture-recapture method to estimate the total number of maternal deaths. Through a survey of recent births we counted all midwives practising in the two study districts. We used case-control analysis to examine determinants of maternal mortality, and cohort analysis to estimate overall maternal mortality ratios. FINDINGS The overall maternal mortality ratio was 435 per 100,000 live births (95% confidence interval, CI: 376-498). Only 33% of women gave birth with assistance from a health professional, and among them, mortality was extremely high for those in the lowest wealth quartile range (2303 per 100,000) and remained very high for those in the lower middle and upper middle quartile ranges (1218 and 778 per 100,000, respectively). This is perhaps because the women, especially poor ones, may have sought help only once a serious complication had arisen. CONCLUSION Achieving equitable coverage of all births by health professionals is still a distant goal in Indonesia, but even among women who receive professional care, maternal mortality ratios remain surprisingly high. This may reflect the limitations of home-based care. Phased introduction of fee exemption and transport incentives to enable all women to access skilled delivery care in health centres and emergency care in hospitals may be a feasible, sustainable way to reduce Indonesias maternal mortality ratio.

Midwifery provision and uptake of maternity care in Indonesia.

Objectives  To examine the association between midwife density, other characteristics of midwifery provision and village contextual factors, and the percentage of births attended by a health professional and deliveries via caesarean section in two districts in West Java, Indonesia.

A practical approach to identifying maternal deaths missed from routine hospital reports: lessons from Indonesia

Background: Accurate estimates of the number of maternal deaths in both the community and facility are important, in order to allocate adequate resources to address such. On the other hand, current studies show that routine methods of identifying maternal deaths in facilities underestimate the number by more than one-half. Objective: To assess the utility of a new approach to identifying maternal deaths in hospitals. Method: Deaths of women of reproductive age were retrospectively identified from registers in two district hospitals in Indonesia over a 24-month period. Based on information retrieved, deaths were classified as ‘maternal’ or ‘non-maternal’ where possible. For deaths that remained unclassified, a detailed case note review was undertaken and the extracted data were used to facilitate classification. Results: One hundred and fifty-five maternal deaths were identified, mainly from the register review. Only 67 maternal deaths were recorded in the hospitals’ routine reports over the same period. This underestimation of maternal deaths was partly due to the incomplete coverage of the routine reporting system; however, even in the wards where routine reports were made, the study identified twice as many deaths. Conclusion: The RAPID method is a practical method that provides a more complete estimate of hospital maternal mortality than routine reporting systems.

Maternal mortality, birth with a health professional and distance to obstetric care in Indonesia and Bangladesh.

To examine the relationship between distance to a health facility, consulting a health professional and maternal mortality.

Impact Evaluation of National Health Insurance toward Access Hospital Inpatient Care in Indonesia

Indonesian government launched officially the National Health Insurance (JKN Program) on January 14, 2014. JKN program constructed with participation is mandatory and there is no selection, the spirit of cross subsidy (rich-poor, healthy-ill, young-old), non-profit and fees calculated as a percentage of wages or income. One of the main objectives of JKN is to improve equity in access to health services. This study aims to evaluate the impact of National Health Insurance program that has been running more than one year over the access to inpatient care at the hospital. This study used Indonesian Family Life Survey IFLS-4 (2007) and IFLS-5 (2014/2015). The analysis used a combination of propensity score matching methods and difference in difference. This analysis enables the research resembles the experiment considering the access changes to the inpatient care on the same individuals were evaluated before and one year after the National Health Insurance starts. The results showed that the National Health Insurance program have impact 2.4% on access to health care of inpatient at the government hospital and or private hospital. The resulting effect of National Health Insurance is not final because the data is just collected in 2014 until mid-2015, about half a year of the commencement of National Health Insurance.

Revealing the Missing Link: Private Sector Supply-Side Readiness for Primary Maternal Health Services in Indonesia

Every hour, the death of a woman from the complications of pregnancy serves as the most vexing reminder of Indonesia’s challenges with maternal health (MH). This is incommensurate with Indonesia’s strong economic development and stature compared with regional peers, especially as MH is a marker of overall health system performance and affects economic opportunities – especially for the poor. The maternal mortality ratio (MMR) is high and progress on improving MH outcomes has been slow, such that the Millennium Development Goal (MDG) for maternal health has already been missed. This policy paper analyzes new data on the ‘missing link’ of primary MH service provision, that is, private providers. This is critical given that more than half of all deliveries in Indonesia occur at private sector providers, which can be empaneled for inclusion under Jaminan Kesehatan Nasional (JKN), Indonesia’s social health insurance scheme. The analysis covers the distribution and characteristics of private primary MH providers, including a measurement of their service readiness, using the World Health Organization’s Service Availability and Readiness Assessment (SARA) framework. Provider ability, using clinical vignettes, was also measured and compared with public MH providers. The policy paper concludes with actionable policy implications for the key health sector stakeholders.