Women’s accounts of giving birth in community health centers and local hospitals in three districts in Indonesia revealed a series of problems with the care and service they received. The women’s stories, told to a team of visiting health professionals, detailed improper assessments, lack of monitoring, questionable management of labor and birth, difficult emergency transport, poor attitudes among providers and numerous out-of-pocket expenses.
The interviews with 45 women offer a unique perspective on conditions that may discourage pregnant women from choosing to give birth in a health facility with skilled attendants, a key contributor to reducing the deaths of mothers and newborns. These first-person accounts provide an opportunity for Indonesian health care providers—with the support of the U.S. Agency for International Development’s Maternal and Child Health Integrated Program (MCHIP)—to strengthen hospital referral servics through a Jhpiego-pioneered quality assurance program that has been successfully implemented in Indonesia and 30 other countries with demonstrable results.
For more than 25 years, Jhpiego has worked collaboratively with the Indonesian government and other partners to help improve health care access and delivery in this nation of islands. This work has included building capacity among midwives, developing a model program for cervical cancer screening and prevention, and preparing health workers in prevention and treatment of avian influenza.
In two recent Jhpiego-supported programs, efforts to improve quality of care at health centers and clinics attended by midwives delivered substantive results. Health providers increased their competency in nine areas, ranging from antenatal care to infection prevention, and women received a higher quality of maternal and newborn services.
For example, when Jhpiego received support from British Petroleum and Rio Tinto in 2007 to improve maternal and newborn health care services in the district of Kutai Timur (pop. 250,000), many small, local health facilities were below standard, village midwives lacked basic emergency and newborn care skills, and poor infrastructure impeded women’s efforts to reach health centers to give birth.
Jhpiego’s pioneering Standards-Based Management and Recognition (SBM-R) approach helped administrators and staff at two community health centers identify problems and gaps in service, propose solutions and assess outcomes. The SBM-R approach gives health providers the means to develop and implement their own self-improvement program. It builds capacity by both motivating and rewarding employees who participate and encourages a sense of ownership in maintaining compliance with performance standards.
In Kutai Timur, to address gaps in knowledge and skills, an on-the-job mentoring program was devised for village and hospital midwives in basic and emergency obstetric care, infection prevention, and family planning counseling and services. Subsequent assessments showed steady improvement in antenatal care, labor and birth, newborn care, postpartum care, family planning, child immunization and infection prevention over the two years of the program, improving from an average of 69.4 percent to 87.9 percent in normal delivery care and from an average of 76 percent to 91 percent in infection prevention. Through the SBM-R approach, the midwives working in health clinics improved their level of care, meeting 90 percent of evidence-based standards, up from 50 percent.
MCHIP, which is led by Jhpiego, is presently working with six hospitals and 17 community health centers in the districts of Kutai Timur, Bireuen and Serang. SBM-R has been introduced in these facilities to identify problem areas and improve care and services. In just six months, the facilities have shown improvement, with some increasing their performance from 22 percent to 61 percent of the standards achieved.
A report from a midwife working in a small village health clinic in Teluk Pandan illustrates the impact of the program in helping to save lives. In May of 2010, the staff had their first complicated delivery since participating in the Jhpiego-supported training. A woman with prolonged labor had a breech birth and the umbilical cord was wrapped around the baby’s neck.
“We managed to deliver the baby, but it did not breathe,” wrote one midwife. “BEONC (basic emergency obstetric and newborn care) team consisted of me and two new midwives. After two minutes of using a resuscitation bag and mask, the baby finally breathes… . If there was no knowledge update from Jhpiego we might have failed to keep the baby alive.”