Summary of Maternal Health Findings in Three Districts-Cities

8/13/2019 Summary of Maternal Health Findings in Three Districts-Cities

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Dr Afzal Mahmood


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Dr Afzal Mahmood


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Documents Reviewed

Examples:

Kaltim Provincial Maternal Health Profile

2010 Kukar Department of Health Report

Evaluation Report (Presentation) Program Kesehetan Keluarga, 2009

Kukar Laporan PWS KIA, December 2010

Kutai Kertenegara Health Profile 2009

Kukar Data Maternal Deaths 2009, 2010

Kukar Maternal Death case study from one puskesmas catchment

area

Kukar Infant Mortality Data

Data dasar kesehatan ibu, Paser

Paser Data Maternal Deaths 2009, 2010, Neonatal death case study

from one puskesmas

Paser Maternal and Infant Mortality Data

Paser Presentation and data provided by four puskesmas (Tanah

Grogot, Muara Komam, Paser Belengkongaser, Long Kali)

Kutai Barat ..................................................

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Interviews &

Discussions

Puskesmas & Community based government

Private Midwifes from across the district,

Hospital based midwifes and dotors, Head of Puskesmas, Dinkes, Provincial Department of Health

Puskesmas & Community based government and private

midwifes from across the district

Hospital based midwifes and doctors

Head of Puskesmas

Dinkes, Provincial Department of Health, and Academy of

Midwifery Training Kukar staff

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Visits & Situation Analysis

Urban & Rural puskesmas, review of information and

discussions with staff

Visits to Hospital: maternity care information review,

discussion about links between Dinkes & Hospital

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Maternal Health Context: Kaltim

Provincial and districts Maternal and Child Health Program, under thevision Indonesia Sehat 2010, prioritise maternal and infant mortalityreduction, provision of safe and high quality antenatal, intrapartum andpostnatal care.

Major strategies include actions that each delivery is assisted byappropriately skilled health personnel, the capacity to provide adequate

care for obstetrics and neonatal complications, management ofcomplications of miscarriage, and reduction in unwanted pregnancies.

Indicators to assess the success include the number of antenatal visits,proportion of deliveries by skilled personnel, effective management ofobstetrics complications, contraceptive prevalence rate.

The focus is on the improvement of services at the primary care level,

increasing the number of skilled personnel, placement of midwives in ruraland remote areas, provision of incentives for provision of care to pregnantwomen and mothers, training of traditional birth attendants, working withthe skilled birth attendant in the private sector and with the traditionalbirth attendants, and efforts to improve the referral system.

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Current situation

Success in terms of improved access, high rate of ANC (92% K1 and 80% K4in Kaltim in 2009).

Overall, 80% deliveries conducted by the skilled attendants.

The overall rate of deliveries by dukun in Kaltim has decreased to only8.7% by 2009 (except in Nunukan and Kukar where dukuns still conductabout 18 and 19%).

In Paser and Kubar only 6% and 8% deliveries were conducted by dukunsin 2009.

However, despite these effort the maternal mortality is still high

Need for much improvement in other pregnancy outcomes as well.

Many women suffer from complications during pregnancy and delivery forwhich they often find it difficult to access services.

One major challenge is to provide adequate and high quality care in ruraland remotes areas.

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Strengths

POPULATION

Relatively small population size

Relatively less absolute poverty due to population size,

mining, infrastructure development with opportunities for

jobs and businesses

HEALTH SYSTEM

A network of services which are strategically located for

universal coverage and ease of access

Motivated senior managers and program coordinators at

Dinkes level, with good understanding of local issues

A large number of staff (nurses, bidan, doctors, admin staff)

Young, motivate able workforce

Existing links with a large number of community volunteersDr Afzal Mahmood


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Strengths

POLITICAL DECISION MAKING

Good interaction between district government and district

health departments

Approachable politicians

Provincial government and Provincial Department of Health

keen to support districts for policy and regulation changes, as

well as for technical assistance to improve maternal health

MATERNAL AND CHILD HEALTH

Maternal mortality on the decline

High coverage of ANC, PNC, TT, deliveries by the trained staff

Many women approaching district hospitals for ANC/deliveries

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Current Approach

The current approach to promote mothers and children is

about access to skilled birth attendants for all pregnant

women in the district.

The strategies within this approach include recruitment of

trained midwives,

on the job training for the midwives,

improving puskesmas services for EmOC, and

improving referrals for pregnancy and delivery complications.

Dr Afzal Mahmood


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Findings

Reported deliveries by Trained birth attendants in the three districts

about 80%

K1 78% to 85%, K4 60% to 80%

High KN1 and KN2 rates (60-80%)

There are however issues with the targets provided by the Bureauof Statistics

Nakes reported 20% women as having one or more risks forpregnancy or delivery

Majority of the reported maternal deaths in hospitals (for exampleout of 9 deaths in Paser 7 in hospital, and out of 27 in Kubar 17 inhospitals)

Many deaths among 30-39 years of age Many deaths in those areas that are only two/three hour distance

from hospitals

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Findings

So far no review conducted to explore reasons and circumstancesbeyond the immediate cause (such as haemorrhage, hypertensionetc),

other serious illnesses,

too many pregnancies

too short period between the consecutive pregnancies,

complications during previous pregnancies

how those complications were managed.

Information about other pregnancy outcomes such as intrauterinegrowth retardation, early rupture of membranes is not available.

Similarly, the information on complications, complications duringpostnatal period, interval between pregnancies, contraceptive useby those who have delivered babies in the last year is not available.

Dr Afzal Mahmood


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Findings: Planning and Management Capacity

Insufficient management capacity: for example reporting delays,misallocation of resources (for example availability of 19 bidans at onepuskesmas covering a population of about 6000),

lack of planning to proactively serve those pregnant women who are athigh risk of complications,

lack of attention to factors such as contraception,

inadequate attention to resolve the referral delay issues,

Lack of capacity at puskesmas and dinkes level to plan and improvecondition of facilities/ambulances/labour room/supplies for emergencyobstetrics care.

Inadequate capacity to use local data for local puskesmas based planning.

Need for capacity to review the current situation/trends and plan for theneeded change.

Kepala puskesmas and bidan coordinators require skills for local planning,and effective management of resources (human resources and facilities)for which they are responsible.

Dr Afzal Mahmood


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Findings: Planning and Management Capacity

Focus on achieving the input and process targets (ANC visits,number of postnatal visits, delivery by skilled attendants).

As thefocus is on extending the coverage the focus on quality ofcare of these human resource is less the optimum.

Dinkes, at present, does not have sufficiently trained enough

number of staff who could provide planning and managementsupport to kepala puskesmas or bidan coordinators.

Generally, the quality improvement efforts are limited to training ofthe staff at a hospital or university

The capacity is also limited because of lack of delegation of

authority to Dinkes about resource planning and allocationdecision; for example the decisions about the number of staffneeded, appointments, placement, type and place of training etc.

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Findings: Data quality and use

The review found little evidence of the use of data for

management purposes. At present the data is mainly used for

projecting targets for the next year. For example, the coverage

of various services vary across different regions within thedistrict. However, the data at present is not reviewed to

highlight this and then to work with the concerned puskesmas

teams to improve the performance.

Dr Afzal Mahmood


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Findings Data quality & Use

Issues with the targets supplied by the Bureau: The projected targets received

from the Bureau are not confirmed through home visits, nor do all pregnant

women visit the centres. In fact utilisation of centre-based services by the

pregnant women is very low. The staff also relies on private midwifes to report

data; however, puskesmas midwifes mentioned that not all high risk

pregnancies, deliveries or complications are reported.

K1 and K2 Information is also unreliable For example, at Puskesmas XXXXX the

Bureau target for Bumil was 177 and target for deliveries was 166. The

puskesmas staff however was able to record only 98 deliveries, which they

believed is the correct number. The staff in XXX insisted that their data accounts

for all the deliveries in the area. If the 420 number was correct, and if Bureau of

Statistics projects are incorrect by similar margin across the whole district, then

the actual number of births might be quite low compared to the estimates. Such

as situation poses serious challenge for health services and human resource

planning. At present this is difficult to judge if the puskesmas are unable to

record all deliveries in all areas. Regardless, this situation presents challenge for

local service planning. Dr Afzal Mahmood


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Recommendation: Quality of Care

Continuation of excellent coverage already achieved:

There is a need to improve the quality of the services provided

by the existing staff, and for which resources are required.

Follow up care for those who are identified as having high risk

pregnancies: In one area, for example, almost half of the

pregnant women were diagnosed with one or more risks.

However, the bidans did not refer the patients to doctors and did

not involve the puskesmas doctors for needed treatment.

Support to bidans for better health education and counselling:

Despite a large number of contacts with pregnant women,perception about hospital use and the role of family towards care

for pregnant women are not influenced.

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Quality of intrapartum care

Equipment Needs: It was highlighted by the puskesmas staff that rural puskesmaslack dopplers, oxygen supplies, bidan kits, blood transfusion facilities. Allpuskesmas in rural and remote areas should be ready to provide EmOC and thatthe midwives placed there should be fully trained to provide basic EmOC. Neonatalresuscitation, blood transfusion and eclampsia management training is needed forthe midwives.

Policy and Protocols to Use Bidan Skills: Some Bidans are trained and some ofthem have experiences for providing additional needed services during pregnancyand delivery. Examples of these interventions include blood transfusion,management of haemorrhage, labor induction, manual removal of placenta, andIUCD insertion. However, the current regulation does not allow bidan to use theseskills even when these interventions are needed and where referral is difficult or isrefused by the family

Coordination with Hospital: Dinkes should interact with, and preferably place onecoordinator at the hospital, hospital for data on delivery outcomes, and arrangefor follow up visits for those mothers who have complications during pregnanciesand for babies who are born with low birth weight or other complications/diseasesor congenital problems.

Dr Afzal Mahmood


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Recommendations: Improve Resource

Management

Basic Emergency Obstetrics Care: at puskesmas that are more than 2 hourdrive from the hospital, with both doctor and midwife trained to manage

basic obstetrics complications, with adequate labour room facilities.

Supervision of Puskesmas: Dinkes mid level managers should visit

puskesmas regularly and work with the Kepala Puskesmas and Bidans to

provide support for planning

Support & supervise midwives for a focus on prevention of diseases (e.g.

malaria, worm infestation), health education, planned pregnancies with

appropriate duration, identification of risk and referral of neonates.

The responsibility focus should be on pregnancy outcomes rather than only

on ANC visits and delivery by skilled attendant

Dr Afzal Mahmood

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Recommendation:

Planning and Management Capacity

Strengthen Service Planning Capacity at Puskesmas level.

Management training , ongoing support and review (by

Dinkes) for kepala puskesmas and bidan coordinators on how to

utilise local information for targeting management of high risk

pregnancies, follow up and home visits

Dinkes train existing staff and appoint additional skilled staff

to strengthen its management capacity

Consider incentives for skilled senior midwives for placements

and continuation of service in rural & remote areas.

Dr Afzal Mahmood


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Recommendation:

Coordination with the local hospitals

Develop SOP and agreements between Dinkes and hospital

about exchange of referral and follow up information

between the hospital and pusban/puskesmas/polindes

Utilise the local hospital for placement/training of dinkes

bidan and doctors

Dr Afzal Mahmood


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Recommendation:

data for local planning

Need to improve dinkes and puskesmas managementcapacity to review, analyse data and use it for planning

Validate the information by conducting census incatchment areas of some of the puskesmas and thenidentify if the Dinkes information is incorrect or if theBureau of Statistics estimates need to be changed.

Interact with the Bureau of Statistics to discuss thesituation

Dr Afzal Mahmood


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Recommendation: Quality of ANC

Plan regular home visits particularly for those at high risk, and plan for

regular support visits by bidan coordinators. Train Kepala puskesmas for

such management skills

Develop and monitor the implementation of specific protocols on how to

manage high risk pregnancies. Involve Kepala puskesmas and doctors at

the puskesmas

Assign responsibility and train puskesmas doctors to work with

bidans/perawat For example, puskesmas doctors should be involved in the

care of those women who have HTN or past history of eclampsia,

eclampsia or other complications in the past.

Improve quality of communication and health education. Home visits will

contribute to this process if home visit are planned carefully.

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Ref System

Dinkes should make sure that the ambulances are functional(equipment, staff, driver, petrol) and available 24 hours a day

and are available at no more than two hour distance for a

comprehensive EmOC centre

Where needed, Puskesmas should be provided with anappropriate vehicle for staff movement.

Communities, Posyandu volunteers, Pustus, Polinkams staff

should have access to the phone number of nearby functional

ambulance.

Dinkes staff should visit the puskesmas when a death is

reported, review the information regarding ref & delays and

plan to avoid future occurrence of such reasons.

Dr Afzal Mahmood


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Recommendation:

Quality of Intrapartum Care

Puskesmas: Plan and implement a system of following up

(phone, and home visits) high risk women during the last

week of pregnancy

Doctors at puskesmas that have Basic/Comprehensive EmOC

should be trained to provide clinical care to those who suffer

from delivery complications.

Dinkes to review the condition at Puskesmas on a regular

basis (availability of equipment, maintenance of equipment

and ambulances, building).

Regularly collect and review information on pregnancy

outcomes

Dr Afzal Mahmood


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Recommendation: Dukuns

Puskesmas should identify the families that still use dukun,

and analyse the reasons for such reliance on dukuns

Dinkes should compare the complication rate and poor

pregnancy outcomes for those cared by the midwives and

those cared by dukuns

Dr Afzal Mahmood

Summary of Maternal Health Findings in Three Districts-Cities

Documents

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