BACKGROUND

HIGHLIGHTS

A number of puskesmas have had significant increases in births.

Puskesmas are capable of successfully managing high volumes of deliveries and stabilizing and referring patients when appropriate.

Increased delivery loads can be sustained over time.

Despite increases in workloads, puskesmas staff can be motivated to perform at high levels.

In Indonesia community health centers, called puskesmas, are designed to provide a variety of primary care services. Since 2000, the Ministry of Health (MOH) has invested in identifying and developing BEmONC (Basic essential obstetrical and newborn care) Puskesmas in each district that would be capable of stabilizing, managing and/or referring maternal and newborn complications/emergencies. However, despite these efforts, the puskesmas is often only minimally able to fulfill this role and is often by-passed by families who prefer to go directly to the hospital for delivery.

Since September 2012, the USAID-funded Expanding Maternal and Neonatal Survival (EMAS) program [1] has worked in partnership with the Government of Indonesia to improve the quality of maternal and neonatal health services in 150 hospitals and 300 puskesmas across six provinces in Indonesia.

EMAS focuses on two overarching objectives: ensuring high-quality emergency obstetric and newborn care within hospitals and puskesmas; and improving the efficiency and effectiveness of the referral process among facilities, particularly during obstetric and newborn emergencies. EMAS has introduced a number of quality improvement interventions to improve the prevention, timely identification, and treatment of the primary causes of maternal and newborn death. Facility-based interventions focus on increasing clinical effectiveness by using performance standards for care, generating and regularly using data and audit findings for decision making, and increasing accountability, communication and leadership within facilities. Interventions outside of health facilities focus on improving communication and collaboration across all levels of the health system as well as on building accountability for the provision of quality services. Between October 2012 and March 2014, several EMAS-supported puskesmas were noted to have significant increases in deliveries. EMAS conducted a qualitative review in mid-2014 to understand the reasons behind the large increases in deliveries at particular facilities.

CASE STUDY

INCREASED DELIVERIES AND CONFIDENCE AT PUSKESMASExploring the reasons behind and impact of increased deliveries at

four puskesmas

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OBJECTIVES

This review was designed to explore:the perceived factors leading to the observed increased number of births between October 2012–March 2014;

the impact of this increase on the facilities and staff; and

the management of maternal and newborn complications at selected puskesmas.

METHODS

A subset of four puskesmas with increased deliveries were selected for the case study: Ciparay Puskesmas and Pacet Puskesmas in Bandung District, West Java [2]; Jatilawang Puskesmas in Banyumas District, Central Java; and Lampa Puskesmas in Pinrang District, South Sulawesi. The following steps were completed for all four puskesmas:

Field observations conducted in February 2014 (two puskesmas) and June 2014 (two puskesmas).

Interviews conducted with puskesmas staff: including the Head of Puskesmas (four puskesmas), midwife coordinators (four puskesmas), midwives (three puskesmas) and BEmONC coordinators (two puskesmas) in February and June 2014.

Review of EMAS-collected facility data pertaining to puskesmas service statistics, referral cases and reported maternal and neonatal complications.

RESULTS

Delivery numbers increased significantly between October 2012 and March 2014 at all four puskesmas. While numbers fluctuated by quarter, a clear trend is evident with percentage increases ranging from 150 to 1460 percent in this period (see Figure 1). Importantly, the higher delivery numbers have been sustained at the puskesmas, and increased even further at Pacet and Ciparay. These two puskesmas have experienced impressive increases of 1770 and 1260 percent respectively in a period of two years.

Figure 1: Number of deliveries at selected EMAS-supported puskesmas, 2012–2014

0

30

60

90

120

150

14

5240

53

26

4538

50

7

88

100

124

10

86

146126

Nu

mb

er o

f d

eliv

erie

s

Case study review period

Oct - Dec 2012

Oct - Dec 2013

Jan - Mar 2014

Most recent data

Oct - Dec 2014

Increases sustained at all 4 puskesmas over 2 years

378%increase

192%increase

1771%increase

1260%increase

Puskesmas

Jatilawang Lampa Pacet Ciparay

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Interviews with staff revealed a set of themes common across the four puskesmas. Perceived reasons for the increase in deliveries in these puskesmas include factors which staff relate to EMAS interventions as well as external factors. External factors include both social health insurance schemes as well as a community-based newborn health pro-gram (discussed below). Those perceived to be related to EMAS interventions include:

increased confidence and skills in handling emergency cases and complications;

staff motivation;

service improvements; and

promotion and awareness raising around the importance of delivering in health facilities.

FACTORS PERCEIVED TO BE RELATED TO EMAS INTERVENTIONS THAT AFFECTED INCREASED DELIVERIES

Increased skills and confidence in handling emergency cases and complications

Lack of confidence in managing maternal and newborn complications at the puskesmas level has been observed as a key factor in low delivery caseloads at puskesmas for some time. Consistent with this, during interviews at all four puskesmas, midwives revealed that their confidence had increased with support from EMAS, which in turn led to an increase in the number of births at their facilities. Staff reported that prior to EMAS involvement, puskesmas midwives did not have enough confidence to perform deliveries and would instead refer patients to hospitals. Following EMAS support, puskesmas staff reported increased skills and confidence in handling emergency obstetric and newborn cases and complica-tions. Staff at one puskesmas stated they now enjoy handling cases with complications, such as severe pre-eclampsia (PE), whereas previously they had feared them.

Before, we were asleep and not motivated to change.

-BEmONC Coordinator, Ciparay Puskesmas

Puskesmas staff mentioned the following activities, supported by EMAS and/or the District Health Office (DHO) specifically when discussing the skill acquisition of midwives:

emergency simulations and quarterly drills by specialist ob-gyn and anesthetist;

support and mentoring from EMAS-supported clinical mentoring teams,

mentoring from referral hospital specialists, via visits, SMS, phone and midwife clinical rotations in referral hospitals;

near miss reviews, skill assessments; and

routine supervision and monitoring by the DHO.

In the past, when we saw a patient come, we had already been scared and it was getting worse if a complication occurred. We right away ad-vised the patient to be referred to a hospital even before they walked through the gate of the health center.-Midwife, Ciparay Puskesmas

Staff motivation

Overall, improved staff motivation was seen as a factor related to midwives accepting more deliveries at the puskesmas (instead of turning away/referring women in labor). Puskesmas staff attributed higher motivation to a variety of EMAS interventions. Staff from two puskesmas reported that EMAS gave them the “push” to change, with one describing an initial meeting with EMAS as a turning point. Staff at one puskesmas reported EMAS scores and clinical standard performance assessments encouraged them to improve. Staff from two puskesmas reported pronounced changes in staff behavior—from poor motivation to a desire to improve.

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Other motivators included increased responsibility for recording patient data and the puskesmas preparing to become a mentor for other puskesmas, as part of the EMAS expansion approach. Finally, strong leadership was also noted as an important factor, with staff reporting that the Head of the Puskesmas played an important role in motivating staff through increased opportunities, trust, encouragement and rewards.

Service improvements

Puskesmas staff also reported that various service improvements supported by EMAS and the DHO had contributed to higher quality service and therefore increased delivery caseloads. One puskesmas extended its opening hours in early 2013 – from 8am-3pm to a 24-hour service. Another puskesmas reported that the delivery room had been expanded and made into a nicer place for deliveries. Other service improvements mentioned included:

implementation of standard operating procedures;

client feedback mechanisms, including feedback boxes and a call center;

more hygienic appearance and practices of the puskesmas;

improved organization, management and governance; and

improved teamwork.

Promotion and raising awareness of puskesmas

A variety of maternal and newborn health (MNH) community health promotion activities, linked with EMAS quality improvement, governance and accountability initiatives, were believed to have contributed to increases in caseloads. Staff at all four puskesmas reported that promoting and raising awareness of the importance of giving birth at health facilities had contributed to the increase in deliveries. Staff at three puskesmas reported promoting the services available for birthing at their specific facility. Two facilities had intensively worked to raise awareness that their services had improved and that their puskesmas were being run according to standards with good, clean facilities, prepared staff and all necessary tools.

Puskesmas staff indicated that word-of-mouth had contributed to the increase in deliveries at their facilities. They believed that women had previously been delivering with traditional birth attendants, (TBAs) private or village midwives, and reported that patients from outside their district now travelled to their puskesmas to deliver. Staff also reported promoting their services to, and with, private and village midwives - one puskesmas even involved village midwives in their emergency drills.

A number of mechanisms/activities were used for raising awareness, including Posyandu, antenatal classes, mosques and religious activities, village meetings and EMAS-supported Civic Forums. Staff at two facilities mentioned that Mother and Child Health Motivators (MKIAs) provided a link between the puskesmas and religious activities, and led to increased cooperation between the DHO, clinic and village midwives.

EXTERNAL FACTORS PERCEIVED TO AFFECT INCREASED DELIVERIES

Two primary external factors were perceived to have an impact on puskesmas delivery caseloads: government health insurance schemes and a local community-based health program.Staff from all four puskesmas felt that government social health insurance [3] had played a role in increasing the number of deliveries at puskesmas, particularly Jampersal [4]. Jampersal has been in effect since January 2011 and was widely pro-moted by EMAS in these districts to increase service utilization. Staff at one puskesmas noted that facility-based deliver-ies are covered under universal health insurance (JKN), but births with village and private midwives are not, and thought this may impact facility delivery numbers. However, one puskesmas noted that not

all obstetric complications are cov-ered by JKN, and mentioned challenges related to registration. It is important to note that JKN did not go into effect until January 2014. Since substantial increases were seen in all four puskesmas prior to the rollout of JKN, it is unlikely that this has significantly impacted delivery caseloads.

The two puskesmas with the largest increases in caseloads (Ciparay Puskesmas and Pacet Puskesmas) are both in Bandung District. These puskesmas believed that a community-level program named ‘SELARAS’ - a health, hygiene and hand washing initiative for newborn survival implemented by Save the Children in these sub-districts - contributed to increases in community awareness and utilization of puskesmas services [5].

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STAFF FEELINGS ABOUT INCREASING DELIVERIES

Staff reported minimal changes to infrastructure, human resources [6] and equipment [7] over the time period reviewed. Despite this, staff at all four puskesmas reported that the increased volume was manageable with the existing facilities and infrastructure. This may be due in part to changes in puskesmas management. For example, staff reported improved staff scheduling, dividing staff into functional teams, and improved protocols for checking emergency equipment and medications. Another facility reported that the district Pokja [8] was useful for liaising with the DHO regarding additional equipment.

Staff at all four puskesmas reported feeling positive about the large increase in deliveries, with staff at one facility hoping for a further increase. Positives associated with the larger number of cases included increased learning opportunities, and financial benefits for the puskesmas. Staff from three puskesmas reported financial benefits for the midwives them-selves due to DHO regulations [9]. However, staff from one puskesmas were less positive, and felt that their resources were not enough to meet needs if complications arose. Staff from another facility thought further increases would re-quire additional staff or space.

Overall, puskesmas staff felt happy that their facility was considered a good model for others, and pleased that community confidence and trust increased. Those interviewed in three puskesmas reported increased deliveries did not make them feel tired or overwhelmed, with staff at one puskesmas stating that although they have more patients, things are more controlled and that the system for recording and reporting has improved.

Feelings at one puskesmas were less positive, however, saying they felt ‘fine’ about the increase in deliveries, but noting too many policies that had no perceived benefit for them. Some reported feeling tired/unhappy/overwhelmed when complications occurred because they felt they didn’t have enough resources (midwives and equipment). Staff at two puskesmas also reported that the increase in deliveries disrupted other midwife services (such as antenatal services or family planning), and that additional cleaning services were needed to free midwives from this task.

IMPACT ON SERVICE STANDARDS, COMPLICATIONS, AND REFERRALS

Despite some feelings of stress related to managing increased complication noted in one puskesmas, none of the pusk-esmas reported any maternal deaths during the time period analyzed and only six newborn deaths occurred among the 1273 deliveries during this time period.

Maternal and neonatal complications and referrals for the four puskesmas were reviewed for the six month period of October 2013-March 2014. Overall, the main maternal complications recorded were membrane rupture (58 cases), moderate-severe PE (58 cases) and PPH (15 cases) [10]. Maternal case referrals remained low at puskesmas with lower numbers of deliveries, and fluctuated at the two puskesmas with higher deliveries. This indicates that the puskesmas overall were able to treat, or stabilize and refer without significant adverse outcomes. Ninety cases of maternal complica-tions were referred during this six-month period (see Figure 2). The maternal complications with the highest referral rates included obstructed labor (86%, or 6 out of 7 cases referred), moderate-severe PE (60%, or 35 out of 58 cases referred), membrane rupture (45%, or 26 out of 58 cases referred) and PPH (35%, or 5 out of 14 cases referred).

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There were relatively few neonatal complications in the period reviewed, with low birth weight (LBW, 27 cases) and as-phyxia (21 cases) the most common. Only a few neonatal cases were referred by three of the puskesmas, and the number of neonatal cases referred by the other puskesmas dropped considerably over the time period reviewed. There were no obvious trends in the percentage of referrals over time across any puskesmas.

Figure 2: Maternal complications reported at four puskesmas, by type (October 2013 - March 2014) (n = 186)

17.8%

5.9%7.5%

0.5%

16.1%

15%

2.2%3.8%

31.2%

Antepartum hemorrhage (n=11)

Postpartum hemorrhage (n=14)

Infection/sepsis (n=1)

Moderate PE/E (n=30)

Severe PE/E (n=28)

Eclampsia (n=4)

Obstructed labor (n=7)

Membrane rupture (KPD) (n=58)

Other maternal complications (n=33)

Figure 3: Newborn complications reported at four puskesmas, by type (October 2013 - March 2014) (n = 50)

54%

4%

42%Asphyxia (n=21)

Low birth weight (<2500 grams) (n=27)

Other newborn complications (n=2)

Coverage of key indicators

EMAS routinely collects specific intervention statistics for facilities involved in the program. Two of these, PE/E cases treated with magnesium sulphate (MgSO4), and immediate breastfeeding following delivery, were reviewed for the four puskesmas for January 2013–March 2014. Coverage of these interventions remained high or increased over the time period.

The percentage of PE/E cases treated with MgSO4 increased or remained high across four puskesmas (see Figure 4). The proportion of newborns breastfed within one hour of delivery increased from 70–100% to 87–100% (see Figure 5).

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Figure 4: Percentage of PE/E cases treated with MgSO4 prior to referral (January 2013 - March 2014)*

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Jatilawang(n=32)

Lampa(n=5)

Pacet(n=66)

Ciparay(n=68)

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50

Case study review period

Jan - Mar 2013

April - June 2013

July - Sept 2013

Oct - Dec 2013

Jan - Mar 2014

Most recent data

Oct - Dec 2014

Figure 5: Percentage of newborns breastfed within 1 hour of delivery (January 2013 - March 2014)

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60

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Jatilawang(n=382)

Lampa(n=304)

Pacet(n=676)

Ciparay(n=741)

Case study review period

Oct - Dec 2012

Jan - Mar 2013

April - June 2013

July - Sept 2013

Oct - Dec 2013

Jan - Mar 2014

Most recent data

Oct - Dec 2014

100 100 100 100 100 100

88

74

9795

87

77 75

94

7670

9298

*Data not available for Oct - Dec 2012 period.

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KEY FINDINGS

No single reason was found to contribute to increased deliveries at EMAS-supported puskesmas during the time period reviewed. A combination of factors related to EMAS interventions as well as external factors (government health insurance and SELARAS) were reported to contribute to increased caseloads observed in the puskesmas.

The increase in births was not associated with an increase in adverse outcomes. While the numbers of births sub-stantially increased at the puskesmas, there were no maternal deaths and only six neonatal deaths. Quality of care improved while the number of deliveries increased significantly at the four EMAS-supported puskesmas. Coverage of specific interventions either increased or stayed at high levels.

Interventions supported by EMAS were found to have increased staff confidence and skills in handling emergency cases and complications. Staff reported that EMAS support contributed to increases in the numbers of deliveries at the puskesmas (due to reduced referrals) and enabled them to successfully manage the increase in deliveries.

Staff motivation has also increased, related to factors such as EMAS interventions and increased leadership from head of puskesmas and/or DHO. The majority of staff felt positive about the increases in deliveries at their facility.

Word-of-mouth regarding women’s delivery experience and puskesmas competence can affect puskesmas utiliza-tion. Staff believed that promoting the importance of facility deliveries and recent service improvements to the community had also contributed to increased caseloads, and that MKIAs were useful for facilitating awareness raising.

LESSONS LEARNED

Overall, this review highlights that the puskesmas reviewed as part of this case study are capable of serving their intended role as the first level of care for basic obstetric and newborn care and management of complications, there-by freeing hospital resources to manage more complicated cases. A number of findings from this review may help district and provincial health officials to further support improvements in the quality of care and increasing numbers of births at puskesmas.

Puskesmas should continue to be supported with a set of interventions (such as those introduced by EMAS), with a focus on staff skills and confidence-building.

Ensuring BEmONC puskesmas are supported and capable of providing first level care for obstetric and newborn complications, including stabilization prior to referral, will become increasingly important as the national insurance scheme, JKN, is increasingly utilized. Civic Forums, MKIAs, and other community-based volunteers should continue to work with communities to promote and assist pregnant women to access JKN.

If staff are supported and motivated, and facilities are well-managed, it is possible to achieve increases in deliveries at the first level of care without large injections of resources (such as infrastructure, HR). However increases need to be monitored and resourced (additional equipment/supplies, staffing, cleaning services) to avoid increased deliveries impacting on staff motivation or other puskesmas services.

Examples of high-performing puskesmas could be shared with staff at other facilities through mentoring visits to rec-ognize their performance and explore how other facilities are responding to similar issues.

Improvements in puskesmas services (delivery numbers, performance standards etc) should be shared with the com-munity, through mechanisms such as Civic Forums, MKIAs, village midwives, media etc, to promote (further) increas-es in utilization. Advocacy and awareness raising activities by puskesmas should be continued and promoted to other puskesmas.

District working groups and the DHO should continue to monitor puskesmas with significant increases in monthly deliveries to see if the quality of care (according the standards and specific interventions) is maintained and/or increases. Also, explore the perceived factors for the increase in other puskesmas to see if there are commonalities that can help inform implementation of EMAS approaches.

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NOTES

1. EMAS is a five-year (2011–2016) USAID program to support the Government of Indonesia to reduce maternal and newborn mortality. EMAS works with the Indonesian government (national, provincial and district), civil society organizations, health facilities (public and private), hospital associations, professional organizations, and the private sector. EMAS is a partnership of five organizations - Jhpiego (lead partner), Lembaga Kesehatan Budi Kemuliaan (LKBK), Muhammadiyah, Save the Children, and RTI International.

2. Selected as they had the largest increases in deliveries.

3. The government of Indonesia has implemented a number of social insurance plans in recent years, including Jampersal, universal health insur-ance (JKN), Jamkesmas, SKTM and other regional health care benefits such as Jakesda and Banyumas Health Cards (KBS).

4. In January 2011, universal maternity insurance (referred to as Jampersal) was launched, offering all uninsured pregnant women free services dur-ing pregnancy, childbirth and the postpartum period. In January 2014, universal health insurance (Jaminan Kesehatan Nasional or JKN]) was launched, replacing Jampersal and extending health coverage to all uninsured. JKN mandates specific referral patterns, routing patients through puskesmas in most cases.

5. Sederhana Berdampak Luar Biasa (SELARAS) aims to reduce newborn mortality in four sub districts of Bandung, including Ciparay and Pacet. The five year project (2012-17) works to: improve hygiene and hand washing among health facility staff, village midwives and TBAs to prevent infec-tion during delivery and postnatal care; improve knowledge and practices of household caregivers in newborn health; and improve the policy and resource allocation environment. SELARAS was intentionally implemented in the same areas of Bandung District as EMAS.

6. Two facilities reported they had begun receiving midwifery placements from local training institutions.

7. All four puskesmas reported receiving some equipment from EMAS (such as resuscitation kids, phantom limbs, NeoNathalie, and/or emergency trolley). Three puskesmas reported receiving equipment (such as incubator, partus equipment), as well as (four) new beds and increasing the size of the delivery room in 2013 through the DHO. One puskesmas reported utilizing old beds from elsewhere in the facility to help cope with in-creased deliveries.

8. Pokjas are working groups comprised of key individuals that help resolve key barriers affecting maternal and newborn survival. These can include issues beyond direct control of facilities or DHO such as budget allocations.

9. E.g. midwives receive a cash incentive through Jamkesmas/Jampersal

10. The two puskesmas with higher deliveries reported larger numbers of maternal complications.