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PROGRAM OF SAVING LIVES AT BIRTH IN INDONESIA

Salut Muhidin (Macquarie University, Australia)

Jerico F. Pardosi (University of New South Wales, Australia)

Rachmalina Prasodjo (Ministry of Health, Indonesia)

Abstract. Indonesia is one of the developing countries in Asia where maternal and child mortality

rates are still high. Accordingly, strong commitments have been actively addressed in this county

in order to reduce the mortality rates. This paper will focus on the health program for saving lives

at birth in the province of Nusa Tenggara Timur (NTT) in Indonesia. The program is so-called

“Revolusi Kesehatan Ibu dan Anak (Revolusi KIA)” or literally means Mother and Child Health

(MCH) Revolution program. It has two main objectives: first, to ensure and facilitate mothers to

have health facility-based births; and second, to improve the quality of health care services through

improvement and strengthening of health facilities. Since the program was implemented in 2009,

there have been some improvements in MCH indicators. However, the program has achieved

variable results in this province. The paper will outline results and findings from a recent study

supported by USAID that aims to understand barriers and enablers to the implementation of the

health program in NTT province.

INTRODUCTION

In the context of developing countries, health facility-based birth has been considered as one of

the most important strategies in reducing maternal and child mortality.1, 2, 3 Nevertheless, several

studies have shown that many women in both low- and middle-income countries still have

difficulties accessing health facility deliveries.1,4,5,6,7 Geographic barriers, cost of services, poor

quality of care, unavailability of health personnel, and lack of reliable transport are some of the

major obstacles that dissuade rural women from delivering at a health facility.8,9,10,11 Home births

are associated with higher rates of maternal and neonatal mortality, especially in rural areas.12,13

The Intervention of Revolusi KIA in Nusa Tenggara Timur (NTT) Province

The NTT province in Indonesia has faced high rates of maternal and child mortality for several

decades. The province, which accounts for approximately 2% of the Indonesian population, is

predominantly rural and consists of 22 districts spread across 566 islands, many of which are

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mountainous, and presents additional challenges of ethnic and linguistic diversity.

Access to health services among disadvantaged and remote communities in NTT province remains

a challenge. Based on the 2012 Indonesia DHS Report, the NTT maternal mortality ratio (MMR)

was 307 deaths per 100,000 live births, compared to overall Indonesian value of 239 per 100,000.

A high proportion of births occurred at home, with lack of adequate health care facilities at the

village level generally considered the main reason.

To address the high MMR and IMR in NTT, the Indonesian government adopted and implemented

a community-based health program in 2009 called Revolusi KIA (Kesehatan Ibu dan Anak,

Provincial Act. No. 42/2009) which translates to Mother and Child Health (MCH) Revolution. The

goal of this program was to enable all mothers to give birth at a health facility meeting certain

standards of adequacy, where deliveries are generally safer and where emergency support is

available. In the program, health facilities are considered adequate if they provide a sufficient

number of capable health staff, standardized health equipment, medicine/health supplies, building

or physical infrastructure, standard operational procedures (SOP) and financial sufficiency. These

included sub-district health centers (i.e. Puskesmas), district health centers or hospitals, and local

women’s clinics (small maternity centers) known as Rumah Bersalin, which are located at the sub-

district or district levels. The program was implemented in urban and rural regions of the NTT

province.

Based on the Revolusi KIA Guidelines,15 the program emphasizes an equitable distribution of

MNCH services. Regardless of the socioeconomic status of family, each mother in NTT province

should have the same opportunity to have a facility delivery. Women from poor families will be

supported by specific health insurance schemes, either national or local. The national health

insurance for pregnant women (Jampersal) covers the costs for regular antenatal care (ANC),

delivery, and postnatal care.

Since Revolusi KIA was introduced, there facility-based deliveries have increased. Figure 1 shows

that the percentage of women delivering in a health facility in NTT nearly doubled between 2008

and 2014.

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Despite its comprehensive approach, the district-level data demonstrate that Revolusi KIA program

has achieved variable success in promoting health facility-based delivery. We therefore undertook

a study to evaluate the implementation of Revolusi KIA program and to determine barriers and

enablers that impacted equitable access to health facility-based delivery.

METHODS

IDHS quantitative data and analysis. The quantitative analysis examined coverage and socio-

demographic and medical factors associated with facility delivery for the entire province for

women who delivered between 2008 and 2012. It was conducted using the birth history data for

NTT derived from the 2012 Indonesian Demographic and Health Survey (IDHS). For each birth,

the age of the mother and her parity at the time of delivery as well as number of ANC visits and

the place of delivery are recorded. Other socioeconomic characteristics that may change over time

such as economic status and insurance ownership, however, were only recorded as self-reported at

the date of interview. IDHS national wealth quintiles were used to assess each household’s wealth

status. Because the implementation of Revolusi KIA began in 2009, the analysis was conducted

separately for 2008-2009, which was prior to and during implementation and the births that

occurred in the three years after implementation (i.e. 2010-2012) as well as for the entire period.

Case Study. A more detailed case study was performed in two villages of the Manggarai Barat

District, one of which (Daleng Village) is located close to the Puskesmas, allowing easy access to

services, and a second village (Golo Ndeweng Village) that is farther away, requiring one hour

travel time by car on road surfaces that are mostly unpaved. The District was purposively selected

because it has health facilities of acceptable quality, is relatively accessible, serves a poor

population, and has a moderate rate of facility delivery (i.e. in 2013 and 2014, the rates were 63%

and 71%, respectively). The study consisted of a review of 100 randomly selected “Kartu Ibu,” an

antenatal card completed by health staff at the Puskesmas among the 312 women who had done

at least one ANC visit in 2013-2014 and a series of interviews that were conducted in July 2014

with 39 participants from two different villages.

Information abstracted from the “Kartu Ibu” included place of delivery, insurance status, antenatal

care history, plan and preference of delivery place, and basic demographic profiles of mother and

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her partner (i.e. age, education, employment). This information was used to assess place of delivery

and predictors of facility delivery for women in the two villages.

The participants interviewed were purposively selected and included staff from the District Health

Office (DHO) and the puskesmas who were involved in the implementation of Revolusi KIA in the

community health centre (Puskemas) of Wae Nakeng. From each selected village, the participants

consisted of a village midwife, a village leader, a traditional birth attendant (TBA), three women

who gave birth in the health facility and an individual who influenced their decision-making (e.g.

husband/mother/mother in law), and three women who gave birth at home and an individual who

influenced their decision-making.

The interviews were recorded and transcribed. The data were then coded and categorized using a

qualitative data management software, and analyzed based on thematic analysis. Three main

categories were identified: 1) decision about place of birth; 2) birth experience; and 3)

recommendations about health facility program.

RESULTS

General Characteristics. Table 1 presents the socio-demographic characteristics for the 498

births that occurred between 2008-2012 from the 404 NTT women who were included in the

2012 IDHS, stratified by year of delivery: 2008-2009 before and during implementation of

Revolusi KIA (n=241), and 2010-2012 after its implementation (n=257). Median maternal age was

29 years, and mothers were generally illiterate or had attended only primary school, were in the

poorest quintile using the national wealth standards, had insurance at the time of survey, lived in

rural areas, and had ≥5 ANC visits. Approximately half had experienced ≥3 births. No significant

differences were observed between the two periods.

Between 2008 and 2012, 43% of women delivered in health facilities (Table 1). Women who were

30-39 years of age, who were more educated, from higher wealth quintiles, had health insurance,

lived in urban areas, had a first birth, and had more antenatal (ANC) were more likely to have a

facility delivery. With both educational attainment and with wealth quintile, there was a striking

gradient, with more educated and wealthier women more likely to have a facility birth.

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The likelihood of facility delivery increased from 34% in the pre-Revolusi KIA 2008-2009 period,

to 51% in the 2010-2012 post-implementation period. The greatest absolute changes in facility

delivery rates occurred among women 15-24 years and 40-49 years, those with higher levels of

education, and those the two poorest wealth categories. Among the poorest women, facility

deliveries increased from 23% to 40%, and in the second-poorest from 46% to 71%. Urban women

had a greater increase than those in rural areas, from 52% to 77%. With respect to parity, the

greatest gains were seen in those with one birth and those with three or more. With regards to

ANC visits, the percentage of facility births increased the most in those with a greater number of

ANC visits.

Barriers and Enablers to Health Facility Births. The case study conducted in Manggarai Barat

district revealed at least six factors regarding the barriers and enablers to health facility births, as

detailed below.

Accessibility of Health Facilities. A review of the sample of ANC cards demonstrated that 85%

of the 55 women in Daleng (near village) who delivered in 2013-14 did so in a facility, compared

with 69% of the 45 women in in Gogo Ndewang (far village).

Interviews with the local village leaders, midwives, TBA, mothers and their families confirmed

the importance of distance in facility deliveries. Distance and lack of transportation to the health

facility were mentioned by several respondents at both sites as the primary reasons for delivering

at home. In addition to actual distance, which may be as far as 30 to 45 km to the puskesmas even

in Daleng, access was also limited by difficult terrain and lack of mobile phones and phone signals

to contact the facility or arrange transport. Some participants mentioned delivering at a ‘pustu’ or

health post at the village level that functioned as maternity waiting homes or delivery places due

to close proximity to the village.

Cost. Cost was an influential factor that was mentioned frequently in both close and far villages.

Residents in both were mostly poor and lived in simple housing, many with dirt floors and without

sufficient sanitation or running water.

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Data from the mothers’ cards (Kartu Ibu) demonstrated that among mothers who had received

services from the Puskesmas of Wae Nakeng in 2014, most of those who delivered in facilities had

some form of health insurance (including 62% who had national insurance and 19% who had pro-

poor supports). Only 11% had no insurance. By contrast, among the women who delivered at

home, 27% had national insurance, 27% had pro-poor supports, and 33% had no insurance.

Information from the interviews demonstrated that insurance alone was not adequate to guarantee

that women would deliver in facilities and that lack of money to pay for transport plays an

important role. A respondent who lived in Daleng reported that he had to pay Rp50,000 (around

US$5, equivalent of one fifth to one fourth the monthly income of local farmers) to hire a car to

bring his wife to the health facility. Costs were even higher for those who live in Golo Ndeweng.

In some cases, midwives paid for the transportation cost with their own money to bring mothers

to the health facility.

Social cost or opportunity cost were also considered influential factors in decision making,

particularly Golo Ndeweng. Many families considered the hidden cost consequences associated

with delivering outside the home at health facilities. These include additional costs for preparing

new baby clothes, which parents are expected to bring to the health facility at the time of delivery,

and for other expenditures related to taking care of their families while they are away.

Inability to predict correctly the likely date of delivery. In remote areas with difficult access, being

able to estimate the date of delivery for planning purposes is important. From the ANC card data,

only 15% of deliveries occurred within 2 weeks (before or after) of the expected due date. The

percentage was lower among those who gave birth at home.

This finding was also validated during the interviews. In both sites, all families who delivered at

home expressed their concern about the uncertainties of the delivery date. According to a husband

from Golo Ndeweng, when asked about his uncertainty:

‘the midwife said the due date of delivery, but the fact is that my wife has given birth before

the due date, that’s why we’re not ready [to go to the health facility].” (Influencer from

Golo Ndeweng, 48 years old)

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A component of Revolusi KIA is the availability of waiting homes that provide a means of dealing

with some of the uncertainties regarding date of delivery. Although women were advised to come

to the waiting home two days before delivery, many did not follow this advice out of concern

regarding the wellbeing of other family members.

“We informed them prediction date of birth, there is waiting home at Wae Nakeng health

centre as well, we [told them that] 2 days before and 2 days after giving birth they should

be at waiting home. The fact is they don’t want to know about it, because they thought about

who will take care of their house?” (Health provider in Daleng, 28 years old)

Attitudes about health workers and facility delivery. Concerns over health care worker skills,

availability, and attitudes were expressed in both villages.

“At midnight my wife was in heavy pain. I was then going to take her to the health facility…

I had tried to reach a village midwife who unfortunately was not available. The midwife

only suggested me to bring the newborn baby to the health center in the morning. So we

did go to the health center in the morning and my newborn baby got a cord cut there”

(Influencer from closer village, 37 years old).

Some mothers and their families mentioned that previous birth experience had also influenced

their decision regarding facility delivery. Having a bad experience in a facility during their

previous delivery led some women to give birth at home.

Roles in decision-making. The people who played a role in the decision-making process regarding

where to give birth were family members including the woman’s parent, mother-in-law, husband,

and aunt, with husbands and mothers playing the most prominent roles. A lack of understanding

regarding the importance of maternal and child health among family members, especially among

husbands, impacted the decision of place of delivery. Women in both of the villages reported that

they were more comfortable to give birth with the present of their close families.

“Family has an important role as a decision maker especially in related with giving birth

and among spouse who still lived with their parents in law. But the decision maker is still

in husband as a head of household” (health provider in WaeNakeng Health Center, 57

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years old)

Some respondents also cited health volunteers, TBAs, and midwives as important sources of

advice during this process. In addition, community involvement, community awareness,

partnership between midwives and TBAs, and involvement of the family and wider community,

including local leaders, also served as facilitating factors.

“I always suggest to the head of the family to go to health centre whatever the problem is.

Even though it’s only common disease, so I always remind them… As soon as the car

available then we bring the mothers to health centre” (Community leader, 34 years old).

Tradition and cultural practice. Beliefs about maternal death, tradition, satisfaction with the

service provided by TBAs, closeness and familiarity with TBAs, and strong cultural practices

related to delivery contributed to the decision to access health facilities in both villages. Some

respondents expressed the belief that there is no difference between giving birth at a health facility

and at home. Additionally, several respondents expressed belief that pregnancy outcomes were in

the hands of God and that they had little control over whether their wives survived pregnancy or

their babies survived birth.

DISCUSSION

In this remote area of Indonesia where most of women are rural and poor and have low educational

attainment and high parity, there was a statistically significant increase in facility deliveries after

implementation of the Revolusi KIA, from 34% to 51%. The greatest changes occurred for many

of the groups at highest risk of poor maternal and neonatal outcomes, including women with the

least amount of education and those from the poorest wealth quintiles, suggesting that the strategy

is pro-poor. The gains, however, were greater in the urban areas, suggesting that additional efforts

may be needed to improve access among the rural population.

To help improve Revolusi KIA, six categories of barriers and enablers were identified in this study.

Cost and physical accessibility are two commonly reported barriers that are also reported here.

Regarding the accessibility of health facilities, the qualitative findings show that it is not just a

matter of distance, but also the ruggedness of the terrain and communication issues such as lack

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of cell phone reception complicate access facility deliveries.

Cost appears to serve as a barrier to facility deliveries for many even after financial barriers to the

delivery itself have been removed. Although Revolusi KIA appears to have increased facility

deliveries among those with and without insurance, findings from the interviews indicate that

indirect costs, such as the need of baby clothes and opportunity costs, act as significant barriers.

Similar findings on direct and indirect cost involved in the maternity care have also been raised by

others7.

Another major factor that impeded facility birth and which may be amenable to relatively rapid

change relates to the availability, credibility, and skills of midwives. In many rural areas, midwives

do not always live in the places where they have been assigned, and many are quite junior, with

issues raised about their competency. Additionally, uncertainty of women about their delivery

dates, which may in part be due to lack of experience or weak skills of the midwives, considerably

influenced place of delivery. Many respondents reported not being adequately prepared to go to a

facility or having gone to waiting homes and returned due to incorrect dates.

This study also found that women appear to have lesser roles in the decision-making process about

place of birth than their husband and other family members. Studies in developing countries have

illustrated the difficulty of women to participate in health-seeking decisions, which tend to be made

by their husbands,28,29,30,31 that husbands’ involvement relating to reproductive health tends to be

greatest during and after pregnancy, and that husbands tend to make the final decisions relating to

their wives’ maternal health and care.32,33,34

Our study has several limitations. First, some of the socioeconomic data from the IDHS is based

on status at time of the interview rather than at the time of the delivery, which may lead to an

incorrect estimation of the characteristics of those delivering before and after Revolusi KIA.

Second, recall about both exposures and possibly place of birth may have differed for those who

delivered in the earlier and later periods. Third, although it is unlikely that other programs would

have produced the rapid changes in facility deliveries observed between 2008-2009 and 2010-

2012, other factors may have at least in part contributed to the changes. Finally, qualitative

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interviews were limited for financial and logistical reasons to two sites, which may not be

representative of the broader experience in NTT.

IMPLICATIONS

Despite the limitations in our methods, we believe that our study nonetheless demonstrates

Revolusi KIA has made a substantial difference in facility deliveries in NTT. However, there is a

need to improve and modify its implementation to further increase accessibility, health staff skills

and promotion among families and key community leaders. With regards to improving access, the

government needs to expand the reach of the facilities and provide trained midwives at the

peripheral level. In the meantime, distributing vouchers for transport and developing a delivery

plan may help, especially for poor families. To improve the quality of health care, the provision of

updated trainings for midwives, such as the skills in estimating delivery dates are needed. Finally,

methods need to be found to provide insurance for those who currently do not have it and to also

overcome some of the non-financial barriers that inhibit women who do have insurance from

delivering in facilities. In this male-dominated culture, efforts should be made to raise awareness

among midwives to educate husbands and families on the importance of giving birth at a health

facility. One solution for this is to increase the partnership between skilled and traditional birth

attendants, as has been done elsewhere in Indonesia.

Our study suggests that improvements in facility delivery are feasible even in difficult settings, but

require continuous and focused improvement of health systems as well as commitment from

family, wider community, and health providers. This is a commitment to reducing inequities,

improving women’s autonomy, and ensuring that motherhood is a safe and rewarding experience.

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Table 1. Demographic and socioeconomic characteristics of women by place of delivery in NTT

Province: Births before (2008-9) and after (2010-2012) implementation of Revolusi KIA and for

the overall period (IDHS 2012)

Characteristics

All Births, 2008-12 Births 2008-2009 Births 2010-2012

Number of

Births

Delivery at Number of

Births

Delivery at Number of

Births

Delivery at

Health

Facilities

Health

Facilities

Health

Facilities

N % N % N %

ALL BIRTHS 498 43.0 241 34.4 257 51.0

Age of mother

15-24 135 33.3 69 21.7 66 45.5

25-29 137 46.0 56 35.7 81 53.1

30-39 195 49.7 103 45.6 92 54.3

40-49 31 29.0 13 7.7 18 44.4

Highest educational

level Illiterate/primary

school 243 26.3 121 19.0 122 33.6

Secondary school 193 53.4 92 47.8 101 58.4

Academy/University 62 75.8 28 57.1 34 91.2

Wealth index

Poorest 336 31.5 162 22.8 174 39.7

Poor 93 60.2 41 46.3 52 71.2

Middle 35 71.4 22 77.3 13 61.5

Richer 19 84.2 8 62.5 11 100

Richest 15 73.3 8 62.5 7 85.7

Birth parity

1 138 49.3 66 33.3 72 63.9

2 120 41.7 54 35.2 66 47.0

3+ 240 40.0 121 34.7 119 45.4

Had insurance

Yes 307 48.5 159 40.3 148 57.4

No 191 34.0 82 23.2 109 42.2

Place of residence

Urban 105 64.8 52 51.9 53 77.4

Rural 393 37.2 189 29.6 204 44.1

Number of ANC visits

Never/no answer 122 18.9 91 25.3 31 32.3

1 or 2 26 3.8 8 0.0 18 5.6

3 or 4 38 39.5 16 31.3 22 45.5

5 or more 312 52.9 126 39.7 186 59.1

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Figure 1. Health Facility-Based Birth in NTT Province: 2008-2014

IDHS Data vs. NTT-PHO Registered Data

Source: The 2012 IDHS and NTT-PHO (2014)

28.2

40.3

51.5

47.157.4

43.8 45.0

66.2

77.781.3

86.0 86.8

0.0

20.0

40.0

60.0

80.0

100.0

2008 2009 2010 2011 2012 2013 2014

Per

cen

tag

e (%

)

2012-IDHS

NTT-PHO (Annual

Registration)

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Figure 2. Health Facility-Based Birth by Residential Area and Wealth Index in NTT Province:

2008-2012

45

22

6262

42

7880 77

8686

71

100

5750

67

0

20

40

60

80

100

All Births (2008-2012) Births 2008-2009 Births 2010-2012

Pe

rce

nta

ge (

%)

Urban Residential Area

Poorest Poor Middle Richer Richest

31

23

38

59

50

6660

78

33

80

0

100

88

75

100

0

20

40

60

80

100

All Births (2008-2012) Births 2008-2009 Births 2010-2012

Per

cen

tag

e (%

)

Rural Residential Area

Poorest Poor Middle Richer Richest