Field Notes

• Field Notes

Field Notes

Empowering Public to Save Indonesian Women and Babies

By Laurel Lundstrom

A day in the obstetric ward of Indonesia’s Tangerang Hospital is filled with the same sense of urgency as its home city, the congested, ever-mobile streets of Jakarta. Every other hour, a woman comes in needing a life-saving procedure. In one day, a midwife can assist 10 or 15 emergency deliveries-severe bleeding, ruptured membranes, retained placenta, pre-eclampsia, shock. They come by car and bus, with family members, friends or community midwives.

Most of the women referred to Tangerang Hospital, which is located on the outskirts of Jakarta, are poor and arrive to the ward straddling a tenuous line between life and death. Their conditions need to be managed within a six-hour window. After journeying from one, two or three hours away, Tangerang’s staff has only an abbreviated moment to save their lives.

These women are not alone. Every day, women risk their lives to give birth in developing countries around the world, because the services aren’t there to help them through their pregnancies safely.

This is why the Extending Service Delivery (ESD) Project runs programs that counsel women on the healthy timing and spacing of pregnancy and family planning, and invest essential resources in maternal, newborn and child health.

Indonesia is part of the project’s initiative in Asia and the Middle East, which offers very small grants, usually of $50,000, and limited technical assistance, to empower countries to save their women and babies. In most cases, ESD awards a local NGO the grant, and helps the organization to spread chosen best practices across the health care continuum by planning the expansion and involving a network of key stakeholders.
Because of this program, Tangerang Hospital has cut the number of women dying in childbirth by two-thirds, and the number of newborn deaths by almost 50 percent in a little over a year. It has emerged as a shining star, a model for care, and something the Indonesian government will try its best to replicate in the years to come.

Through replication and spread, the government will try to curb maternal mortality rates. Although there are fewer women dying in childbirth now than there were four years ago, Indonesia still suffers from one of the highest rates in Southeast Asia.
Indonesia’s JNPK - the ministry of health’s prime health training organization - chose Tangerang Hospital as the demonstration site for improving emergency obstetric and neonatal care, in a large part, because it expressed a great and dire need for the training.

A Typical Day

An amalgamation of young women with swollen bellies lay gaunt and fragile about the Tangerang Hospital maternity ward, awaiting care. A glance through the door of the postpartum room revealed rows of women, most looking younger than 20, recovering side by side without their babies. Some had lost them. Others were waiting for them to receive care in the emergency neonatal ward.

Damayanthy, a slight woman with long narrow eyes and delicate features, was one of them. Inside her womb, her baby was trying to come into the world feet first. Entry by butt or foot often results in the baby’s head getting trapped in the mother’s pelvis, or its oxygen supply getting cut off. Despite the risks, Damayanthy’s husband and mother-in-law wanted her to deliver “the natural way,” as she had during her other births. While the doctor tried to convince the family members about the necessity of the cesarean section, Damayanthy, by a miracle of her own making, brought a healthy baby into the world.

Like most of Tangerang’s patients, Damayanthy came to the hospital because she could not afford private care, and her delivery was not going well. When she was shuttled off to Tangerang for treatment, Damayanthy did not know what to expect of hospital care. She delivered her first three children - ages 9, 7 and 5 - at home with either a skilled - or unskilled - birth attendant or a community midwife, as 67 percent of Indonesian women still do.

Seventy million people in Indonesia continue to live below the poverty line. For them, access to life-saving health services is extremely low. Improving their access to emergency care at government facilities is integral to bridging the gap in services between the rich and the middle class, and the poor.

To transform Tangerang, JNPK trained hospital providers, community midwives and primary health care physicians to better manage complications through the timely referral and stabilization of emergencies, monthly on-the-job trainings and randomized competency-based testing. Community midwives and primary health care physicians were also taught newborn resuscitation techniques. Other best practices included placing partitions between hospital cots to enhance client privacy; developing an ER triage system that sends women straight to the delivery room; and various infection control measures. The ministry of health donated new emergency equipment.

None of this would have been possible without the commitment of ESD, and the international community to a “zero tolerance policy” for maternal mortality. This international agenda pushed the Indonesian government to launch its Making Pregnancy Safer Campaign, a national policy that prioritizes the health of mothers and newborns, and commits the government to trying to meet Millennium Development Goals 4 and 5 by 2015.

The government launched its “Social Safety Net” program last February, offering free care to women delivering at public facilities if they are classified as poor by the Indonesian government. Previously, deliveries ranged from $50 to $80 each. In 2009, more than twice as many women came to Tangerang Hospital for deliveries than during the previous year.

Indonesia’s public health community has realized that expanding improved emergency care across Indonesia is not just an ideal, but is feasible and mandatory. JNPK is now poised to train providers in three more hospitals, and surrounding communities.

 Laurel Lundstrom is a communications officer with the ESD Project