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Overview of good practices on
safe delivery
Excerpt from
Tata Kelola Persalinan Aman
(Kinerja 2014)
Kinerja 2015
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Introduction
Kinerja has worked in the field of safe delivery since 2012 in 24 districts throughout five Indonesian pro i es: A eh, East Ja a, South Sula esi, West Kali a ta , a d Papua. Ki erja s odels – all of which were existing government programs to which Kinerja adapted and added multiple governance elements – were widely replicated in 2014 and 2015, both within partner districts and in new districts.
In safe delivery, Kinerja provides support on a number of activities and programs. These include partnerships between midwives and traditional birth attendants that are participatory and transparent; service standards and standard operating procedures that encourage accountability and transparency; complaint management systems that involve members of the community; pregnancy monitoring systems that ensure both midwives and health centre managers are aware of who is pregnant in their catchment area and what their health status is; and educating influential members of the community on the importance of antenatal care and safe delivery so that they can share that information with others.
How has good governance in health been applied in Kinerja’s partner
districts?
1. Government officials formulate policies, plans, regulations, procedures and standards based on evidence of the effectiveness of health interventions, resource allocation, spending patterns, and other elements.
2. Government officials make evidence-based decisions on the allocation of resources for healthcare services in accordance with policies.
3. Policy makers seek input from technical experts in government and civil society organizations and from healthcare users regarding proposed laws on health, including on the role of the community, civil society, and the private sector.
4. Service providers regularly review and renew healthcare services on the basis of evidence on effectiveness, patient needs, and health issues.
5. Protocols, standards, and codes of conduct, including certification procedures for training institutes, healthcare facilities, and healthcare providers, have been developed for actors involved in the provision of healthcare and have widely been distributed.
6. Public sector organizations, volunteers and the private sector monitor compliance with protocols, standards, and codes of conduct.
7. Structures (for example, regulatory agencies with appropriate human resources) and procedures for supervision enable service providers, patients and other stakeholders to pursue problems when regulations, protocols, standards, and/or codes of conduct are not fulfilled.
8. Systems of financing and supervision in place that offer incentives for public, private and NGO-run health facilities to improve their healthcare performance.
3 10. Allocation and utilization of resources are regularly monitored, and information on results is
available to be reviewed by the public and relevant stakeholders.
11. This system exists to report, investigate and judge misallocation and misuse of resources. 12. The government and healthcare provider organizations regularly hold forums to ask for the
input and opinion of public stakeholders and beneficiaries (vulnerable groups, groups with certain health problems, etc) on health priorities, services and resources.
13. Civil society organizations (including professional organizations relating to health and media) monitor how healthcare services are delivered and paid for.
14. Relevant actors and stakeholders have regular opportunities to meet with healthcare service management (hospitals, health centers, clinics) to raise issues on the quality and efficiency of services.
15. Relevant actors and stakeholders have the financial means, tools, materials, and abilities to support and effectively participate with public officials in the formulation of policies, plans and budgets for healthcare services.
16. Information is available for the public on the quality and cost of healthcare to assist patients in making choices on which healthcare unit is the most suitable to their needs and desires.
17. Procedures or systems are available to reduce, eliminate and control bias and injustice in accessing healthcare.
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Examples of Kinerja-supported Good Practices
1. Traditional Birth Attendant and Midwife Partnerships, East Java
Tens of partnerships between traditional birth attendant (TBAs) and midwife were revitalized to include governance principles in East Java through a series of activities:
1. Each group of midwives and traditional birth attendants conducted a SWOT analysis to identify the strengths and weaknesses of the existing partnerships.
2. The results of the SWOT analysis were confirmed with the other group (results of the analysis by the group of midwives were confirmed with the TBAs, and vice versa).
3. The results were compiled to formulate mutually-beneficial partnership patterns in line with local needs and conditions.
4. Memoranda of Understanding (MoU) were drafted and signed, with the assistance of all partners.
Incentives for TBAs were then developed and included:
. Free asi health are for TBAs i ediate fa il e ers.
2. TBAs that refer expecting mothers to midwives for antenatal care or childbirth receive financial incentive, as agreed to by multi-stakeholder forums and community health centers.
2. Traditional Birth Attendant and Midwife Partnerships, Sukamaju
Community Health Center, North Luwu District, South Sulawesi
Partnerships between traditional birth attendant (TBAs) and midwife were revitalized to include governance principles in Sukamaju sub-district through a series of activities:
1. Each group of midwives and TBAs conducted a SWOT analysis to identify the strengths and weaknesses of the existing partnerships.
2. The results of the SWOT analysis were confirmed with the other group (results of the analysis by the group of midwives are confirmed with the TBAs, and vice versa).
3. The results were compiled to formulate mutually-beneficial partnership patterns in line with local needs and conditions.4. A Memorandum of Understanding (MoU) is drafted with the involvement of TBAs
5. Photos of midwives and their TBA partners were printed and hung on the walls of maternal health rooms to illustrate the midwife and TBA partnership system to patients.
Incentives for TBAs are realized in the form of:
5 2. TBAs are permitted to enter and remain in delivery rooms when a woman goes into labor in order to provide non-medical support (prayers, massage, etc).
The partnerships have had a positive impact on the quality of care received by mothers in Sukamaju sub-district. The number of deliveries assisted by TBAs has declined since the program was revitalised in 2012, when there were 15 deliveries with TBAs. In 2013, there were 9 deliveries with TBAs. In the first six months of 2014, there were only 2 deliveries with TBAs in the catchment area for Sukamaju Community Health Center. This shows a clear shift towards midwife-assisted delivery.
3. Pregnancy Monitoring Systems, Sejangkung Community Health Center,
Sambas District, West Kalimantan
The women of Sejangkung sub-district, Sambas, frequently use the childbirth services of traditional birth attendants (TBAs). This is influenced by the lack of good-quality health facilities in rural areas, high rates of midwife absenteeism from their village posts, poor infrastructure, and issues relating to health insurance. These problems represent major challenges for Sejangkung Community Health Center as it continues to strive to improve its services, particularly maternal and child healthcare.
Although the facilities and infrastructure of Sejangkung Community Health Center are relatively li ited, the e ter s ater al health ser i es continue to a focus of improvement, covering antenatal care (ANC), deliveries, and postpartum visits. One of the ways Sejangkung is trying to improve the health outcomes of pregnancy and delivery is through better pregnancy monitoring, usi g a s ste alled deli er po kets (see picture on right), where the information of all pregnant women in the area is stored on a hanging hand-made paper a d aterial po ket o the all of the a te atal services room.
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4. Suggestion Boxes, Batua Community Health Center, Makassar City, South
Sulawesi
Makassar has built and placed suggestion boxes in each of the 20 community health centers throughout the city. The suggestion boxes are opened and discussed every month with the involvement of health volunteers and multi-stakeholder forums, in order for a resolution and follow up actions to be agreed on and carried out together. This suggestion boxes are locked, and the keys held by health staff such as midwives or health volunteers.
5. Seven Minute Lecture Contest in Bondowoso District, East Java
Bondowoso District in East Java chose to work with Kinerja on three areas relating to maternal health: safe delivery; immediate & exclusive breastfeeding; and child marriage prevention. The District Head developed District Head Regulation no.41/2012 to ensure these three issues are covered by policies. The District Head was also appointed as Ummi Persameda, the other of safe deli er , i ediate &
exclusive breastfeeding, and reproductive health.
Traditional beliefs and the use of dukun bayi or traditional birth attendants remain popular in Bondowoso. Practices such as child marriage and giving newborns food and drink other than milk are common, and require strategic innovation to overcome. One of the efforts made by the Bondowoso District Government is a campaign involving religious figures, where influential figures (scholars and teachers) take part in supporting breastfeeding awareness raising efforts through incorporating information into their sermons, as well as through taking part in giving lectures on safe delivery, breastfeeding, and delayed marriage at community events.
Bo do oso s religious s holars a d tea hers ha e sho e elle t o it e t i o ati g these issues, and they are highly-skilled in delivering information in a populist and easy-to-understand manner. One activity that has been held up by the government as being particularly successful was the Seven Minute Sermon Contest, where religious scholars and teachers competed to give the best seven minute sermon on the theme on maternal and child health.
6. Standard Operating Procedure for Antenatal Care, Probolinggo City
Community Health Centers, East Java
7 To make the SOPS compliant with governance principles, additional information is now provided on each service available – such as who is responsible for providing it, when it is available, and how long it should take. SOPs are also printed and displayed on the waiting room and antenatal care room walls and doors to ensure that all patients are aware of their rights to antenatal care.
STANDARD ANTENATAL CARE
6 Tetanus Toxoid injection Midwife Every working day 5 minutes
7 Iron Tablets (90 tablets) Midwife Every working day 1 minute
8 Lab Test (blood group,
haemoglobin, HIV, STI. , Hepatitis B)
Lab Every working day 20 minutes
9 Management of high
Midwife Every working day 5 minutes
Day : Monday to Friday Time : 7.30 – 14.00
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7. Bridal Makeup Artists, Market Sellers, Herbal Medicine Sellers and
Motorbike Taxi Drivers, Probolinggo City and Jember District, East Java
One of the most creative campaigns Kinerja witnessed in its partner districts was developed in Probolinggo City in East Java, where perias manten or bridal makeup artists committed to support safe delivery and immediate & exclusive breastfeeding. The women were trained on maternal and child health issues so that they were able to provide advice to the brides-to-be under their care to ensure they had a good understanding of the benefits of safe delivery and breastfeeding.
Some of the multi-stakeholder forums in Jember and Probolinggo City have also been very innovative in raising awareness of the importance of exclusive breastfeeding and safe delivery. The forums have been training market sellers and herbal medicine sellers, for example, so that they are able to provide health advice to expecting mothers. These sellers frequently come into contact with pregnant women and women with young babies, so they are uniquely placed to deliver crucial messages on maternal and child health, such as encouraging women to get antenatal checkups, to give birth at a health facility, and to breastfeed their child exclusively for the first six months.
