Health Policy and Planning Advance Access originally published online on October 30, 2007
Health Policy and Planning 2008 23(1):67-75; doi:10.1093/heapol/czm036
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Midwifery provision in two districts in Indonesia: how well are rural areas served?
1Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
2Centre for Family Welfare, University of Indonesia, Depok, West Java, Indonesia.
*Corresponding author. Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. Tel: +44 (0) 20 7927 2812. E-mail: krystyna.makowiecka{at}lshtm.ac.uk
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Abstract |
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Attention has focused recently on the importance of adequate and equitable provision of health personnel to raise levels of skilled attendance at delivery and thereby reduce maternal mortality. Indonesia has a village-based midwife programme that was intended to increase the rate of professional delivery care and redress the urban/rural imbalance in service provision by posting a trained midwife in every village in the country. We present findings on the distribution of midwifery provision in our study area: 10% of villages do not have a midwife but a nurse as a midwifery provider; there is a deficit in midwife density in remote villages compared with urban areas; those assigned to remote areas are less experienced; midwives manage few births and this may compromise their capacity to maintain professional skills; over 90% of non-hospital deliveries take place in the woman's (64%) or the midwife's (28%) home; three-quarters of midwives did not make regular use of the fee exemption scheme; midwives who live in their assigned village spend more days per month on clinical work there. We conclude that adequate provider density is an important factor in effective health care and that efforts should be made to redress the imbalance in provision, but that this can only contribute to reducing maternal mortality in the context of a supportive professional environment and timely access to emergency obstetric care.
Key Words: Midwife, Indonesia, maternal health, workforce, workload, delivery, distribution, density, equity
KEY MESSAGES
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Introduction |
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The 2006 World Health Report proposes that density of health care provision is key to achieving the fifth Millennium Development Goal: reduction of maternal mortality by 75% by 2015 (WHO 2006
). Over two-thirds of maternal deaths are a direct result of obstetric complications (Ronsmans and Graham 2006), and most could be avoided with good quality skilled care at delivery (Graham et al. 2001; WHO/ICM/FIGO 2004; Campbell and Graham 2006). High levels of skilled care can only be achieved with adequate and equitable distribution of health personnel (Anand and Baernighausen 2004; Campbell and Graham 2006; Koblinsky et al. 2006) operating in a well-functioning and supportive system with timely access to emergency obstetric care. In this paper we focus on one aspect of such care: the distribution of providers in relation to both their density and their professional characteristics.
There exists a substantial wealth gradient and urban/rural split in developing countries in both maternal mortality (Graham and Bell 2004) and uptake of skilled attendance (Gwatkin 2000; Hatt et al. 2006). Wealth tends to be concentrated in urban areas and services are provided in the places where demand is high and people are able to pay. Globally, the proportion of services in towns and cities exceeds the proportion of population living there and rural deficits are substantial. For policy-makers to fill these gaps in provision, local knowledge of health provider density and skills is needed, as well as epidemiological and demographic profiles of the community they serve (Lancet Editorial 2006), yet the 2006 World Health Report reveals a paucity of such information (Anand and Baernighausen 2004; WHO 2006).
Indonesia has been identified as one of 57 countries with a critical shortage of health personnel (WHO 2006), but on a national level there is no shortage of midwives, largely a result of the village-based midwife programme. This initiative, launched in 1989 (Government of Indonesia 1989), was unique as a national effort to follow the World Health Organization's (WHO) guidance for safe motherhood. It sought to address high maternal mortality, thought to be a result of a dearth of midwives and under-use of services (World Bank 1994), particularly in rural areas, by assigning a midwife to each village in the country and thereby raising skilled attendance. Existing nurses were to be trained in midwifery under an intensive 1-year programme, to live in and work from a village birthing facility provided by the community for which they had responsibility, and to operate as multi-purpose providers, but with specific responsibility for pregnancy, delivery and post-partum care (Government of Indonesia 1989; Hull 1998; Geefhuysen 1999; Shiffman 2003). Within 7 years, over 54 000 new midwives had been posted (Ministry of Health 1997), virtually each village in the country had its own assigned provider and the percentage of births in rural areas managed by a midwife doubled, from 22.5% in 1990 (BPS et al. 1995) to 55% in 2003 (BPS and ORC Macro 2003). Midwives received a monthly income for their routine public-sector clinics and in addition were allowed to charge a fee for delivery care. Families defined as ‘poor’ were entitled to free delivery care and in these cases midwives were remunerated through a fee exemption scheme.
The challenges to sustaining such a programme are substantial. Ever since near-universal coverage was achieved in the mid-1990s, there have been problems of retention, especially in remote areas (UNICEF 1997; Daly et al. 1998; World Bank 1999). Indonesia experienced a major economic crisis in 1997 and government expenditure on health and education declined along with use of public health care services (Frankenberg et al. 1999; Simms and Rowson 2003; Waters et al. 2003). Furthermore, under the national decentralization plan (Government of Indonesia 1999), financial responsibility for the village-based midwife programme, traditionally the central government's, increasingly fell to the authority of districts, which had variable capacity to pay.
In addition, the 1-year midwifery training programme was of questionable quality, inadequate duration and, because of a combination of the high number of midwives being trained, low fertility and low use of facilities, many midwives had virtually no experience of managing a delivery during their training. Small-scale evaluations suggest that midwives who qualified under this scheme did not have the skills or knowledge needed to perform their midwifery duties effectively (Depkes/POGI/IBI 1998; McDermott and Beck 1999; HMHB 2001; McDermott et al. 2001; Koblinsky 2003; Sadjimin 2003; MSH 2004). This is of particular concern because although village-based midwives were under the general formal supervision of the health centre, they were to manage normal deliveries alone and may not have had the skills to recognize an obstetric emergency and the need for referral. In 1996, additional training needs arose when those working out of reach of facilities were given formal authority to practice independently and to perform a range of procedures, including vacuum extraction and forceps delivery (Government of Indonesia 1996). To address these needs, competence-based in-service training courses, comprising classroom-based training using models and supervised clinical training, were developed by the newly formed National Clinical Training Network in the management of normal delivery and life-saving skills. In 1996, the 1-year pre-service training course was replaced by a 3-year specialist programme open to high school graduates.
In this paper we examine the village-based midwife programme by describing the provision of midwifery services in two districts on Java Island. We examine the midwives’ professional characteristics and their place of work relative to the population and area that they serve, and discuss the place of workforce density in a strategy to reduce maternal mortality.
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Methods |
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Study area
We conducted the study in Serang and Pandeglang districts in Banten Province on Java, Indonesia. Serang City is the provincial capital and is situated 100 km west of Jakarta, the national capital. The district of Serang comprises 373 villages and a population of 1.8 million. There are three hospitals (a large Provincial tertiary hospital and two smaller private hospitals) and 36 health centres. Its economy is based on medium-scale manufacturing, tourism and small-scale fishing and agricultural activity. It borders a large industrial development to the West and rapid urbanization to the East. Pandeglang district comprises 335 villages and is characterized by small-scale farming, mountains and forest, with some palm oil and tea plantations and coastal tourism. It has a population of 1.1 million who are served by one district hospital and 30 health centres.
Study population
The study population comprised all practitioners registered to provide midwifery care in the two districts in July 2005, irrespective of whether they held a contract with the District Health Office (DHO), and those nurses who were assigned to villages to offer maternal and child health care. We obtained a list of these providers from the DHOs. Free and informed consent of all respondents was obtained.
Data collection
We drew on four sources to describe midwifery provision in the study area. First, all midwives and nurses with midwifery responsibility listed by the DHO were invited to complete a questionnaire in September 2005 on their professional characteristics, including training, type of employment contract and workload. Secondly, those who had been assigned responsibility for one or more villages were asked to complete a questionnaire on their clinical work in the villages. Thirdly, we drew on National Statistical Office data for the size and population of each village and for its classification as urban or rural. Finally, field staff generated data on distances from a village to the nearest public hospital within the study area using Geographic Positioning Systems.
Definition of variables
Providers were characterized by their principal midwifery role: village-based midwives (midwives who had been assigned responsibility for midwifery provision in one or more villages); health centre midwives (midwives who have administrative and supervisory duties in the sub-district health centre and in addition may have been assigned responsibility for villages); nurses (who, in addition to their nursing duties, had been assigned responsibility for village-based midwifery care); private community midwives (whose principal midwifery role was in the community and whose work was in the private sector only); general hospital midwives (whose principal midwifery role was in a public hospital); other hospital midwives (whose principal role was in a military or private hospital); and other midwives (whose principal role was in the District Health Office or midwifery academy).
Providers were further characterized by their years of service, the nature of their contract, whether or not they offered private care, the nature of their pre- and in-service training and their obstetric workload. We distinguished three types of contracts: private; public with security of tenure and pension rights; and public with 3-year rolling employment and no pension rights. Pre-service training comprised a 1-year diploma course for graduates of the nursing high school or a 3-year midwifery diploma for graduates of any high school. We defined obstetric workload as the median number of times providers attended women at the time of delivery or in the immediate postpartum period in the preceding 3 months. The deliveries attended outside hospital were also broken down by place of delivery: the woman's home, the midwife's home (in a small number of cases this has been provided by the community to function as a place of clinical work), a private community facility or a public community facility (health centre or health post). In general, the health centre has an administrative and supervisory function and does not provide routine intrapartum care.
In Indonesia the village is the smallest unit of government administration and all villages are defined by the National Statistical Office as urban or rural. In this paper we extended this classification to include a ‘remote’ category. Remote villages exist only in Pandeglang and were defined as those that lay further than 33.3 km (the median distance of non-urban villages in this District) from the nearest government hospital in the study area. Although some villages in Serang are further than 33.3 km from a government hospital, these are not classified as remote because they lie close to neighbouring suburban or industrial areas and are well served by transport and service infrastructure.
Village-based and health centre midwives and nurses may be assigned one or more villages of responsibility, possibly sharing this assignment with another provider. The assigned provider may or may not live in the village and other midwives who live in the village may also offer delivery care. In order to examine the intensity of midwifery provision, we described villages by the resident midwife to population ratio and the number of resident midwives per square kilometre. In these calculations we excluded nurses because they do not have a license to manage normal deliveries and have had no midwifery training. We also describe villages in relation to the assigned provider (generally a midwife but where no midwife is available, nurses take on this responsibility): the number of other villages for which she has responsibility; how long she has been assigned to the village; how long she has been a midwife and her principal role.
Data analysis
Data analysis was undertaken using Stata9 (http://www.stata.com). We compared provider characteristics according to the professional role of the provider, and the intensity and nature of the assignment comparing urban, rural and remote villages. Proportions were compared using the 
2 test and medians and provider per population rates using weighted Kruskal-Wallis test of significance.
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Results |
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Characteristics of midwifery providers
The DHO identified 753 midwives and nurses with a midwifery role in the two districts in 2005. 737 (98%) agreed to participate in the study. Of these, 464 (63%) worked in Serang and 273 (37%) in Pandeglang. Almost half (49%) were village-based midwives, over a quarter (26%) health centre midwives and 9% were nurses with no midwifery qualifications. Only 50 (7%) providers worked exclusively outside the public sector (Figure 1).
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Village-based midwives were less experienced than health centre midwives (Table 1). Ninety-four per cent of village-based midwives had worked for 15 years or less, compared with 67% of health centre midwives (P < 0.001). Village-based midwives were also more likely than health centre midwives to have temporary contracts (46% vs. 3%; P < 0.001) (Table 1). 572 (79%) of the 724 respondents had a village assignment, comprising all 361 village-based midwives, all 69 nurses and three-quarters (74%) of the 193 health centre midwives (P < 0.001) (Table 1).
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Most (79%) midwives qualified under the 1-year diploma course and were therefore nurse-midwives, but a larger proportion of private and hospital midwives than village-based or health centre midwives had completed 3-year specialist training. Of the public community providers, nearly all (94% of village-based midwives and 95% of health centre midwives) had completed some in-service training courses to improve their capacity to recognize and manage complications, except for nurses, only 17% of whom had received any such training.
Obstetric workload and private care
Almost all (98%) village-based and (94%) health centre midwives had assisted women around the time of delivery over the preceding 3 months, while fewer than half the nurses (46%) had done so (Table 1). Among those who had attended women during labour, delivery or the immediate postpartum period, the total number attended was very low, with a median of 10 (IQR: 6–18) over 3 months. Nurses assisted fewest deliveries (median: 3, IQR: 2–7) and hospital midwives the most (median: 20, IQR: 9–50) (P < 0.001) (Figure 2).
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The number of non-hospital deliveries that took place in the woman's home, the midwife's home and in a health centre was calculated for each midwife based on data from the midwives’ questionnaire on their attendance at deliveries in the preceding 3 months. Just 7% of non-hospital deliveries took place in a community facility and most took place in the woman's (64%) or the midwife's (28%) home (Figure 3). Three-quarters (75%) of the respondents, regardless of the provider type, charged a private tariff for all the deliveries they had managed outside a hospital over the preceding 3 months (data not shown).
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Coverage of midwifery care in villages
Village characteristics
Of the 708 villages in the two districts, 55 were in urban Serang and 318 in rural Serang, and 23, 156 and 156 in urban, rural and remote Pandeglang, respectively. The median population per village was 3500 and the median village area 4 km2. Urban villages are smaller and more highly populated than rural villages (Table 2).
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Resident midwives
Over half the urban villages had three or more resident midwives, compared with 3% or less in rural and remote villages (Figure 4). Of the 626 midwives who were residents of Serang and Pandeglang, 310 (50%) lived in urban areas, resulting in 4.8 resident midwives per 10 000 urban population. This is two and a half times as high as in rural Pandeglang (1.9 per 10 000) and nearly four times as high as the resident midwife to population ratio in rural Serang (1.3 per 10 000) or remote Pandeglang (1.3 per 10 000) (Table 2). Midwife density measured by square kilometre for each resident midwife is over 30 times higher in urban (0.77 km2 per resident midwife) than in remote villages (25 km2 per resident midwife).
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Assigned providers
The 708 villages were covered by 572 providers with a village assignment, comprising 503 midwives and 69 nurses. Most (61%) villages had an assigned provider who worked solely in that village, while one-third (29%) shared their provider with one other village and 10% shared with two or more other villages (Table 2). These divided assignments were most common in remote villages: nearly all (94%) villages in urban areas had their own assigned provider, while less than a quarter of villages in remote Pandeglang (24%) did so. In only a third (29%) of villages overall was the assigned provider resident, and this was the case in a higher proportion of urban villages (44%) than outside the urban areas (24% in rural Serang, 29% in rural Pandeglang and 31% in remote Pandeglang).
Assigned providers spent an average of 10 days per month doing village-based clinical work. In remote Pandeglang they spent 7 days (IQR: 3–19) per month, significantly fewer (P < 0.001) than the 20 days (IQR: 10–25) spent in urban areas (Table 2). An assigned provider who is resident in her village of responsibility spends a median of 20 days (IQR: 12–26) on clinical work there, irrespective of the location of the village (P = 0.2). In contrast, assigned midwives who are not resident spend less than half the number of days on village-based clinical work and this differs significantly by location (P > 0.001) (Table 2). Midwives had had responsibility for their village for an average 4.7 years: 6 years in urban areas, compared with 3 in remote villages (P < 0.001). Villages in urban areas were more likely to be assigned a health centre midwife and nurses were particularly highly represented in rural Pandeglang (P < 0.001). Midwives had had their village assignment for a median of 6 years (IQR: 3.5–8) in urban areas, and only 3 years (IQR: 0.8–6) in remote Pandeglang.
The unequal deployment of providers in urban, rural and remote villages resulted in a considerable range in the population and area to be covered by the assigned provider. The median population covered by providers assigned to urban and remote villages (6800 and 6700, respectively) was significantly higher than those working in both rural Serang (4700) and rural Pandeglang (3500). The median area of responsibility of an assigned provider in remote Pandeglang was over six times greater (18 km2) than in urban villages (2.7 km2). Assigned providers in remote Pandeglang managed a significantly larger number of deliveries than those working in other areas (P < 0.0001) (Table 2). Providers assigned to remote villages managed a median of 14 deliveries over 3 months (IQR: 8–28), significantly more than those assigned to other villages [urban 10.5 (IQR: 6–36); Serang rural 9 (IQR: 6–20), Pandeglang rural 10 (IQR: 6–24)].
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Discussion |
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It was the vision of the village-based midwife programme that each village in the country would have an assigned midwife who would live in and be part of the community she serves. Considerable efforts were made to bring midwifery care to the villages and there have been achievements in terms of midwife to population density. Indeed, the figure of 2.2 midwives per 10 000 population in the two districts is broadly consistent with the national midwife to population density of 2.0 per 10 000 (WHO 2006
). However, figures that describe national coverage mask local variation. The distribution of midwives in the study districts reflects global trends (WHO 2006), with inequitably distributed provision and remote villages in particular being underserved compared with urban areas. This translates into considerable advantages to urban residents. In contrast to rural villages, urban areas have a more stable and experienced workforce and are more likely to have resident midwives. In addition, a larger proportion of assigned providers are resident, can focus their professional attention on one village only and therefore spend more days per month on clinical work there and be a better-known figure in the community. In remote villages the area of responsibility per assigned provider is larger so the midwife is less likely to be a familiar figure. Transport infrastructure is also less well developed, affecting the midwife's accessibility, her ability to reach a woman in labour and her capacity to refer her to hospital should there be an obstetric emergency (Thaddeus and Maine 1994). A tenth of our villages have a nurse as an assigned provider because there is no midwife available, and only one of these villages is in an urban area. The nurses’ role is principally organizational (they are licensed to manage deliveries only in emergencies), but in reality they do offer delivery assistance without midwifery qualifications, and in only few cases with in-service training.
Midwives are attracted to urban areas because they can generate viable and sustainable clinical practices. Most, irrespective of their contract status or place of work, offer private services outside their government working hours, under a formal arrangement designed to enable public sector providers to supplement their government pay. Midwives in remote areas manage more deliveries than others: the provider to population density is lower and there is limited competition for their skills. However, notwithstanding the higher workload, income remains lower in remote areas since the professional fees reflect the population's ability to pay (Center for Health Research 2001). Remote postings may not have the capacity to provide an adequate income for midwives and therefore may be unsustainable without subsidy. The Ministry of Health has adopted strategies to retain midwives in remote areas: financial incentives in the form of an income supplement and a guarantee of renewal of the rolling contract. However, these incentives may be insufficient. The extra income earned from private work with a wealthier population may exceed that gained through government subsidy, and a renewal of a rolling contract is not valued as highly as a tenured contract with security of employment until retirement and a pension for life. In addition, working in remote areas carries with it professional isolation, greater pressure from a more traditional community and less opportunity for career development.
As a consequence of the village-based midwife programme, Indonesia has a midwife to population density of 2.0 per 10 000, a figure similar to neighbouring Malaysia and Sri Lanka, both countries which have achieved near universal skilled attendance, with midwife densities of 3.4 and 1.6 per 10 000, respectively (WHO 2006). However, midwives do not work in isolation, and in order to save lives, they depend on a supportive environment and access to a referral facility. Indonesia has a workforce density of doctors, nurses and midwives of 9.5 per 10 000, while that of both Sri Lanka and Malaysia is over twice this size (22.9/10 000 and 23.9/10 000, respectively). Indonesia's health centres are poorly equipped and poorly stocked (Setiarini 2003a,b), and while the increased pool of midwives may have increased skilled attendance, it has not yet been shown to have increased access to emergency obstetric care, particularly for the poor (Ronsmans 2001; Hatt, in press).
In our study, the distribution of midwives in urban, rural and remote areas no doubt contributes to a substantial differential in the uptake of skilled attendance. A recent population-based survey in the two study districts suggests that 33% of deliveries took place with a skilled attendant, 62% in urban areas, and 24% and 19% in rural and remote areas, respectively (unpublished data). It is noteworthy that in urban areas, where the density of midwives is 4.8 per 10 000 population, where assigned midwives spend more time than in other areas on village-based clinical work, and where other physical barriers such as transport are unimportant, skilled attendance is still low, suggesting that supply alone is not the problem.
Women who deliver with a traditional attendant may have a strong attachment to birth traditions and would call a midwife only in the event of an emergency. While demand for professional birth attendance may be stimulated though public health messages, the financial barriers to using a midwife are acute, particularly among the deprived populations. The fee exemption scheme for the poor introduced in 1997 and revised in 2005 represents a positive step; the low uptake in our study may be because midwives were hesitant to use a system that had recently been altered. Even though awareness of the programme should be raised among service users and professionals alike, a targeted fee exemption scheme may not be enough to render services accessible, since all countries that have reduced their maternal mortality ratio have done so in the context of free care (Koblinsky et al. 1999).
Midwives attend a median of 40 births per year. There is no internationally agreed minimum number of deliveries that a midwife should perform to maintain her midwifery skills, but Scotland and Bullough (2004) recommend an optimal annual workload for obstetricians of between 100 and 125 normal deliveries. If the same recommendation is applied to Indonesian midwives, their delivery volume falls well below optimal levels, and their capacity to manage complications and recognize the need for referral may be compromised because they come across these situations so infrequently.
Most health centres in Indonesia have an administrative and supervisory role, and few offer routine intrapartum care (Hatt, in press). When the village-based midwife programme was conceived, clinical care, including delivery care, was to take place in a village-based birthing facility to be provided by the community as a home and work base for the assigned midwife. The facilities were of variable quality and in many cases were not used (Hull 1998). The current system of community-based midwifery provision effectively promotes home-based care. Our results indicate that almost two-thirds (64%) of non-hospital deliveries managed by midwives (estimated to be 96% of all professionally managed deliveries in the study area—unpublished data) took place in the woman's home. In such circumstances, midwives work alone and with one woman at a time, and the extent to which they can increase their coverage and gain sufficient experience to maintain skills is uncertain (Koblinsky et al. 2006). In addition, conditions of home-births can be basic (Chowdhury et al. 2006), and intra-partum care less effective in terms of a midwife's capacity to cope with emergencies and less efficient than facility-based deliveries in terms of the midwife's time. An additional 28% of non-hospital deliveries managed by midwives took place in the midwife's home, where conditions may be better but the midwife remains a single-handed provider. Globally, midwives working in health facilities with an active role in intra-partum care assist more deliveries because they can give care to more than one woman in a given period and because they work in teams (Koblinsy et al. 2006). The WHO proposes that such an approach enables a midwife to manage 175 births per year (WHO 2005). A policy shift from home to facility births may help establish a more supportive working environment for midwives, may be more efficient and effective in terms of the care that women receive and, in terms of the retention of midwives in remote areas, may be more sustainable. Data from Bangladesh indicate that such a shift is possible even in settings with strong attachment to home births (Chowdhury et al. 2006), and such a strategy may be more efficient, effective and sustainable in reaching out to women.
The Indonesian government has made great strides in extending midwifery coverage to rural villages. Provision has increased in all areas and skilled attendance rates have followed. Notwithstanding a commitment to reducing maternal mortality and attempts to introduce universal midwifery coverage and fee exemption for the poor, it seems that the primary beneficiaries have been the urban populations. Midwifery services are least developed among the most vulnerable women—those who live in remote areas.
We have examined the village-based midwife programme 16 years after its launch. The government's vision of village-based provision with qualified midwives living as part of the community they serve has not been realised and today less than 30% of providers live in the village to which they were assigned. Redressing inequity in the distribution of midwives is an important move towards improving maternal health services for women in these areas, but it must be undertaken in the context of other necessary elements of effective provision: an accessible and affordable service comprising well-skilled midwives operating in a supportive environment, with access to emergency care. This would represent an important step towards achieving the fifth Millennium Development Goal.
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Acknowledgements |
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We thank our colleagues in the District Health Offices for their support and cooperation: in the DHO Serang, Dr H Sulchi Aziz, Dr Sri Nurhayati, Bd Euis Wangsih, and in the DHO Pandeglang, Dr Gatot Supriadi, Dr Susi Badrayanti, Bd Oom Rochmulyati. From the Ministry of Health, Jakarta, we thank Dr Sri Hermiyanti and Dr Lukman HL. For their contribution to the efficient running of the research, we thank Dr Anhari Achadi, Reni Setiawaty, Nathya S Yahya, Sujoko Bayuaji, Eko Setyo Pambudi, and Elang Rusdi.
This work was undertaken as part of an international research programme, IMMPACT (Initiative for Maternal Mortality Programme Assessment), funded by the Bill & Melinda Gates Foundation, the UK Department for International Development, the European Commission and USAID (see http://www.abdn.ac.uk/immpact). The funders have no responsibility for the information provided or views expressed in this paper. The views expressed herein are solely those of the authors.
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Accepted for publication 13 August 2007.
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