Presentation

Sri Hermiyanti
Director of Mother’s Health
Ministry of Health, Republic of Indonesia
Gulardi Wiknjosatro
Chair of National Clinical Training Network, Indonesia

INDONESIA
# #
Largest archipelago in the world to form single state, consist
17.508 Vital Statistics
6.000
84 %
33
440
220
Islands & Islets
Inhabited
Sea & 16 % Land
Provinces
Districts
Millions people
Life Expectancy
Maternal MR
Infant MR
U5 Malnutrition
69,4
262
30,8
23,6
years
Per 100.000 live births
Per 100.000 live births
%
Source: Central Statistic Bureau, 2005

Trend of Maternal Mortality in
Indonesia
Maternal Mortality Ratio in Indonesia
500
450
400
350
300
250
200
390
334
307
262
226
Accelaration
150
100
50
0
MDG
102
1980 1985 1990 1995 2000 2005 2010 2015 2020
IDHS Target Trend Linear (IDHS)

Background
Causes of Maternal Death in Indonesia
4500 deaths annually
Indirect causes
23%
Hemorrhage
30%
Abortion
5%
Prolonged labor
5%
Infection
12%
Pre/Eclampsia
25%
Source: Mortality Study, Surkesnas 2002

Background
Government-funded maternal health services are provided
by 1,176 hospitals, 8,114 sub-district Health Center
/Puskesmas and 36,861 village midwives
Village midwives (Bidan di Desa) are the professional
maternal health services closest to mothers
70,000 midwives total in Indonesia
67% of deliveries are attended by a health provider, with
the majority of providers being village midwives (IDHS
2002/2003)
60% of deliveries take place at home

Indonesia has in Place Most Elements
to Influence Positive AMTSL Practices
Policy
Provider
Collaboration
of MOH,
WHO, NGOs
National
Guidelines-
APN
Presence in
pre-service
training
Knowledge,
skills in
AMTSL
AMTSL
protocol
in hospital
“Compliance” for
use of AMTSL
Motivation
to use
Expected
behavior
in hospital
Implementation
Proper
storage
Woman
receives
AMTSL
Logistics
Uterotonics
included on
Essential
Drug List
(oxytocin=
drug of
choice)
Sufficient
ammount
procured
Transport
issues
Procurement
at hospital
Level and
BdD
Availability
of sufficient
oxytocics,
needles,
syringe on site

Availability of Uterotonics
Oxytocin & ergometrine are on the national essential drug
list, and generally found in hospitals, Puskesmas and
village midwife practices
Misoprostol is not on the essential drug list yet
Misoprostol is not registered in FDA as uterotonic, only as a
gastric ulcer drug

Midwife Training in AMTSL
The quality of village midwife training varies, but is
improving
In 1999, the GOI assisted by USAID (JHPIEGO’s MNH
program) launched a competency-based “Normal Delivery
Care” in-service training program for midwives (Asuhan
Persalinan Normal/APN)
The APN reference manual has always included AMSTL
as a standard practice

AMTSL standards (2000-2006):
Give mother a uterotonic drug < 2 minutes after the baby is
delivered (drug of choice is oxytocin, 10 unit IM)
Controlled cord traction
Uterine massage after the placenta is delivered
Since most deliveries are assisted by a single provider,
MOH & professional associations thought that the FIGO
standard of 1 minute was too short given that a midwife
might have to manage other complications (e.g., newborn
asphyxia) modified to 2 minutes

Maintaining Quality of Clinical Training
JNPK (National Clinical Training Network/NCTN)
Consists of professional association members
(obstetricians, pediatricians, nurses, midwives)
Has Provincial clinical training centers in 31 of Indonesia’s
33 provinces, and District training centers in 139 of 440
districts (only 50% are active)
Trainers include: OBs, Pediatricians, GPs & Midwives
JNPK has in place a system to qualify trainers and accredit
clinical training sites

Maintaining Quality of Clinical Training
Trainings are limited to 12-15 participants
The 10-day APN training includes 4 days in class, 6 days
practicum minimally 3 observed deliveries
Competency assessment:
Pre- and post-tests to measure competency in key skills on
Day 1 and Day 10 of the training
A qualification and clinic accreditation should take place in
the provider’s workplace 2-6 weeks after training. JNPK
data shows that this QA visit greatly improves longer-term
retention of competency

Competency in Standard Practices Among Trained Midwives:
Differences among Midwives who Received and Did Not Receive post-training QA visit
N
o
Essential Skills
Tangerang district
NQA
n: 62
QA
n: 60
Cianjur district
NQA
n: 57
QA
n: 60
1
2
3
4
5
6
Infection Prevention
•Decontamination
•Cleaning
•High Level Disinfection
Partograph
AMTSL
Episiotomy (non-routine)
Standard Cord Care
Immediate & Exclusive
Breast Feeding
45%
52%
48%
36%
27%
32%
42%
20%
85%
92%
88%
86%
87%
80%
88%
33%
32%
52%
44%
42%
37%
37%
40%
18%
88%
95%
90%
91%
88%
82%
90%
37%
Note:
CR : Compliance Rate to the International Standard
NQA: Non Qualificati on and Accreditation Area
QA : Qualificati on and Accreditation Area
Source: NCTN Qualification and Accreditation in Tangerang and Cianjur District, June and September 2006

Scaling Up Clinical Training
Since 2006, MOH has provided central-level
“deconcentration” funds to improve maternal and child
health services
2006: Rp. 500 billion (US$55 million)
2007: Rp. 600 billion (US$66 million)
Most districts utilize a good portion of their funds for
clinical training. The proportion of midwives trained per
district ranges between 10% to 70%.

AMTSL Practices in Indonesia
An assessment of AMTSL practices was conducted in
2006, in collaboration with POPPHI
The assessment was done by direct observation of 104
home based deliveries (by village midwives) and
deliveries in 27 hospitals
The village midwife sample was taken in the Cirebon
district, where 66% of midwives surveyed had been
trained in AMTSL through the APN course

Type of Uterotonics Used for AMTSL by
Village Midwife in Cirebon District, 2006

Oxytocin Dose given by Village Midwives
Cirebon District, 2006

Timing of Uterotonic Administration by Village
Midwives, Cirebon District, 2006

Practice of Controlled Cord Traction, Immediate Massage of
the Uterus & Uterine Massage Every 15 Minutes
by Village Midwives in Cirebon District, 2006

Overall Correct Practice of AMTSL
by Village Midwives in Cirebon District 2006
Note: Graph shows point estimates with their 95% confidence intervals

Practices of AMTSL in Village Midwives
by AMTSL Components, Indonesia 2006
FIGO/ICM standard : administration of uterotonics in 1 minute after delivery of
the baby, controlled cord traction, immediate massage of uterus after delivery
of the placenta followed by palpation of the uterus every 15 minutes

But, in hospitals,
AMTSL is less regularly practiced
Results of observations in 27 hospitals (MOH & POPPHI, 2006) showed:

Conclusions
Using competency-based training & followed by posttraining
quality assurance, Indonesia is practicing AMTSL
as one of various best practices
The Cirebon study found that most village midwives were
able to deliver the uterotonic in < 1 minute In 2007, the
national clinical guidelines on AMTSL for midwives were
updated to match FIGO recommendations of uterotonic
injection in

Next Steps
Continuous monitoring to ensure practicing of AMSTL in
every level of maternal health care
Increasing AMSTL practices in hospital
Sustaining high level of AMSTL practices in primary
health care
Government and donors resource mobilization for
maintaining quality of care through best practices
implementation