Skilled delivery care in Indonesia

Providing adequate access to maternal health care is a test of the entire health system.

Care for most women before, during and after delivery can be provided within a well equipped primary care setting. Where complications arise there is the need for speedy referral to higher level facilities. Primary care is thus a main care provider as well as a crucial link to more specialist forms of care.

Since the 1980s Indonesia has attempted to improve women's access to maternal health care by assigning professional midwives to each village. But although the number of midwives has increased, maternal mortality remains high compared to other countries with similar Gross Domestic Product per capita.

A recent study in Zanten Province, Java, demonstrates a positive association between the presence of midwives and the use of professional care. However, even in areas with relatively large numbers of midwives, the proportion of births attended by a professional remained low at 33 percent, and access to emergency obstetric care is inadequate. The higher uptake of care by the wealthiest women and those with health insurance suggests that economic barriers are deterrents to use. Findings include the following.

• There is a strong relationship between wealth and use of professional care during delivery. Three-quarters of births in the richest households are attended by a midwife or doctor, compared to less than ten percent amongst the poorest households.
• Village midwives rely on private income (representing nearly two-thirds of earnings) so may be unwilling to deliver women who cannot pay.
• The costs of emergency obstetric care are enough to push non-poor households into poverty.

The study indicates that while increasing the supply of midwives is important in improving maternal health, their presence alone is not sufficient. The financial cost of delivery care is a barrier both to accessing skilled help for normal delivery and in reaching emergency obstetric care.

Implications for the Indonesian maternal health financing strategy at primary health care level include:

• Increased investment in local health centres will support midwives' services, offer basic emergency care and organise referrals.
• Increased incentives for maternal health care staff will serve poor rural clients.
• Covering the costs of emergency obstetric care for all who need it will help, as poor people are often are unable to meet such unexpected payments.
• Health insurance for poor people was introduced to overcome financial barriers to care, but targeting those living in poverty is notoriously difficult, and may leave many without help.
• Increased investment is necessary to overcome other demand side barriers to care, such as perceptions of the quality of care, lack of knowledge about services, or the opportunity costs of accessing care.

Tim Ensor
Immpact, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
tim.ensor@opml.co.uk