Reaching the poorest: a strategy to increase skilled delivery in Indonesia

Indonesia recently introduced a programme that provides a trained midwife for every village, in an effort to increase access to professional delivery care among the poorest, particularly rural women. Has this strategy achieved its aim?

Renewed concern has beenexpressed about inequalities in maternal health and the use of health services.Large gaps exist between socioeconomic groups in access to professional deliverycare in low- and middle-income countries. There is a need to develop programmesthat enable all women to access skilled delivery care, including emergencyobstetric care. However, there are few examples of successful interventionprogrammes that demonstrate how to reduce inequalities effectively.

In 1989, the Indonesiangovernment launched a village midwife programme in an effort to reduce maternaldeaths by increasing the proportion of births attended by trainedprofessionals, especially in poor rural villages. The aim was to train and posta midwife to each village, and by 1996 more than 50,000 midwives were in theirposts.

A study by the Johns HopkinsBloomberg School of Public Health, the London School of Hygiene and TropicalMedicine and the Centre for Family Welfare at the University of Indonesiaexamined the extent to which the village midwife programme increased accessamong the poorest women to professional delivery care. It used data from theIndonesian Demographic and Health Surveys (DHS) for 1991, 1994, 1997 and 2002,to assess trends in the percentage of births attended by a health professionaland the percentage of caesarean section deliveries. It analysed live birthsthat occurred in the 5 years before each survey,covering 66,727 deliveries between 1986 and 2002.

 The study concluded that after the programmewas fully implemented in 1991, the poor were reached successfully and the gapin access between rich and poor was reduced. More specific conclusions includedthe following.

• Thebiggest increases in professional attendance at delivery were recorded for womenin the poorest two quintiles, which increased by eleven percent a year comparedto six percent a year for women in the middle quintile. Remarkably, thesetrends continued despite the economic crisis of 1998-99.
• Therate of emergency obstetric care increased to ten percent for women in thewealthiest quintile but remained under one percent for women in the poorest twoquintiles, demonstrating a substantial unmet need for emergency obstetric careamong most of the population.
• Themother’s socioeconomic status had a major effect on professional attendance atbirth and access to caesarean section delivery.
• Almost90 percent of women in the wealthiest quintile had a health professional attendingthe birth, compared to only 16 percent of women in the poorest quintile.
• Caesareansection delivery was relatively high among women with higher education,reaching a rate of 13.5 percent, compared with only 0.3 percent for those withno education. 

The gap in access to emergencyobstetric care has widened in Indonesia despite the programme. This drawsattention to the importance of understanding the barriers to accessingemergency obstetric care and the ways in which these can be overcome, especiallyamong the poor.