Skilled delivery care in Indonesia

Providing adequate access to maternal health care tests 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 hasattempted to improve women’s access to maternal health care by assigningprofessional midwives to each village. But although the number of midwives has increased,maternal mortality remains high compared to other countries with similar Gross DomesticProduct per capita.  

A recent study in Zanten Province, Java, demonstrates a positive associationbetween the presence of midwives and the use of professional care. However,even in areas with relatively large numbers of midwives, the proportion ofbirths attended by a professional remained low at 33 percent, and access toemergency obstetric care was inadequate. The higher uptake of care by thewealthiest women and those with health insurance suggests that economic barriersare deterrents to use.

Findings include thefollowing. 

• There is a strongrelationship between wealth and use of professional care during delivery. Three-quartersof births in the richest households are attended by a midwife or doctor,compared to less than ten percent amongst the poorest households.
• Village midwivesrely on private income (representing nearly two-thirds of earnings) so maybeunwilling to deliver women that cannot pay.
• The costs ofemergency obstetric care were enough to push non-poor households into poverty.

The study indicates thatwhile increasing the supply of midwives is important in improving maternalhealth, their presence alone is not sufficient. The financial cost of deliverycare is a barrier both to accessing skilled help for normal delivery and inreaching emergency obstetric care.

• Implications for theIndonesian maternal health financing strategy at primary health care levelinclude:
• increasedinvestment in local health centres will support midwives’ services, offer basicemergency care and organise referrals
• increasedincentives for maternal health care staff will serve poor rural clients
• covering the costsof emergency obstetric care for all who need it will help, as poor people are oftenare unable to meet such unexpected payments
• health insurancefor poor people was introduced to overcome financial barriers to care  but targeting those living in poverty isnotoriously difficult, and may leave many without help
• increased investment is necessary to overcome other demand sidebarriers to care, such as perceptions of the quality of care, lack of knowledgeabout services, or the opportunity costs of accessing care.