Poor women miss out as Indonesia’s midwives shun remote villages

A major issue in maternal health policy is how to provide incentives for midwives to work in remote areas and deliver services to poorer women. Since the early 1990s, Indonesia has placed rural midwives in every village in an attempt to reduce maternal mortality. But it is uncertain if the incentives are enough to attract midwives to more remote locations.

Researchersfrom the University of Aberdeen (UK) and theUniversity of Indonesia report on a survey of rural midwives in Banten province, Java, Indonesia. The survey was part ofthe Village Midwife programme run by IMMPACT (Initiative for Maternal MortalityProgramme Assessment). The survey examined both the public and private incomeof rural midwives and focused on the effect of financial incentives on theirchoice of location for work.

Themidwives’ public income consisted of a basic salary and top-up allowances.However, most were able to earn a substantial additional income from privateclinical practice. The survey reveals midwives are unwilling to move to moreremote areas. This is not necessarily because of financial reasons or careerconcerns, but rather because of community and family ties, particularly theneed to be close to one’s parents’ home, children’s schools and husband’s placeof work. Thesurvey also found that:

• More than half the midwives wouldmost like to be permanently employed as civil servants with pensions.
• Most did not wish to give up theirpublic position but had to supplement their salaries with private income.
• Private income was stronglyassociated with competence and experience, with very experienced midwivesable to earn two-thirds of their total income from private practice.
• Public pay increased closer tourban centres, which therefore attracted more experienced midwives.
• Mostmidwives demanded very high payments to move: a doubling of public salaryto move an hour away from home and a tripling of public salary to movefive hours away for work.
• Younger midwives who had not yetsettled into a community were more willing to move to remote locations.

The researchers argue that the salaryincreases demanded by midwives as a condition for moving their place of workare unrealistic and exaggerated. However, they accept that retaining andmotivating workers in priority areas will require substantial benefits. Theyconclude that:

• Policymakersneed to develop longer term contracts with a promise of civil servicestatus for younger, less experienced midwives in return for working inremote areas.
• Suchcontracts are likely to be more effective if midwives are recruited fromremote areas.
• Morefunding is needed to guarantee salaries.
• Policymakersshould also consider substantial settlements for those working in verypoor villages with low population densities, perhaps based on the numberof poor people living in the area.
• Policymakers may need to reconsidertheir strategy of basing skilled attendance at birth on the availabilityof village services around the country and look at alternative models.