Initiative: Fostering Partnership to Reduce Maternal and Infant Mortality
Institution: District Health Office, Aceh Singkil
Problem: Indonesia was not on track to meet the Millennium Development Goal on reducing maternal mortality by 75 per cent by 2015. According to the 2012 Indonesian Demographic and Health Survey, Indonesia’s maternal mortality rate was 359 births per 100,000 live births, while its infant mortality rate was 32 births per 1,000 live births. In Aceh Singkil, one of 23 districts in the province of Aceh, its 110,000 residents are served by 11 basic health clinics (puskesmas). Although there were medically-trained midwives available, they did not speak the local dialect and were often seen as outsiders. A 2010 report by Indonesia’s Central Bureau of Statistics showed 38.28 per cent of deliveries in the district were handled by traditional birth attendants (TBAs) who often lacked medical training on safe birthing procedures. Families tended to choose TBAs who were well-respected elders and were believed to possess special spiritual and medicinal powers. More importantly, their low cost makes them attractive alternatives to many families living in remote areas. As a result, many births were handled by TBAs who were ill-equipped to handle complications that threaten the health of mothers and babies.
Solution: The health department in Aceh Singkil aims to ensure that all births in the district are attended by trained midwives or other medical personnel. Key stakeholders were mobilized to take part in discussions on the problem of unskilled deliveries and maternal mortality. The idea of partnerships between TBAs and midwives was presented as a potential solution to these issues during the meetings, and it was supported by the village head, head of the local mosque, community leaders, religious leaders, and local health volunteers, as well as by TBAs and midwives themselves. The district health office issued an instruction letter on the replicating of TBA-midwife partnerships, providing formal support for the expansion of the initiative. Local regulations legislated that every TBA would receive an honorarium from the village for their services in assisting trained medical personnel with child deliveries and that TBAs were eligible under the regulation to receive additional compensation from the national insurance scheme. Memorandums of Understanding signed between the traditional birth attendants and the midwives included information on the respective roles and responsibilities.
Impact: The partnerships between TBAs and midwives ultimately led to a decrease in births assisted by TBAs in all 31 villages (2 pilots and 29 replications). As permitted by the MoUs, TBAs are now frequently involved in births at local health clinics where they provide spiritual support to mothers during the delivery. Mothers report feeling more at ease now that they can be assisted by both TBAs and medically-trained midwives and most importantly, no maternal deaths have occurred since the partnerships began. 1,047 births were attended by midwives in the initiative’s five sub-districts between January and the end of August 2014. Statistics managed by Singkil Health Centre show a decrease in the number of births attended only by TBAs in the area around the clinic from 17 in 2011, to eight in 2012, to just two in 2013.