Questions/Answers

Flores Timur or East Flores is an archipelagic district in Nusa Tenggara Timur Province (NTT) of Indonesia with 250 villages in 19 sub-districts covering an area of 3,079.2 KM². There are 20 health centers at sub-district level: 3 in Solor Island, 8 in Adonara island, 9 on the mainland and 1 (one) district hospital as a referral hospital located in Larantuka. Travel time from each health center to district hospital from Solor and Adonara island is around 2-3 hours by crossing the sea. A baseline survey result in 2009 showed that Maternal Mortality Rate (AKI) is 316/100,000 live birth; Neonatal Mortality Rate is 10,16 /1000 Live birth, and Under-5 Mortality rate is20,5/1000. One of root of the problem is the high maternal, neonatal and under-5 mortality due to the high rate of labor at home (35%); topographic conditions of East Flores Regency, islands, mountains and poor infrastructure conditions; and Flores culture where husband is the decision maker of the place. All of these things hinder the delivery process and the labor referral process. In 2010 it is launched 2H2 Center program of Mother and Baby which is moral and technical movement to involve all stakeholders to care about pregnant mothers and to decrease mortality rate of mother and neonatal. In 2020 particularly for vulnerable groups who live in remote area to become below 70/100,000 living born and neonatal mortality rate below 5/.000, infant 7/1000

This 2h2 Center Program is to provide quality, equal and fair service for groups of people who live in remote areas, those who are low income, illiterate and vulnerable so they can have the same access and health services as residents living in the regency government center. Through 2H2 Center, all pregnant women, including those in remote and vulnerable places will be documented in the target database of pregnant women, childbirth and newborn mothers in real name, by address, by case so they all are well monitored. All pregnant women will be monitored and supervised, delivered to health services (puskesmas/hospitals) until they return home again by the midwife for free

This breakthrough is very appropriate to help pregnant women go through pregnancy, childbirth in quality through close supervision by the 2H2 TEAM Center and all relevant stakeholders. All labor processes including those living in islands, vulnerable and remote are carried out by health workers and take place at health facilities. This innovation also monitors the development of pregnant women up to 42 days postpartum. Target of this program is in 2020 maternal mortality rates in East Flores district are below 70 / 100,000 live births and neonatal mortality rates are 5/1000 live births and under-5 7/1000 live births. The target is even lower than 3.1 and 3.2 SDGS. This program is strengthened by Local Regulation No. 9 of 2011 concerning the Health of Mothers, Children and Newborns

Since 2010 to 2017, 2H2 Center has had women cadre network in village level up to 1450 people and assisted 24,879 pregnant women. Through strict mentoring and good health campaigns, the number of pregnant women who deliver at home has decreased from 35% in 2009 to 1% in 2016 and 2017, this also shows that the role of pregnant women in decision making in delivery has well improved. The measures taken in order to reduce maternal and child mortality and encourage mothers to give birth in health facilities are: 1. Establish community cadres to care for mothers and children throughout the village and establish partnerships with traditional birth attendants to monitor and assist pregnant women heading to health facilities. 2. In order for the condition of the pregnant woman to be noticed by the neighbors and all stakeholders, then her house will have a pink flag (KIA flag). Then the 2H2 center forwards information on the condition of the pregnant woman (mother's condition, estimated date of birth etc.) to the nearest health care provider, hospital, village apparatus, sub-regency, religious leaders and traditional leaders through sms gateway. 3. Pregnant women and their families also receive assistance about maintaining the condition of the pregnancy, obtaining the medicines needed and the importance of labor in health facilities. Mentoring of pregnant women by health workers (midwives) and village cadres which are coordinated by 2H2 center.

Based on observations for 3 years, the Health Office gave birth to an out of box strategy, namely 2h2 center. This program approaches all elements of society to care about pregnant women. This program places village cadres, traditional birth attendants, and religious leaders as the main partners in maintaining pregnant women. 2H2 Center conducts centralized monitoring and evaluation and routinely informs the existence of pregnant women, estimates of delivery to all partners in the region via SMS and telephone. This increases the awareness of the surrounding community towards the existence of pregnant women. The 2H2 center is also a coordination center for referrals or emergencies in the delivery process, provides 24-hour consultations served by obstetricians and coordinating midwives, and guarantees the availability of land and sea ambulances free of charge

East Flores Regency is an archipelago with three large islands namely Larantuka, Adonara and Alor, inter-island liaison can only be passed by boats, does not have internet network and has minimal signal, most of them are iliterate women so they are in a vulnerable condition. The community has a patriarchal culture, where the husband is the determinant of where pregnant women deliver. So that the level of labor outside of high health facilities. (35% in 2009). 2H2 Center is a program that was born to answer the problem of high maternal and infant mortality rates in accordance with the conditions of East Flores Regency. By increasing citizens' awareness of pregnant women, providing information and providing facilities easily and for free.

The main idea of 2H2 center is to build partnerships and collaboration with the community and all health support officers to care for pregnant women in their area. The technology used is simple and inexpensive, namely the sms gateway as a communication link with all stakeholders and the flag as a sign of the existence of pregnant women to get the attention of the surrounding residents. The 2H2 center model can be adopted in both island and land areas. The use of technology and systems can be adjusted to the conditions of each region. this program has been adopted by 22 regencies in the Province of NTT, studied by the provinces of Aceh and Papua, disseminated to 33 provinces by the Ministry of Health. 2H2 Center won the 2011 MDG’s Award Special Category by the Ministry of Health.

Human Resources in the implementation of 2H2 Center are: 1) Network of awareness of mothers and infants: there are 1450 volunteer cadres, Sub-Regency Heads, Village Management, PKK, and Birth Attendants, Religious Figures in 250 villages. 2) 2H2 Center Team consists of: secretary, technical teal, operator, ambulance driver. 3) Community health center (puskesmas) network : 21 community health center (puskesmas) and 40 assistant community health center (puskesmas) and Regency hospital. The total funding of 2H2 centers per year is IDR 15,000,000 (1,154 USD) with details of telephone credit of IDR 9,000,000 (692 USD) and ambulance fuel of IDR 6,000,000 (461 USD). Annual community self-help funding is around Rp 122,000,000 (9,385 USD) in the form of text pulse used to provide information or answer text from 2H2 center.

Social aspect: the system of partnership and collaboration with all stakeholders has succeeded in pushing 100% of pregnant women to decide to give birth in health facilities. The use of flags, the provision of information through SMS, regular dissemination, is a breakthrough that makes people from do not care to care for each other for pregnant and childbirth mothers. Economic aspect: The government has a childbirth guarantee program for all pregnant women, transportation and medicine assistance that has encouraged citizens and families' awareness of the importance of maintaining pregnancy and childbirth at health facilities and health workers. Cultural aspect: there is a paradigm shift that originally considered the pregnancy is a normal process, to become a gift that must be welcomed with joy. In order to support the sustainability of 2H2 Center, the government of East Flores Regency issues: 1. Regional Regulation no 9 year 2011 regarding Health of Mother, Children and Neonatal 2. Decree of Regent no 127 year 2012 regarding 2H2 Center system. Through the 2H2 center program, women are brave enough to express their opinions regarding pregnancy and childbirth. This indicates that 2H2 center successfully advocated for the role of women in their reproductive health. The development of the 2H2 center program includes 2H2 Plus, to monitor babies with low birth weight (<2500 grams), nutrition, and family planning.

Yes

Internal Monitoring: 1. Monthly monitoring through monthly meetings of the Puskesmas coordinator midwife at the East Flores Regency Health Office to discuss target data, home deliveries and their causes, as well as reports of maternal and neonatal deaths for 1 month. Evaluation involves external: 1. Annual evaluation: Since 2010, every May there is regular evaluation meeting with all 2H2 Center stakeholders (cadres, sub-district administrators, community leaders, etc.). 2. Evaluation of extraordinary cases or cases of death: performed 1 x 24 hours after the incident, attended by the head of the puskesmas, the coordinating midwife and the guard team from the puskesmas which contributes to the death with the 2H2 Center team and the Head of the Health Office.

The indicators used in this innovation were coverage of deliveries in adequate health facilities, coverage of deliveries assisted by health workers, coverage of obstetric and neonatal emergency care, maternal mortality rate, and infant mortality rate.

The evaluation result shows increase of quite significant achievement results among other things: 1) Decreased neonatal mortality rate from 10.16 / 1000 Live births in 2009 to 7.12 / 1000 in 2017 and under-5 mortality from 20.5 / 1000 LB to 8.7 / 1000 LB in 2017 2) Decreased mortality of pregnant women, mothers giving birth from 317 / 100,000 LB in 2009 to 92.9 / 100,000 LB in 2017 3) Increased coverage of deliveries in health facilities from 64.4% in 2009 to 99.5% in 2017; and childbirth assisted by health workers from 69%, to 99.5% in 2017 4) Increasing the coverage of handling 59.1% of obstetric and neonatal emergency cases in 2009 to 100% in 2017.

One of the keys to the success of 2H2 center is collaborating with maternal and infant care networks tasked with monitoring each pregnant woman in her area according to the interpretation of labor; Religious leaders, community institutions have a strong influence in encouraging pregnant women to care for pregnancy and decide to give birth in a health facility. In general, the roles of stakeholders are: 1) The head of sub district, Village Administrators: a) Monitoring every pregnant woman in the area; b) Encouraging all pregnant women to give birth in adequate health facilities. 2) Traditional Birth Attendant and Health Cadre a) Taking the mother to give birth in Health Center at sub-district level b) Accompanying the mother who will give birth 3) Religious Leaders a) Approaching and providing spiritual counseling, as well as giving an encouragement b) Visiting the pregnant women who need special spiritual service 4) 2H2 Center a) Becoming the center of referral; b) Providing information about referral cases from health center at sub-district level to all relevant units in the Hospital; c) Administering obstetric and neonatal emergency cases; d) Sending the feedback of the handled cases to the 2H2 Center.

The important lesson of this innovation are 1. The role of women in making decisions regarding reproductive health, should begin to be taken into account because it involves physical and psychological health. 2. This will be very meaningful if the husband, extended family or the surrounding environment provide endless support and advocacy 3. Support from other women around pregnant or childbirth mothers such as cadres, traditional birth attendants, midwives, mothers of village and sub-district PKK team leaders have very important meanings in the success of the program and increasing gender equality 4. The government not only guarantees budget allocations for the birth process, but also persuasively provides assistance in caring for pregnant women and disseminates the importance of giving birth to health facilities.