Questions/Answers

Stiputsbra, is an innovation which is carried out by Dr.Saiful Anwar General Hospital (RSSA) as a solution to reduce maternal and infant mortality. In Indonesia, maternal and infant mortality rate was relatively high. Based on population survey in 2015, maternal mortality in Indonesia was 305 per 100,000 live births. Meanwhile, the target set by the UN was 102 per 100,000. While the infant mortality rate in Indonesia was 22 per 1,000. In Malang Regency, there were 20 cases of maternal mortality in 2013. One of the causes of maternal mortality was the length of labor due to lack of contractions. In 2013, there were 585 referrals who came to RSSA due to prolonged labor and 84 of them ended in sectiocesaria. Then, RSSA as a tertiary referral hospital, initiated the use of Stiputsbra in laborprocess at the primary and secondary level. The Stipusbra was expected to cut the time of laborprocess, so the number of patients which referred because of prolong labor can be suppressed. Woman who is going to give birth normally should wear the bra. Since then, the rate of prolonged labor decreased from total of 585 incidents in 2013to become 0 incidents in 2018.

Innovation of Stiputsbra has gender responsive values. It is relevant with category of gender responsive public service promotion to reach SDGs. Women's reproductive health has more complex problems. During labor, woman experiences critical phase both physically and psychologically. So, support is needed to go throughhealthy and qualifiedlabor period. Innovations in Stiputsbra guarantee that labor will not increase maternal and infant mortality. In addition, the emphasis on maternal and infant mortality is stated in point 3.1 of the SDGs, namely reducing the ratio of global maternal mortality to less than 70 per 100,000 live births by 2030.

Stiputsbra innovation is related to the value of SDGs2030 points 3.1 and 3.2, the target is to reduce ratio of maternal mortality to less than 70 per 100,000 and infant mortality to at least 12 per 1,000. By using Stiputsbra, labor process is faster from average 12-14 hours to 5-8 hours. One of the causes of maternal and infant mortality during labor is prolong labor process. The direct effect of prolong labor processis mother loses more blood and the baby lacks oxygen and has potential to suffer asphyxia. By usingStiputsbra will stimulate contractions that summarize labor time.

Besides central government, hospitals also work hard to reduce maternal and infant mortality. Since Dr.Saiful Anwar General Hospitallaunched Stiputsbrain 2013, the number of prolonged labor referrals has decreased rapidly. In 2013 there were 585 long term referral cases and become 5 cases in 2017. In other words, Dr.Saiful Anwar General Hospital contributed reducing maternal and infant mortality in Malang. In 2013, there were 20 cases of maternal mortality, in 2014 it was decreased into 13 cases, 8 casesin 2015, 9 casesin 2016, and 5 cases in 2017. Every mother also gave good appreciation of the delivery process, they claimed to be happy after giving birth because privacy was more awake, because before, manual nipple stimulation was done bydelivery attendant’s fingers, many patients’ complaints include embarrassment, tickled, and fatigue. The using of Stiputsbra also increased number of rooming in(mother and baby treated in one room). From 2013 to 2014, there was an increase of 11.42% rooming in patients. This meant that number of asphyxia or respiratory disorders in neonates due to prolonged laborprocess had been suppressed to 0 events since 2014.

In Indonesia, prolonged labor is one of the biggest causes of maternal and infantmortality during labor. Normally, the labor process takes 12-14 hours. Unfortunately, in unexpected conditions, many pregnant women find it difficult to give birth normally during this period. For this reason, Dr.Saiful Anwar General Hospital created Stiputsbra which replaced manual nipple stimulation techniques. This tool served to produce uterine contractions to the maximum and avoided complaints of nipple pain. Previously, the technique of nipple stimulation was done manually. This made the patient uncomfortable, embarrassed, and tickled because it was done by delivery attendants’ fingers.

Stiputsbra innovation is an original innovation from Dr.Saiful Anwar General Hospital which is under the auspices of East Java provincial government. The basic idea and design was result of research from The Diamond team, a quality innovation team at Dr.Saiful Anwar General Hospital, which was then technically done by hospital team itself. Since this innovation was carried out in 2013, there had been three improvements in maximizing its function. These improvements included cup size, speed of nipple stimulation and ingredients of the cup. This innovation had also been patented to belong to Dr.Saiful Anwar General Hospital in 2015.

Stiputs Bra has been replicated by 16 hospitals in East Java, namely: a) Many Public Health Centre in Malang City IncludeKendalkerep, Janti, Kedungkandang and Karangploso. b) Many Association of Obstetric Gynecology as Malang Obstetric Gynecology Association, Malang City Health Office, Indonesia Midwifery Association. c) Many hospital in Malang Regency and around as Army Hospital, BenMari Hospital, MelatiHusada Hospital,PuriBunda Hospital, Malang City Hospital, Tulungagung City Hospital, Bangil City Hospital, Blitar City Hospital, Probolinggo City Hospital. In the process of replication, RSSA helped provide assistance with 1 set of Stiputsbraand socialization of how to implement and maintain the tool.

1) Fund Budget operationalcosts of hospital for meetings, outreach and surveys (USD20/ month), making Stiputsbra(USD60 / set). 2) Formal legal Decree of Dr.Saiful Anwar General Hospital Director about program and work guidelines as the person in charge of maternal and infant health program. 3) Human Resources. a) The Diamond Team as idea and design team consists of facilitators, leader and members, responsible to Hospital Director through Quality Guard Team and Head of obstetric gynecology department. b) Implementing officers (Midwives, Obstetrician Specialists, Medical and Midwifery Students). c) Engine technician team to assemble the Stiputsbra.

During 2013, RSSA felt the results of this innovation. To disseminate the perceived benefits of Stiputsbra, in 2014 RSSAformed a special team to take care of Stiputsbra. The team consisted of representatives of the Spesialize Team for Mother and Baby Care(RSSIB) who were responsible for providing socialization and mentoring during the replication of Stiputsbra. As a result, Stiputsbra is also available at health facilities at pre-primary and secondary levels. This is in accordance with the Presidential Decree on tiered Goverment referrals. Every month, reports on maternal and infant health programs, especially mortality due to prolonged labor and infant mortality rates are collected and made quarterly and annual analysis. The results will be used as a reference to improveStiputsbra. Cross-sector cooperation is also carried out with Malang Obstetric Gynecology Association (POGI), National Network of Reproductive Health Clinic Training (JNPK-KR) and Comprehensive Obstetric Neonatal Emergency Services (PONEK). Regular meetings for coordination are held every three months. With efforts to embrace many sectors and disseminate the benefits of Stiputsbra, RSSA expects the maternal and infant mortality rates to continue to decline. Because, economically, improving the health of mothers and neonates will improve the life quality of the family itself.

Yes

Every month, the internal team evaluates reports of mortality due to prolonged labor and infant mortality rates. Meanwhile, externally, Stiputsbra was tested at the national level Indonesia Quality Conventionin Solo held by the Indonesian Quality Management Association (PMMI) in 2014. As a result, Stiputsbrawas declared standard according to excellent service quality and feasible to use. In 2015, Stiputsbraalso received the Gold Illumination award from the Korean Standards Association for the presence of the Diamond team to present Stiputs Bra in the International Convention on Quality Control Circle forum attended by 13 countries.

Indicators used in Indonesia Quality Conventionby PMMI included: 1) Frequency How this innovation is able to reduce incidence that will be corrected. 2) Potential losses to hospitals How Stiputs Bra helped to reduce hospital losses from labor problems 3) Waste of costs for patients In order to reduce patient's financial expenditure to meet health needs 4) Level of patient safety Innovations made are able to guarantee patient safety according to 2012 Severity Assessment Code. 5) Wasting staff time Innovations facilitated work and provided time efficiency. 6) Potential for asphyxia in infants This innovation provided great benefits for neonates

The evaluation results presented by the Quality Safeguard Competition stated that after the use of Stiputs bra, the rate of long-term labor at Dr Saiful Anwar General Hospitaldecreased 82% in 2014. The waste of time the staff in handling labor patients with Nipple Stimulation decreased to 0 minutes. In the first year of the implementation of the Stiputs Bra, the incidence of asphyxia declined by 100%.

Reducing maternal and infant mortality is a big goal that cannot be done alone. The 2013 Quality Control Circle (QCC) Team, as the originator of the idea of Stiputsbraassisted by engine technicians, was instrumental in making Stiputsbra. When Stiputsbra were used, the Spesialize Team for Mother and Baby Care (RSSIB) was invited to be responsible for making observations for their effectiveness and efficiency. Furthermore, Dr.Saiful Anwar General Hospital through the Diamond team collaborated with the RSSIB team carried out socialization and mentoring replication at other hospitals or institutions. In addition, the team from the Institute of Technology of Tenth November Surabaya (ITS) also took part in giving advice about the technical materials used to make Stiputsbra. Because for the patient's safety and comfort, the team must ensure that the ingredients really do not harm the patients.

The lesson learned from the implementation of this innovation is that reducing maternal and infant mortality is not impossible if it is done systematically and together. With the ongoing cooperation and communication of all parties involved, this innovation can be carried out well and achieve maximum results. In the future, it is expected that the provision of Stiputsbra can be made from health facilities that have replicated this innovation.