Questions/Answers

In Banyuwangi, one of the districts in East Java,Indonesia, 25 pregnant women died in 2015, as well as 163 babies. These high death rates were caused by several factors. Firstly, there was a lack of data concerning the existence and whereabouts of women with high-risk pregnancies. This weakness in terms of available data was the consequence of an insufficient number of village midwives to cover all corners of Banyuwangi, plus the district’s topography, which makes accessing some areas incredibly challenging. As a result, a full range of activities at integrated health-service posts and pregnancy checks are not always available in these areas. The second factor was the already heavy workload on midwives. Besides provide healthcare services, midwives also undertake a number of administrative tasks that require a great deal of time and energy. These include overseeing finances, programme coordination, administration, and managing auxiliary health clinics, so that their primary function is effectively eroded to a side job. This essentially prevented efforts to locate women with high-risk pregnancies in villages, given the lack of time available to carry out necessary checkups at existing healthcare facilities. Thirdly, there was a lack of awareness about women with high-risk pregnancies in these village areas. They did not always report their pregnancies or seek regular checkups, resulting in many cases where women did not know whether their pregnancies would be regarded as high risk. Moreover, many pregnant women only sought the services of a midwife a few days before they were due to give birth, which left midwives only able to help during childbirth rather than enabling them to make the necessary preparations to help ensure safe deliveries. In 2016, Sempu Healthcare Center initiated High-Risk Pregnancy Seekers (HRPS). It was created to solve this problem, specifically to reduce the high rate of maternal and infant mortality.

This initiative is in line with category Enhancing the effectiveness of public institutions to reach the SDGs. It has addressed the problem of lack of human resources (shortage of midwife) and geographic constrain that made community health center was not able to provide effective and efficient services for the high-risk pregnant women in the area. This condition has increased the risk of maternal and infant mortality in Sempu. If this situation persist, then, it is very difficult for Indonesia to achieve SDGs on health sector. This initiative serves as a shortcut to cope the problem.

This initiative achieves SDG Goal 3. Through the empowerment of mobile vegetable sellers and midwives, SAKINA initiative reduced maternal and infant mortality to zero. It is in line with this goal: (3.1) By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births; (3.2) By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births. Since its implementation in the mid of 2016, this initiative has successfully reduced the maternal mortality to zero and infant mortality to two cases in the last five years. This successful story has drawn national attention to scaling up this initiative to other local governments and province in Indonesia. Until this writing several local governments in Indonesia have successfully adopted this initiative in attempt to reduce maternal and infant mortality as mandated by SDGs.

Socially, the initiative created a new volunteer system utlizing mobile vegetable sellers for early detection of pregnancy in the toughest area. From them, the information then coordinated with the community healthcare center. Economically, this initiative has been able to empower mobile vegetable sellers. The Center provides incentives of Rp 50,000 (USD 4.00) each month and healthcare protection as rewards for their contribution. Environmentally, the initiative is able to create more conducive social supports for women and infants. The community’s responsibility in protecting the lives of mother and child also contributes to creating better living environments.

Before this initiative was developed, healthcare services for pregnant women were only available in healthcare facilities. The topographic condition brings challenges for vulnerable pregnant women: the healthcare center is quite far from the villages and the journey takes more time. Cost and transportation are also obstacles. Therefore, these women often had to refrain from going to the community health center and high-risk pregnancy could not be detected. This initiative has brought significant changes. Mobile vegetable sellers were empowered to seek women with high-risk pregnancy, so the women can be located early on. The seekers then report their findings every day, even before the community health center (puskesmas) opens. The findings are then documented by the midwives for intensive assistance. Thus, there will not be late detection of pregnant women. With the midwives’ assistance, their pregnancy can be monitored. Another positive impact is the improving awareness and knowledge of communities about high-risk pregnancy: for example, being pregnant at too young or old an age, being pregnant too often, and being pregnant with height less than 140 centimeters. This initiative is proven to be able to improve community participation in taking care of the lives of pregnant mothers and infants

This initiative is focused on providing services to high-risk pregnant women who are generally a marginalized group in society because they come from poor families. Women play an important role in this initiative, from the planning stage, implementation to the evaluation. All the seekers are women, pregnant women who also contributed to provide input regarding the services provided, training of trainers (ex high-risk pregnant women) before they serve as motivator for new other high-risk pregnant women. On the other hand, this initiative also erodes some husbands 'indifference to their wives' pregnancies by involving them in the pregnancy monitoring.

The main target groups are high-risk pregnant women who are pregnant at the age of less than 20 years or more than 35 years, have had an abortion, have had a C-section, have a height of ≤140cm, have a history of multiple pregnancies, or have chronic diseases (heart, kidney, tuberculosis, hypertension, diabetes mellitus). Data of high-risk pregnant women were obtained from records carried out by mobile vegetable sellers through their interactions with women in the village. In the past, data on high-risk pregnancy did not yet exist, making monitoring by midwives was difficult to conduct. In 2015, only 72% of antenatal care was achieved and birth assistance by midwives was only 78%, the rest was assisted by traditional birth attendance that contributed significantly in increasing maternal and infant mortality cases. This initiative has brought significant changes. The empowerment of vegetable sellers as high-risk pregnancy seekers is starting to show results. Awareness of first trimester pregnancy examinations rose sharply to 92.6% and fourth trimester examinations rose from 73.2% (2015) to 96.6% as of November 2021. The midwives' assistance increased from 78% (2015) to 98.7% (2021). During the period 2016-November 2021, the seekers have successfully identified 610 high-risk pregnant women.

The programme’s strategy and approach were implemented in the following way: 1. Prepare supporting infrastructure for the high risk-pregnancy seekers. The programme team created a WhatApps Group that could be used to report real-time data concerning high-risk pregnancies. The high risk-pregnancy seekers use the application to upload photographs of the home or living conditions of a woman with a high-risk pregnancy together with her name, age, address, husband’s name, and symptoms. Then, this information then was sent to midwives at Sempu Health Center. 2. Recruit high risk-pregnancy seekers. Recruitment was carried out by holding consultations with women living in villages throughout the catchment area. Teams of midwives visited every village to identify vegetable vendors operating in each of them, with the aim of securing 10-15 high risk-pregnancy seekers in each section of the Center’s overall work area. One of the priorities during the recruitment process was to find vegetable sellers that already had smartphones. 3. Train the high risk-pregnancy seekers. The aim of the training was to enable the hunters to understand the key indicators linked to high-risk pregnancies; these include being pregnant under the age of 20 or over the age of 35, being too close to delivery, already having a lot of children, being under 140 centimetres in height, having previously had a caesarian section, a swollen face and legs, etc. The seekers were also trained on how to use the smartphone application. 4. Establish a high-risk pregnancy task force to follow up on the seekers’ findings. The head of the community health centre formed the task force, which is provided with all relevant data that includes the locations of women with high-risk pregnancies. 5. Head of Community Health Center conducts monitoring and evaluation every six months to identify the implementing problems and progress.

Firstly, although the pregnancy seekers were provided with smartphones, they encountered some difficulties using them.This was resolved by providing additional assistance to the seekers who experienced difficulties with the smartphones. A second challenge were several points in three villages within the programme’s working areas that had no 3G signal or data access, meaning that no applications could be used other them SMS. To overcome this problem, the pregnancy seekers were advised to send information about at-risk pregnant women via SMS to a midwife who then entered the data onto the health clinic’s information system.

This initiative employs female mobile vegetable sellers to support the midwives detecting high risk pregnancy in villages. This method is the first conducted in Indonesia and is a breakthrough to deal with limited number of midwives. It is effective and efficient because it is low cost but it brings great benefits. Mobile vegetable sellers are agents of change for saving women with high risk pregnancy. They can get information about pregnant women’s location and condition easily through daily interaction. The midwives and village activists become the partners to look after the health of women with high risk pregnancy.

High-Risk Pregnancy Seekers initiative is original idea developed first in Banyuwangi District or even Indonesia. This initiative is born from the local wisdoms. The presence of mobile vegetable sellers is inseparable part of social life in Java. This unique initiative also triggers supports of other agencies. One of them is from Indonesian Police Department which initiated a shelter for women who live far away from health facility that going to deliver their babies also supported transport to healthcare facilities with their cars. This social volunteering has been an original character of Indonesian which prioritizes mutual assistance.

One of the priorities during the recruitment process was to find vegetable sellers that already had smartphones as this initiative utilizing a simple WhatApps Group for reporting purposes. If some of them did not own a phone of any kind, the centre would purchase a smartphone for her, as the cost was quite cheap but its reliability was assured. On the other hand, if a vegetable seller only had an ordinary mobile phone, he could use it to send relevant information via SMS to the nearest available midwife, who would then upload the data onto Sempu’s Health Center information system.

High-Risk Pregnancy Seekers initiative has been replicated in 87 community healthcare centers (puskesmas) in Banyuwangi and across Java. In Indonesia, this initiative is studied through educational visits. More than 166 regional governments and central agencies have visited to see firsthand the practical implementation and impacts from this initiative. This initiative is transferable and adaptable for other places because it is simple and low-cost. Through intensive communication with stakeholders, it can be implemented. In Indonesia context, all local governments operate Community Healthcare Center at sub-district level. They have almost the same resources, facilities, and capacity. This has made horizontal replication is much easier to be conducted. Most relevant, almost all of the Center across the country experience with shortage of midwives, so this has become catalyst factor to speed up transfer or replication of this initiative. For example, in 2019 District of Kebumen in Central Java successfully adopted this initiative without modify it and succeeded to curb maternal and infant mortality to zero in 2020 and 2021. Then, Central Government awarded this successful replication effort to local government of Kebumen. To this writing, this initiative has being transfered to hundreds of local governments across the country.

This initiative has being transferred to other local governments in Indonesia. In addition to that, it should be noted that in the beginning of this initiative in 2016, which is barely one year into its implementation, did not yet possess strong legislation such as a regional regulation or district head decree. Nevertheless, the intense coverage that the programme has received and the number of visits from people in other areas in Indonesia proves that it is hugely beneficial for local communities, which is acknowledged by many parties. This is a tremendous encouragement to Sempu Community Health Center and the Banyuwangi Health Office to continue implementing the programme. A number of other regions have been studying and learning from this innovation, including Central Java, South Sulawesi, East Nusa Tenggara, and several other districts/cities in Indonesia. This is a proof that potential of transferability is relatively high even though without prior regulations availability. In Indonesia context, in many cases, formal regulation availability has become the main precondition in initiating the initiative. High-risk pregnancy seekers has become a kind of eye opener for other local governments that the existence of regulation was not a mandatory to initiate a new innovative solution.

The total cost of this initiative is Rp 91,800,000 (USD 6,120). This is from regional government, village funds and third parties. It is allocated for workshops, smartphone procurement, vests, boots and helmets for the seekers and for incentives for village companions and seekers for a year. This initiative is run by 23 companions, 10 female mobile vegetable sellers, 10 midwives and 1 village policeman. Supporting resources are 1 unit ambulance, 1 evacuation car and 10 smartphones for mobile vegetable sellers to report their findings.

The innovative High Risk-Pregnancy Seekers programme continues to be implemented. The uniqueness of this initiative even captured the attention of the Banyuwangi District Head, who promoted it on a number of occasions, resulting in different media entities (electronic, online and print) showing an interest and reporting on it. The district head’s commitment is also shown by his allocating Rp 1.7 billion (US$125,500) from the LG budget to renovate buildings and facilities belonging to this programme’s innovative center. Appreciation has also come from Indonesia’s Ministry of Health, which awarded a new ambulance to the centre to assist in its day-to-day operations.

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Evaluation is conducted at the end of each month by holding internal discussions in the Community Healthcare Center (Puskesmas), attended by all midwives, nutritionists, laboratory staff, health promotional officials, administrative staff, mobile vegetable sellers and companions and is led by the Head of Puskesmas. The teams in the field are asked to report their findings and activities for a month including their success and obstacles. Results are reported to an external forum at sub-district level led by the Head of the sub-district, attended by village heads, police and women organizations. Any developments and obstacles are discussed to find solutions.

There are two indicators used for evaluation. Firstly, effectiveness of teamwork, making sure the internal team in Puskesmas or field teamwork is as expected. One of these aspects is incentives paid to mobile vegetable sellers and companions every month. Another aspect is the flow of reports from vegetable sellers and finally, making sure all women with high-risk pregnancies are assisted. Secondly, data of pregnant women, new findings, number of high-risk pregnancy and number of women who do not regularly check their pregnancies at healthcare centers. There is a pro-active service, including referral to specialists and data on childbirth due date.

This initiative has an immediate outcome: the maternal and infant mortality rate was reduced to zero since the initiative was implemented in 2016, until the end of November 2021. Before, the maternal mortality rate was at 16 in 2015. Infant mortality, from 28 deaths in 2012-2013, has also been reduced to two cases in the last five years (2017-2021). Moreover, trimester visits for pregnant women to Community Healthcare Center increased from only 87% in 2013 to 100%, demonstrating that participation and awareness in pregnancy health is improving. This initiative also brings a new social element in the community: the village community work together and become responsible for the lives of pregnant women. In addition to this findings, several external evaluation were also conducted by academics. The main finding states that the program is successfully considered to improve local people health quality in rural areas, as appreciated by national and international organizations. Unfortunately, this program is still dominantly conducted by Health Agency of Banyuwangi Government at recent time. The initiative should be reinforced through building creative culture on rural community to improve participation and awareness of this program and to sustain it in the next period of leadership in Banyuwangi Regency.

One indicator of the success of development in the health sector is the maternal and infant mortality rate. This area is the responsibility of the Ministry of Health. So that this innovation becomes the main task and function of the Heath Center as an extension of the Ministry of Health. This innovation has been upscaled by the ministry with the "Care & Quick Response" branding through a strong commitment from the head of Banyuwangi District. This commitment is also equipped with guidelines for implementing the initiative. As a result, 44 Health Center have replicated the initiative and other centers replicated the mentoring strategy for high-risk pregnant women by utilizing mothers as social agents. This inter-agency collaboration was strengthened by the memorandum of understanding with Sempu Health Center to directly guide the implementation process. The local police department who are law enforcers also show their empathy for pregnant women. They built a shelter on the edge of the forest to transit pregnant women who will give birth from remote areas. This police department commitment reflects two agencies with different functions, which can be united in the interests of saving the lives of mothers and newborn babies.

a. Banyuwangi Regent, the inspiration and motivator for the initiative, emphasizes public service improvement via a breakthrough which people directly benefit from. b. The Head of Public Health Agency, the initiator, prioritizes fast reduction in maternal, newborn, and infant mortality by providing special allocation from the Government. c. The Head of Puskesmas Sempu, the initiator, motivator, and driving force of the innovation, keeps communication going between stakeholders and responsible for designing the initiative. d. Sub-district Head, the host, initiates and evaluates the initiative, not to mention has issued a decree on the Initiative. e. The Head of the village provides incentives for vegetable sellers and companions which is allocated from Village Funds. f. Village policeman, the shelter initiator, evacuates high-risk pregnant women from isolated area. g. Ten mobile vegetable sellers, the spearhead, look for and report high-risk pregnant women to health centers and become the agent of change in the society. h. Twenty-three village female public figures together with midwives face the formidable task to assist high-risk pregnant women until the labor day. i. TRANSFORMASI, an international development program implemented by GIZ, actively facilitates training for female vegetable sellers. j. MUSLIMAT women organization with its 3600 members plays a highly active role to disseminate the initiative.

Commitment and cooperation are the keys to success. The initiative has succeeded due to the commitment and bureaucratic reform of the programme’s leader. Collaboration among all interested parties within the local community was also an essential ingredient. One does not need to be a health worker in order to make a valuable contribution; the role played by the vegetable sellers is proof of this. All the potential that exists within local communities can be utilised to support improvements to the quality of public healthcare. Cross-sector cooperation is another important factor. Close collaboration with subdistrict and village administrations helps to safeguard the sustainability of this initiative. Initially, there was a lack of optimism by embracing village administrations. However, they are fully aware of just how much the High Risk-Pregnancy Seekers’ efforts benefit local residents in their villages. Just as important is the role played by local communities – especially by volunteer health workers who immediately follow up on the pregnancy seekers’ findings. Village midwives would be unable to fulfil all their tasks without the assistance provided by the volunteers. Basically, the more people available to monitor the condition of at-risk pregnant women, the greater the likelihood of good results.